Biliary cannulation techniques: Optimizing success and minimizing risk

Table 1 Comparison of American Society of Gastrointestinal Endoscopy and European Society of Gastrointestinal Endoscopy criteria for difficult cannulation

Parameter	ASGE	ESGE
Competence benchmark	≥ 90% selective cannulation success rate	> 80% selective cannulation success rate for precutting
Definition of difficult cannulation	Not explicitly defined in ASGE guidelines; ACG 2026 quality indicators discuss difficult cannulation but without specific criteria	> 5 contacts with papilla OR > 5 minutes cannulation time OR > 1 unintended; pancreatic duct cannulation (5-5-2 criteria)
First-line technique	Guidewire-assisted technique recommended	Guidewire-assisted technique (strong recommendation, moderate quality evidence)
Escalation strategy	Advanced techniques include double-guidewire, needle-knife sphincterotomy, transpancreatic sphincterotomy; endoscopists should be familiar with ≥ 1 advanced technique	Pancreatic guidewire-assisted cannulation with prophylactic pancreatic stenting; needle-knife fistulotomy preferred for precutting; transpancreatic sphincterotomy for small papilla with inadvertent pancreatic access
Rescue after failed ERCP	EUS-guided biliary drainage as alternative; percutaneous transhepatic biliary drainage; interval ERCP	Anterograde guidewire insertion via percutaneous or EUS-guided approach; EUS-rendezvous technique

ERCP: Endoscopic retrograde cholangiopancreatography; ACG: American College of Gastroenterology; EUS: Endoscopic ultrasound; OR: Odds ratio; ASGE: American Society of Gastrointestinal Endoscopy; ESGE: European Society of Gastrointestinal Endoscopy.

Table 2 Comparison of precut and pancreatic duct-assisted salvage techniques for difficult biliary cannulation

Feature	Needle-knife papillotomy	Needle-knife fistulotomy	Transpancreatic sphincterotomy
Approach	Freehand incision at papillary orifice	Freehand incision above papillary orifice	Incision of septum following pancreatic duct wire access
Best clinical scenario	Failed standard cannulation without stable PD access	Long or bulging papilla; when avoiding pancreatic duct trauma is desirable	Repeated unintended PD cannulation or stable PD wire access
Key prerequisites	Experienced endoscopist; ability to maintain orientation of papillary anatomy	Clear papillary anatomy; endoscopist expertise with needle-knife techniques	Pancreatic duct cannulation; ability to place PD stent
Adjuncts	Rectal NSAIDs; prophylactic PD stent if PD manipulated	Rectal NSAIDs; PD stent rarely required	PD stent placement strongly recommended; rectal NSAIDs
Advantages	Widely used; effective in experienced hands	Avoids PD trauma; high success in long papilla; effective in experienced hands	Stable access; high success when PD access is obtained
Risks/limitations	Loss of landmarks; higher risk of PEP; bleeding; perforation	Requires skill; risk of bleeding or perforation	Higher pancreatitis risk; perforation; difficult with complex morphologies; risk of pancreatic duct injury or stricturing

PD: Pancreatic ductal; NSAIDs: Nonsteroidal anti-inflammatory drug; PEP: Post-endoscopic retrograde cholangiopancreatography pancreatitis.