LAUSR

Next year will mark the 50th anniversary of the first report of ERCP. Despite 5 decades of improved duodenoscopes and accessories, deep cannulation of the desired duct in a native papilla remains the most challenging step to successful completion of the procedure. Although many reports attempt to distill cannulation down to a science, it remains primarily an art. No single technique is uniformly successful. We hope that providing our thoughts on basic principles of cannulation will improve your cannulation success rate. The most important components to successful cannulation include (1) Take time to study the conformation of the papilla, (2) spend the necessary time to achieve proper positioning of the duodenoscope before touching the papilla, (3) initiate cannulation, with the leading edge of the accessory perpendicular to the ampullary orifice, (4) first obtain a free “insinuation,” (5) use either the guidewire or a limited injection of contrast material (or both) as the first approach for deep cannulation, and (6) never fight with the papilla. A wide variety of accessories is available for cannulation, but, in most circumstances, start with a soft-tipped guidewire and a papillotome. There is no universal best or perfect accessory. Be inquisitive, and expose yourself to a broad spectrum of available accessories in order to select the ones that are optimal for you. Begin all ERCPs with a careful inspection of the papilla. What is the intraduodenal length and conformation of the papilla? Can deep cannulation be achieved with a single trajectory (“straight shot,” no intra-papillary angles, single axis) or will you need to manipulate the endoscope to allow redirection of the catheter tip within the ampullary segment to maneuver around angles? The next step in cannulation is to position the scope tip in optimal orientation to the papilla. This is an