Management of difficult bile duct cannulation in ERCP

Table 1 Tools and methods for cannulation

Standard techniques

Catheters:

Standard

Steerable

With or without guide wire

Sphincterotomes:

Single or multi-lumen

Rotatable

With or without guide wire

Guidewires:

Nitinol

Hydrophilic

Advanced techniques without precut

Double wire technique

Over pancreatic stent

Precut access with

Needle knife:

Starting at orifice

Fistulotomy above orifice

Over pancreatic stent

Sphincterotome:

Erlangen sphincterotome

Transpancreatic with guide wire

Papillectomy for duct access

EndoUS-guided biliary access

Table 2 Success and pancreatitis rates with cannulation techniques

	%	Ref.
Primary success in cannulation
Standard catheter	54 to 67	[3,30]
Standard catheter with guide wire	81	[3]
Sphincterotome	78 to 84	[4,29]
Sphincterotome with guide wire	97 to 99	[26,30]
Success in difficult cannulation after primary failure with standard method
Persistence	73 to 75	[2,49]
Needle knife	67 to 91	[2,6,9,34,37]
Erlangen knife	78 to 100	[32,50]
Pancreatic sphincterotomy	91 to 100	[10,12,13,22,40,41]
Pancreatic stent	97 to 100	[28,47]
Pancreatic guide wire	73 to 93	[5,8]
Pancreatitis rate after difficult cannulation
Persistence	2-4	[2,49]
Needle knife	1-11	[2,6,9,34,37]
Erlangen knife	3-7	[32,50]
Pancreatic sphincterotomy	0-12	[10,12,13,22,40,41]
Pancreatic stent	5-7	[28,47]
Pancreatic guide wire	0-2	[5,8]

Randomized controlled trials were used in literature 2, 3, 5, 10, 26, 28, 29, 30 and 49.