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Although inserting the side-viewing duodenoscope represents a challenge to the novice, cannulation of the native papilla remains the main obstacle in many ERCP procedures. Several components come together to ensure a successful ductal access. Appropriate positioning and angulation relative to the duct in question must precede any cannulation attempt. Using a sphincterotome for cannulation with a preloaded guidewire is the tool of choice. Aim for bile duct toward 11 o’clock alongside the duodenal wall, and pancreatic duct at 2–3 o’clock more perpendicular. Pass the guidewire before injecting contrast. If the guidewire does not pass easily, do not use force; instead retract wire and catheter tip and retry with a slightly different position and/or angle.
If the guidewire passes repeatedly into the pancreatic duct despite a biliary indication, leave the wire, retract the sphincterotome, and reinsert with a new guidewire alongside the original. Then cannulate alongside the pancreatic wire, ideally more up-/leftward. When successful, consider placing a pancreatic stent as pancreatitis prophylaxis before removing the pancreatic wire and proceeding with the procedure.
Various additional factors can complicate papillary cannulation; some important ones will be covered separately in this chapter.