Endoscopic sphincterotomy in patients with difficult cannulation: use of an antegrade guide.

Difficulty in introducing a sphincterotome into the common bile duct remains a problem in the technique of endoscopic sphincterotomy. An antegrade guide passed through a percutaneous transhepatic catheter or a choledochal tube was successfully used to help retrograde insertion of the sphincterotome in 6 patients with difficult cannulation. This method is a safer and simpler alternative to precutting, decreasing the risk of acute pancreatitis. Also, when the papilla is located inside a diverticulum and difficult to reach by endoscopy, the antegrade guide is helpful for bringing it out of the diverticulum, allowing one to enter the common bile duct with the cutting probe.