《Table 1 Maneuvers to facilitate selective biliary cannulation in difficult cases》

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《"Difficult biliary cannulation: Historical perspective, practical updates, and guide for the endoscopist"》

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MPD:Main pancreatic duct；WGC:Wire guided cannulation；CBD:Common bile duct；EUS:Endoscopic ultrasound；PEP:Post-endoscopic retrograde cholangiopancreatography-pancreatitis；ST:Sphincterotome；BD:Biliary duct.

Successful ERCP hinges on proper scope placement and adequate visualization of the papilla.Most commonly，a side-viewing duodenoscope with a channel of 3.7-4.2 mm is used（except in rare situations such as duodenal stenosis，in which a small scope is necessary）[5].Good visualization of the major duodenal papilla for biliary cannulation is achieved by placing the duodenoscope below the papilla（Figure 1）.Shifting the patient into a left lateral decubitus or supine position can help improve the orientation of the scope and prevent it from falling back into the stomach.If a long scope position is required，the scope tip should be placed below the level of the papilla while applying gentle（counterclockwise）torque，thus allowing for appropriate infrapapillary orientation while maintaining visualization[6].This view can facilitate better visualization of the major duodenal papilla and a more stable scope position in patients with a very proximal papilla，among other potential indications（Table 1）.Note，this differs greatly from attempting main pancreatic duct（MPD）cannulation，in which the duodenoscope tip is usually positioned perpendicular to the duodenal wall[7].Importantly，when pursuing ERCP limit insufflation as overdistention of the gastric tract can make duodenal visualization more difficult.Occasionally，passing the duodenoscope into the stomach and aspirating gas，can prevent this.Once in position，with a steady hold on the duodenoscopy，the endoscopist is ready to choose a preferential technique for initial attempt of biliary cannulation.