ERCP WITH OPENING WINDOW FISTULOTOMY AND NEEDLE PUNCTURE FISTULOTOMY (WITH VIDEOS)

Abstract

This article describes two entirely novel precut techniques for biliary cannulation: opening window fistulotomy (OWF) and needle puncture fistulotomy (NPF). Both methods involve incision of the oral protrusion without touching the papillary orifice, potentially minimizing the risk of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis to the greatest extent possible.

OWF involves making a wide “window-opening” mucosal incision on the oral protrusion to expose the submucosal tissue, followed by a deeper incision to directly visualize and access the bile duct. Because the submucosal layer can be dissected under a wide field of view, this technique allows for better control of the incision depth, potentially enhancing safety and improving the success rate of biliary cannulation.

On the other hand, NPF is a versatile technique using a needle-type knife originally designed for endoscopic submucosal dissection (ESD) to create a fistula on the oral protrusion through which biliary cannulation is performed. This technique is also applicable to the small papillae. The primary goal of NPF is not to increase the cannulation success rate but rather to prevent post-ERCP pancreatitis. Although small papillae do not necessarily make cannulation difficult, they may carry a higher risk of post-ERCP pancreatitis. In such cases, primary NPF may be particularly beneficial.

The two techniques introduced in this article are considered clinically valuable for reducing the incidence of post-ERCP pancreatitis. However, unless performed precisely and safely, the expected outcomes cannot be achieved. Therefore, acquisition and mastery of fundamental techniques and adequate training are essential.