Box 1.

Tips for successful pancreatic cannulation post ampullectomy

If possible, cannulate PD (and CBD) prior to ampullectomy and obtain a pancreatogram to determine the location of the pancreatic orifice

Remember the anatomical relationship between biliary and pancreatic orifices. If imagined on a clock face, the CBD is at 11 o'clock and PD at 5 o'clock (Fig. 5)

Attempt PD cannulation as the first manoeuvre after ampullectomy whilst visualisation is optimal

If the PD cannot be identified then cannulate the distal aspect of the CBD with a sphincterotome and lift it up to ‘stretch’ the pancreatic orifice and improve visibility (Fig. 6)

Be wary of underlying pancreas divisum. The benefit of stenting the ventral duct is limited and attempts to do so can be frustrating