ERCP Biliary Access

As the first critical step during endoscopic retrograde cholangiopancreatography (ERCP) procedures, biliary access cannulation can be a stressful moment for advanced gastroenterologists. Gaining access can be technically complex, and difficult cannulation* is common – putting patients at risk for post-ERCP pancreatitis (PEP), bleeding and perforation.¹ PEP can:

Impact 2–10% of all ERCP patients
Affect 30–50% of high-risk ERCP patients
Lead to life-threatening complications when severe²

Boston Scientific is dedicated to helping you navigate cannulation challenges and plan appropriately to avoid complications.

Well-informed techniques and strategies can help you:

Anticipate barriers

Select an approach

Mitigate risk

Anticipate barriers to biliary access

It’s vital to know what to do in that decisive moment when you encounter difficulty accessing the bile duct. Ahead of the procedure, GIs typically consider the clinical indication, review relevant imaging, prepare for any altered anatomy, and evaluate potential challenges that may arise during cannulation.

See a case example of how Sumit Singla, Vice-Chief Operations and Director of Endoscopy at Henry Ford Health System, plans his biliary access strategy for accurate guidewire placement.

Select a cannulation approach

There are several techniques for managing difficult biliary access cannulation, such as contrast-guided and short or long wire-guided approaches. Both American Society of Gastrointestinal Endoscopy (ASGE) and European Society of Gastrointestinal Endoscopy (ESGE) guidelines suggest the wire-guided approach to avoid pancreatic duct contrast injection and prevent PEP in difficult cannulation cases.^3,4

Dr. Srinadh Komanduri, Interventional Gastroenterologist with Northwestern Medical Group shares a case study of how he approached a challenging cannulation for a patient withi hilar biliary obstruction.

Risk mitigation during cannulation

When encountering that decisive moment of difficult cannulation, it's all about mitigating risk. Planning appropriately and knowing all your options is critical. While utilizing physician-controlled cannulation, consider the following factors:

How scope and patient positioning impacts access
When to move from single to a double wire technique
How an angled tipped wire can aid in cannulation
How sphincterotome rotation and bowing can improve orientation

As you advance the guidewire, consider common options based on the patient and anatomy, including the use of a dynamic drill, knuckle wire, angled tip and shorter or longer wires.

Hear from Dr. Sammy Ho, Gastroenterology Specialist at Montefiore Einstin Department of Medicine, as he discusses his strategies for challenging cannulation and biliary access cases.

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References

1 Dumonceau J.-M., Kapral C., Aabakken L., Papanikolaou I.S., Tringali A., Vanbiervliet G., Beyna T., Dinis-Ribeiro M., Hritz I., Mariani A., et al. ERCP-related adverse events: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy. 2020;52:127–149. doi: 10.1055/a-1075-4080.

2 Cahyadi O, Tehami N, de-Madaria E, Siau K. Post-ERCP Pancreatitis: Prevention, Diagnosis and Management. Medicina (Kaunas). 2022 Sep 12;58(9):1261. doi: 10.3390/medicina58091261. PMID: 36143938; PMCID: PMC9502657.

3 Buxbaum, J. L., Freeman, M., Amateau, S. K., Chalhoub, J. M., Coelho-Prabhu, N., Desai, M., Elhanafi, S. E., Forbes, N., Fujii-Lau, L. L., Kohli, D. R., Kwon, R. S., Machicado, J. D., Marya, N. B., Pawa, S., Ruan, W. H., Sheth, S. G., Thiruvengadam, N. R., Thosani, N. C., & Qumseya, B. J. (2022). American Society for Gastrointestinal Endoscopy guideline on post-ERCP pancreatitis prevention strategies: Summary and recommendations. Gastrointestinal Endoscopy, 97(2), 153-612. https://doi.org/10.1016/j.gie.2022.10.005.

4 Cahyadi O, Tehami N, de-Madaria E, Siau K. Post-ERCP Pancreatitis: Prevention, Diagnosis and Management. Medicina (Kaunas). 2022 Sep 12;58(9):1261. doi: 10.3390/medicina58091261. PMID: 36143938; PMCID: PMC9502657.

* ESGE defines difficult cannulation as cannulation time >5 min, >5 contacts with the papilla or ≥1 accidental PD cannulation (the so-called “5-5-1” rule). ASGE defines it as the inability to achieve selective biliary cannulation by standard ERCP techniques within 10 minutes or up to 5 cannulation attempts or failure of access to the major papilla.