Biliary cannulation during endoscopic retrograde cholangiopancreatography (ERCP) remains
challenging in 1 %–10 % of cases [1]. A variety of sphincterotomes and cannulation techniques have been developed. Complications
including pancreatitis remain a significant concern, particularly if repeated instrumentation
or pancreatic duct injection or precut techniques are used.
Pancreatic duct stenting reduces the incidence of post-ERCP pancreatitis by up to
20 % [2]. Stent placement is technically feasible in about 95 % of cases, although there
is an increased risk of pancreatitis when placement fails. Placement of a pancreatic
duct stent to facilitate biliary access has been described as a useful adjunct to
biliary cannulation in difficult cases [3] ([Fig. 1]).
Fig. 1 Pancreatic stent used to aid biliary cannulation.
We placed a 5 cm 5 Fr Wilson Cook (Winston-Salem, North Carolina, USA) pancreatic
stent with an external phalange to facilitate common bile duct (CBD) cannulation in
five consecutive patients in whom standard techniques for CBD cannulation (excluding
precut sphincterotomy) had failed. The reason for cannulation failure appeared to
be due to a combination of factors including angulation of the distal CBD and an abnormal
appearing papilla. Pancreatic stent placement was successful in four patients, and
subsequent biliary cannulation using the pancreatic stent as a guide was successful
in 4 / 5 with a standard sphincterotome. The fifth patient required a precut sphincterotomy
over the pancreatic stent to facilitate biliary cannulation. None of the five patients
suffered any ERCP-related complications.
Pancreatic duct stent placement for prophylaxis of post-ERCP pancreatitis has become
standard practice for higher-risk patients in many centers, including our own. Stent
placement to facilitate biliary cannulation has been suggested to be safe and effective
[3]. The pancreatic stent most likely facilitates biliary cannulation by straightening
distal CBD angulation but possibly also by overcoming difficulties posed by a short
common channel [4]. We suggest that pancreatic stent placement to facilitate biliary cannulation in
difficult cases may be preferable to initial precut techniques, although further prospective
study is required.
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