ERCP Cannulation in the Difficult Duct: Which technique should you pull out of your bag?

Golf and endoscopic retrograde cholangiopancreaticography (ERCP) share a commonality where the highs of the successes are balanced by the lows of the frustrations. ERCP cannulation is one of the most difficult maneuvers in gastrointestinal endoscopy and is a requirement for the procedure's therapeutic benefit. As such, many different techniques have been developed to facilitate cannulation. The mission of the procedure is to provide access to the biliary or pancreatic duct typically with a guidewire, which can then be utilized as a platform for therapeutic and diagnostic procedures. An inherent challenge in ERCP is that the operator must make use of a two-dimensional imaging surrogate through fluoroscopy and navigate the three-dimensional biliary or pancreatic duct pathway.

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