What is done if the guide wire for the common bile duct (CBD) enters the pancreatic duct?

Management of Inadvertent Pancreatic Duct Cannulation During CBD Access

When the guidewire intended for the common bile duct enters the pancreatic duct during ERCP, leave the wire in place and insert a 5-Fr straight plastic pancreatic stent, then attempt CBD cannulation above the stent using the double-guidewire technique. 1

Immediate Management Algorithm

Step 1: Pancreatic Stent Placement

• Insert a 5-Fr, 4-cm long straight plastic stent into the pancreatic duct immediately after unintentional guidewire entry 1
• Use stents without internal flaps to facilitate spontaneous expulsion 1
• In patients older than 60 years, perform pancreatic sphincterotomy before stent insertion 1
• This approach achieves successful CBD cannulation in 95.6% of cases 1

Step 2: CBD Cannulation Techniques

After pancreatic stent placement, two validated approaches exist:

Double-Guidewire Technique (Primary Option):

• Leave the guidewire in the pancreatic duct (or use the placed stent as a guide) 2, 3
• Attempt CBD cannulation above the pancreatic wire/stent 1, 3
• This technique achieves CBD cannulation in 69.7% of difficult cases 2

Transpancreatic Biliary Sphincterotomy (Alternative):

• Perform sphincterotomy over the pancreatic guidewire directed toward the bile duct 2
• This achieves significantly higher success rates (84.6%) compared to double-guidewire technique 2
• No difference in post-ERCP pancreatitis rates between techniques (13.5% vs 16.2%) 2

Post-Procedure Pancreatitis Prevention

Administer rectal NSAIDs (100 mg diclofenac or indomethacin) to all patients without contraindications 4, 5

• This is the most important prophylactic measure regardless of technique used 4
• The pancreatic stent provides additional protection beyond NSAIDs 5
• Combined approach reduces pancreatitis risk to 2.17% 1

Critical Technical Considerations

Guidewire Selection

• Use 0.035 inch or 0.025 inch guidewires with hydrophilic floppy tips for pancreatic duct manipulation 4
• These reduce kinking and buckling when negotiating strictures 4
• Avoid 0.018 inch or 0.021 inch wires as they kink easily and lack stability 4

Risk Factors to Monitor

Any manipulation of the pancreatic duct significantly increases pancreatitis risk (11.9% vs 3.5% without MPD entry) 6

• Multiple cannulation attempts (>10) independently increase PEP risk 6
• Unintended pancreatic duct cannulation or contrast injection elevates risk regardless of technique 7, 6

Common Pitfalls and How to Avoid Them

Failed Pancreatic Stent Placement:

• Failed stent insertion dramatically increases pancreatitis risk 4
• Ensure adequate training in pancreatic stent placement before attempting this rescue technique 4
• If stent placement fails, consider aborting the procedure and using alternative biliary access (percutaneous drainage) 4

Stent Management:

• Most pancreatic stents spontaneously expel within hours to days 1
• Perform plain abdominal X-ray to confirm spontaneous migration 4
• If stent remains in place, endoscopic removal is required 4

Contrast Injection After Pancreatic Wire Entry:

• Avoid contrast injection into the pancreatic duct once the wire has entered 7, 6
• Guidewire entry alone has lower pancreatitis risk (1.1%) compared to contrast injection (9.5%) 7

When Initial Techniques Fail

If both double-guidewire and transpancreatic sphincterotomy fail:

• Consider precut sphincterotomy, though this further increases PEP risk 6
• Alternative biliary access via percutaneous transhepatic drainage may be necessary 4
• Ensure multidisciplinary support including interventional radiology is available 4