Commentary

Cannulation of the pancreatic duct (PD) in patients with a long common channel (pancreaticobiliary maljunction) may be challenging as the PD orifice is small and the angle of the PD is sharp. Common strategies include opacification of the ductal anatomy with minimal amounts of contrast, bending and rotation of the sphincterotome in the direction of the PD orifice, and the use of a thinner (0.025-inch) guidewire with an angulated tip. When these conventional approaches fail cholangioscopy is a valuable tool that allows identification of the orifice and guides PD cannulation [1]. Cholangioscopy has previously proven successful in similar situations where cannulation of the cystic duct or biliary strictures failed using a conventional technique [2] [3].

This video underlines that in rare cases where conventional intraductal cannulation techniques are failing one should escape the tunnel vision and upscale to a cholangioscope to shine a light in the dark.

Publication History

Article published online:
27 September 2023

• References

• 1 Zhang WL, Zhong N, Ji R. A light in the dark: Peroral cholangioscopy provides a new strategy for difficult cannulation in pancreaticobiliary maljunction. Endoscopy 2023; 55: E792-E793 DOI: 10.1055/a-2096-1950.
• 2 Kastelijn JB, Didden P, Bogte A. et al. Digital single-operator cholangioscopy to guide selective cannulation of complex biliary strictures. Surg Endosc 2022; 36: 9476-9480 DOI: 10.1007/s00464-022-09665-1.
• 3 Yoshida M, Naitoh I, Hayashi K. et al. Four-step classification of endoscopic transpapillary gallbladder drainage and the practical efficacy of cholangioscopic assistance. Gut Liver 2021; 15: 476-485 DOI: 10.5009/gnl20238.