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Review
. 2025 May 18;61(5):913.
doi: 10.3390/medicina61050913.

The Role and Appropriate Selection of Guidewires in Biliopancreatic Endoscopy

Daniele Alfieri  1   2 , Claudia Delogu  1   2 , Stefano Mazza  1 , Aurelio Mauro  1 , Erica Bartolotta  1   2 , Alessandro Cappellini  1   2 , Davide Scalvini  1   2 , Francesca Torello Viera  1 , Marco Bardone  1 , Andrea Anderloni  1   2
Affiliations
Review

The Role and Appropriate Selection of Guidewires in Biliopancreatic Endoscopy

Daniele Alfieri et al. Medicina (Kaunas). .

Abstract

Guidewires are indispensable tools in biliopancreatic endoscopy, playing a critical role in facilitating access and enabling the advancement of various devices during interventions such as Endoscopic Retrograde Cholangiopancreatography (ERCP) and Endoscopic Ultrasound (EUS)-guided procedures. These devices are primarily used to achieve and maintain access to lumens, ensuring the success of complex therapeutic maneuvers. Guidewires vary widely in terms of material, structure, length, diameter, and tip shape, offering distinct advantages depending on the clinical context. Therefore, selecting the appropriate guidewire is crucial and must be tailored to the specific requirements of each procedure. This article provides a comprehensive review of the current landscape of guidewire use in biliopancreatic endoscopy, emphasizing their importance, characteristics, and best practices for selection to optimize patient outcomes. By reviewing existing guidelines and the literature, this paper aims to enhance the endoscopist's understanding of guidewire technology and its application in biliopancreatic endoscopy.

Keywords: ERCP; EUS; biliary drainage; biliary stricture; biliopancreatic endoscopy; difficult biliary cannulation; hepaticogastrostomy; pancreatic cannulation.

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Conflict of interest statement

A.A. is a consultant for Boston Scientific and Olympus; these roles are general and not related to the current work. No commercial entity had any input in the conception, design, or writing of this manuscript. Guidewire brand names are mentioned only when directly referenced in the peer-reviewed literature and not as a form of promotion. The authors declare no other conflicts of interest.

Figures

Figure 1
Figure 1
(a,b) Two views from different angles of the RX locking system (Boston Scientific) mounted on the duodenoscope; (c) the RX locking device disassembled, showing its components: a rubber clamp that is fixed externally to the working channel port and a plastic locking mechanism that secures the guidewire in place.
Figure 2
Figure 2
Comparison between straight-tip and angled-tip guidewires. The angled tip facilitates selective cannulation and navigation through strictures or tortuous anatomy, while the straight tip may offer enhanced pushability in straight trajectories. These configurations are chosen based on procedural needs and anatomical challenges.
Figure 3
Figure 3
Algorithm for guidewire selection to optimize ERCP success. The procedure typically begins with a 0.035” hydrophilic-tipped, standard shaft guidewire. In case of technical failure, guidewire choice is adapted based on the clinical indication such as choledocholithiasis, distal or hilar strictures, or pancreatic duct cannulation, with tailored strategies for each scenario to enhance cannulation success and procedural efficiency.
Figure 4
Figure 4
(a) Wire-guided cannulation in ERCP; (b) double-guidewire technique: the first guidewire is positioned in the main pancreatic duct, followed by placement of the second guidewire into the biliary duct.
Figure 5
Figure 5
Guidewire-assisted pancreatic cannulation followed by contrast injection showing a dilated and tortuous main pancreatic duct in the context of chronic pancreatitis.
Figure 6
Figure 6
Algorithm for guidewire selection in EUS-guided procedures. Initiation with a 0.025”/0.035” hydrophilic-tipped guidewire is generally recommended, with adjustments based on failure or specific procedural contexts such as EUS-HGS, EUS-RV, EUS-AG, and EUS-PD, highlighting tailored guidewire characteristics suited to each approach.
Figure 7
Figure 7
(a) EUS-guided puncture of intrahepatic bile duct with subsequent guidewire advancement; (b) placement of a self-expandable metal stent across the hepaticogastrostomy secured over the guidewire.
Figure 8
Figure 8
Radiological image of the EUS-PD rendezvous technique. (a) After placing a stent across pancreaticogastrostomy, the guidewire is advanced in an antegrade manner into the pancreatic duct under EUS guidance, followed by standard ERCP and transpapillary stent placement over the wire for pancreatic duct drainage. (b) The end of the procedure with the two stents (highlighted by the red arrows) in the main pancreatic duct.
Figure 9
Figure 9
(a) Guidewire-assisted advancement of a double-pigtail stent through an 8 × 8 mm lumen-apposing metal stent (LAMS) used for choledochoduodenostomy (EUS-CDS) to secure biliary drainage and prevent LAMS obstruction; (b) EUS-guided gallbladder drainage (EUS-GBD) performed using an electrocautery-enhanced lumen-apposing metal stent (LAMS). A 0.035-inch guidewire was used to improve stability and maintain access during deployment.
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