Bret T. Petersen, MD, FASGE

Associate Editor



Bret T. Petersen, MD, FASGE is Professor of Medicine in the Division of Gastroenterology and Hepatology at the Mayo Clinic in Rochester, Minnesota. His practice is focused in the Mayo Pancreas Clinic and the Advanced Endoscopy Group. His professional interests include pancreatic and biliary diseases, performance and outcomes of ERCP, and delivery of endoscopic services. At Mayo, Dr. Petersen is a past Director of Endoscopy and has served on multiple clinic and foundation committees. He has directed numerous American Society for Gastrointestinal Endoscopy (ASGE) and Mayo courses, particularly related to the performance of ERCP. He has received the Mayo Award for Excellence, GI Fellows Award for Outstanding Teacher, and Department of Medicine Laureate Award (GI), as well as the Master Endoscopist Award of the ASGE. Dr. Petersen is the incoming Secretary for (ASGE) and a past Chair of the Technology and Quality Assurance in Endoscopy committees.



Boston Scientific 

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Ethicon/J & J



Difficult Biliary Cannulation: Second Guidewire or Pancreatic Stent?

Bret T. Petersen, MD, FASGE reviewing Eminler AT, et al. Gastrointest Endosc 2018 Aug 24.

Deep biliary access is required prior to all endoscopic therapy within the bile ducts. Several techniques are available to facilitate deep access when standard cannulation fails. When initial cannulation efforts yield passage of a guidewire into the pancreatic duct (PD), subsequent biliary access can be facilitated by cannulating with a second guidewire (SGW) while maintaining the first within the PD, or following placement of a small 3 to 5 French pancreatic stent (PDS) into the pancreas. When either approach fails, precut needle-knife sphincterotomy is often employed. The authors performed a randomized study comparing the success of deep access via the SGW vs PDS techniques when unintended pancreatic passage of a guidewire occurred. One hundred patients were randomized to SGW vs PDS techniques. Deep access within 5 minutes of employing the randomized technique was accomplished, without use of precut sphincterotomy, in 45/50 SGW patients and in 27/50 PDS patients (P< .001). Needle-knife precut was employed in 10% of SGW and 46% of PDS patients (P< 0.001). Overall, deep access was achieved in 98% of each group.


The ancillary techniques for difficult biliary cannulation each have their own benefit, efficiency, challenge, and incremental costs. If formal sphincterotomy is intended for therapy and the anatomy is advantageous, direct use of non-guided needle-knife incision may be least injurious and most efficient. When a PD stent is planned for prophylaxis against pancreatitis, then placement to facilitate cannulation makes sense, as it is often most easily accomplished at the time of first wire access. When repeated wire access without contrast or trauma occurs, and prophylactic stenting is not desired, the SGW technique is least likely to resort to needle-knife incision, at the cost of a second guidewire but without need to remove a stent at the same or a subsequent procedure.

Note to readers:
At the time we reviewed this paper, its publisher noted that it was not in final form and that subsequent changes might be made.

Bret T. Petersen, MD, FASGE
Bio and Disclosures

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Eminler AT, Parlak E, Koksal AS, Toka B, Uslan MI. Wire-guided cannulation over a pancreatic stent method increases the need for needle-knife precutting ın patients with difficult biliary cannulations. Gastrointest Endosc 2018 Aug 24. (Epub ahead of print) (