Strategies for achieving successful cannulation in endoscopic retrograde cholangiopancreatography: A technical overview

Table 1 Differences between contrast-assisted cannulation and wire-guided cannulation

Category	Contrast-assisted cannulation	WGC
Primary challenge	Repetitive probing and multiple contrast injections increase papilla trauma and PEP risk	Achieving proper wire placement in cases of variant anatomy (e.g., tortuous or stenotic ducts)
Risks	Higher risk of PEP due to pancreatic duct opacification	Intramural dissection, perforation of side branches, or creation of false passages
Technical difficulties	Less precise, time-consuming, and challenging in cases of small, floppy, or abnormally positioned papilla	Choice between “touch” and “no-touch” techniques can impact success in mobile or difficult papilla
Anatomical challenges	Difficult in cases of small papillary orifice or variant anatomy	Challenging in cases of variant anatomy (e.g., tortuous bile ducts or stenotic regions)
Combined techniques	May require switching to WGC after initial contrast opacification for better visualization	May require contrast opacification in complex cases to determine bile duct direction

WGC: Wire-guided cannulation; PEP: Post-endoscopic retrograde cholangiopancreatography pancreatitis.

Table 2 Selected studies with identified risk factors for difficult canulation[23,24,26,29-31]

Ref.	Number of patients	Identified risk factors
Noda et al[30]	102	Type III (enlarged/protruding) papillary morphology
		Absence of the ampullary bile duct
Saito et al[31]	1406	Non-expert endoscopist
		Low-volume center
		Absence of cholangitis
		Normal serum bilirubin
		Intradiverticular papilla
		Type of major papilla
Cáceres-Escobar et al[24]	498	Gender female
		Acute care hospital setting
		Redundant papilla
		Peridiverticular papilla
		Pancreatic cancer
Chen et al[23]	286	Small papilla
		Protruding papilla
		Malignant bowel obstruction
		Age
Tabak et al[29]	614	Periampullary diverticum
		Ampullary carcinoma
		Papillary anatomy
Williams et al[26]	3209	Billroth surgery
		Multiple/large stones
		Old age
		Physical status
		Presence of trainee
		Suspected biliary stricture
		Ampullary tumor

Table 3 Selected studies reporting post-endoscopic retrograde cholangiopancreatography pancreatitis incidence, mean ± SD/n (%)[50-69]

Ref.	Country	Design	Total patients/females	Age, years	PEP incidence
Zhu[50]	China	Retrospective cohort	988/493 (49.9)	52.74 ± 9.81	52 (5.2)
Sharma et al[51]	India	RCT	144/109 (75.7)	51.7 ± 15.6	13 (9)
Palomera-Tejeda et al[52]	United States	Retrospective cohort	681/361 (53.0)	54.6 ± 16.1	12 (1.7)
Lou et al[53]	China	Retrospective cohort	6944/3450 (49.7)	60.7 ± 17.1	362 (5.2)
Hattori et al[54]	Japan	Retrospective cohort	98/231 (42.4)	68.8 ± 13.7	13 (5.6)
Jiang et al[55]	China	Retrospective cohort	193/ 89 (46.1)	54.13 ± 6.87	55 (28.5)
Chung et al[56]	Korea	Retrospective cohort	527/231 (43.8)	65.2 ± 16.2	45 (8.5)
Agarwal et al[57]	India	Retrospective cohort	769/426 (55.4)	48 ± 16	428 (55.7)
Parvin et al[58]	Bangladesh	Retrospective cohort	1042/446 (42.8)	54.08 ± 14	204 (19.6)
Makhzangy et al[59]	Egypt	RCT	120/66 (55.0)	43.8 ± 14.9	5 (4.2)
Aleem et al[60]	Pakistan	RCT	203/118 (58.1)	49.3 ± 15.4	32 (15.8)
Suzuki et al[61]	Japan	Retrospective cohort	1932/774 (40.1)	72.9	142 (7.4)
Romano-Munive et al[62]	Mexico	RCT	548/380 (69.3)	51.05 ± 20.9	24 (4.4)
Parvin et al[63]	Bangladesh	Retrospective cohort	125/51 (40.8)	55.76 ± 13.57	26 (20.8)
Deng et al[64]	China	Retrospective cohort	66/35 (53.0)	7.1 ± 4.3	19 (28.8)
Maruyama et al[65]	Japan	Retrospective cohort	168/102 (60.7)	70.1 ± 9.1	26 (15.5)
Ogura et al[66]	Japan	RCT	146/55 (37.7)	70.8 ± 9.8	27 (18.5)
Miyatani et al[67]	Japan	Retrospective cohort	60/41 (68.3)	61 ± 15	14 (23.3)
Kim et al[68]	Korea	Case control	258/136 (52.7)	61.83 ± 16.68	86 (33.3)
Debenedet et al[69]	United States	Case control	371/274 (73.9)	52.3 ± 15.9	123 (33.2)

PEP: Post-endoscopic retrograde cholangiopancreatography pancreatitis; RCT: Randomized controlled trial.

Table 4 Stapfer classification

Perforation type	Localization
1	Lateral or medial duodenal wall, endoscope related
2	Periampullary perforations, sphincterotomy related
3	Ductal or duodenal perforations related to the passage of instruments
4	Guidewire-related perforations with retroperitoneal gas on imaging