Difficult Selective Biliary Cannulation (SBC)

Factors associated with difficult SBC:

 - SMALL PAPILLA: can be difficult to identify, when + excessive mucosal folds, when + architectural distortions, the tip of the ST may be too large, associated with initial contact of the ST with the septum instead of smooth insertion into the BD

 - EXTRA LARGE PAPILLA: can be more relaxed and unstable, the larger the papilla the more difficult further cannulation is, even with successful initial ST-papilla contact.

 - LOCATION OF THE PAPILLA: when in the 3rd duodenal portion, more proximally or distally

 - PARARELL tract of the MPD & CBD: difficult to pick up the correct tract, It's sometimes beneficial to inject

contrast to better visualize the anatomy

 - PAD: can obscure the papilla or distort its orientation, no need to angulate the ST upward (the

BD direction runs horizontally), If unsuccessful -> standard catheter

 - ALTERED ANATOMIES: Billroth II gastrectomy / Roux-en-Y surgery, typically papilla in a portion of the duodenum retrograde from the gastrojejunotomy site

 - OTHERS: biliary malignancies, tumour infiltration of the papilla or duodenum, malignancy makes the cystic tracts and vasculature=more friable



Dr. Katarzyna Monika Pawlak @KM_Pawlak



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