Difficult Cannulation and Sphincterotomy

Abstract Endoscopic retrograde cholangiopancreatography (ERCP) requires several years of dedicated training and continuous refinement of knowledge and skill. With the dissemination of endoscopic ultrasound (EUS) and magnetic resonance cholangiopancreatography (MRCP), ERCP has evolved from a diagnostic to an almost purely therapeutic procedure. General issues on cannulation have already been highlighted in Chapter 40 . This chapter concentrates on variations of standard techniques to overcome challenges to standard cannulation and sphincetrotomy, including in patients with anatomic variations, gastric outlet obstruction, and surgically altered anatomy.