What is the step‑by‑step technique for performing an endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy?

ERCP with Sphincterotomy: Step-by-Step Technique

ERCP with sphincterotomy involves advancing a side-viewing duodenoscope to the major papilla, achieving selective biliary cannulation using guidewire-assisted technique, performing electrocautery incision of the sphincter of Oddi, and extracting stones or placing stents as needed. 1

Pre-Procedure Prophylaxis

Before starting, administer 100 mg rectal diclofenac or indomethacin immediately before or after ERCP in all patients without contraindications to NSAIDs—this significantly reduces post-ERCP pancreatitis risk 2. For high-risk patients (female, guidewire in pancreatic duct, precut sphincterotomy, prolonged cannulation >10 minutes), consider prophylactic 5-Fr pancreatic stent placement 2.

In primary sclerosing cholangitis patients specifically, give prophylactic antibiotics before ERCP to prevent cholangitis and bacteremia 2.

Step 1: Endoscope Positioning and Papilla Identification

• Position the side-viewing duodenoscope in the second portion of the duodenum
• Carefully inspect the papillary anatomy and optimize accessibility through scope positioning 3
• Note any anatomical challenges: retracted papilla from left liver lobe hypertrophy, periampullary diverticulum, or altered surgical anatomy 2

Step 2: Biliary Cannulation

Use guidewire-assisted cannulation as the first-line technique—this increases primary cannulation success and reduces post-ERCP pancreatitis compared to contrast-assisted methods 2.

• Insert a sphincterotome with soft-tip hydrophilic guidewire (not a standard catheter) 3
• Direct the sphincterotome toward the bile duct orifice at the 11 o'clock position
• Advance the guidewire gently into the bile duct under fluoroscopic guidance
• Avoid repeated pancreatic duct cannulation (increases pancreatitis risk 8-fold) 2

Primary cannulation success rates: 85-90% with standard techniques 1, 2

Step 3: Managing Difficult Cannulation

If standard cannulation fails after reasonable attempts (avoid >10 attempts to minimize pancreatitis risk 4):

Rescue techniques in order of preference:

1. Double-guidewire technique: If inadvertent pancreatic duct cannulation occurs, leave a guidewire in the pancreatic duct and attempt biliary cannulation alongside it 3

2. Transpancreatic sphincterotomy: Perform pancreatic sphincterotomy as access technique (used in 11.8% of difficult cases) 2

3. Precut (needle-knife) sphincterotomy: Freehand needle-knife incision from the papillary orifice upward toward the bile duct 2, 5, 4, 3

   • Critical caveat: Precut is markedly associated with post-ERCP pancreatitis, likely reflecting difficult cannulation and prolonged procedure time 2
   • Success rate increases biliary access to 80-98% 5, 4

4. Rendezvous technique: For failed endoscopic access, percutaneous transhepatic guidewire placement through the papilla, which the endoscopist snares to facilitate cannulation 1

Step 4: Performing Sphincterotomy

Once selective biliary cannulation is achieved:

• Position the sphincterotome with the cutting wire oriented toward the bile duct (11 o'clock position)
• Apply blended electrocautery current while gently bowing the sphincterotome
• Incise the sphincter in a controlled manner, typically 10-15 mm
• Observe for adequate bile drainage and absence of bleeding

Complication rates: 6-10% major complications in general population; up to 19% in elderly with 7.9% mortality 1

Step 5: Stone Extraction (if applicable)

For choledocholithiasis (the primary indication for sphincterotomy):

• Use balloon-tipped catheters or baskets to extract stones
• For large stones (>10-15 mm), perform mechanical lithotripsy or fragmentation 1
• Success rate: 90% for standard stone extraction 1
• Lithotripsy success: 79%, though 30% require multiple sessions 1

Step 6: Stent Placement (if needed)

• For incomplete stone extraction or severe cholangitis: place internal plastic stent to ensure biliary drainage 1
• For malignant obstruction: consider self-expanding metal stents (SEMS) 1
• Leave internal/external catheter to ensure adequate decompression 1

Step 7: Post-Procedure Management

• Confirm free flow of contrast into duodenum on fluoroscopy
• Monitor for immediate complications: bleeding, perforation, pancreatitis
• In PSC patients with previous sphincterotomy, pancreatitis risk decreases, suggesting pre-emptive papillotomy may benefit patients requiring repeat procedures 2

Critical Pitfalls to Avoid

• Prolonged papilla contact time increases pancreatitis risk—limit cannulation attempts 2
• Repeated pancreatic duct cannulation dramatically increases pancreatitis risk (OR 8.2) 2
• Contrast injection into pancreatic duct increases PEP risk—use guidewire technique instead 2
• Delaying precut sphincterotomy beyond 10 attempts may increase complications more than early precut 4
• Omitting rectal NSAIDs—this simple intervention significantly reduces pancreatitis 2

ERCP should be performed by experienced pancreaticobiliary endoscopists, particularly in complex cases like PSC where complication rates range from 1.8-18.4% 2.