Clin Endosc.  2023 Jul;56(4):490-498. 10.5946/ce.2022.130.

Safety and feasibility of opening window fistulotomy as a new precutting technique for primary biliary access in endoscopic retrograde cholangiopancreatography

• Kuraishi Y
• Hara K
• Haba S
• Kuwahara T
• Okuno N
• Yanaidani T
• Ishikawa S
• Yasuda T
• Yamada M
• Mizuno N

• KMID: 2544572
• DOI: http://doi.org/10.5946/ce.2022.130

Abstract

Background/Aims
Post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) is the most common and serious complication of endoscopic retrograde cholangiopancreatography. To prevent this event, a unique precutting method, termed opening window fistulotomy, was performed in patients with a large infundibulum as the primary procedure for biliary cannulation, whereby a suprapapillary laid-down H-shaped incision was made without touching the orifice. This study aimed to assess the safety and feasibility of this novel technique.
Methods
One hundred and ten patients were prospectively enrolled in this study. Patients with a papillary roof size ≥10 mm underwent opening window fistulotomy for primary biliary access. In addition, the incidence of complications and success rate of biliary cannulation were evaluated.
Results
The median size of the papillary roof was 6 mm (range, 3–20 mm). Opening window fistulotomy was performed in 30 patients (27.3%), none of whom displayed PEP. Duodenal perforation was recorded in one patient (3.3%), which was resolved by conservative treatment. The cannulation rate was high (96.7%, 29/30 patients). The median duration of biliary access was 8 minutes (range, 3–15 minutes).
Conclusions
Opening window fistulotomy demonstrated its feasibility for primary biliary access by achieving great safety with no PEP complications and a high success rate for biliary cannulation.

Keyword

Biliary cannulation; Endoscopic retrograde cholangiopancreatography; Fistulotomy; Pancreatitis; Precut

Figure

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  Fig. 1. Needle-knife fistulotomy with the opening window method. (A, B) Schema of this technique. (A) Incision direction. A laid-down H-shaped incision line is made. (B) Opening of a bile duct-like window by elevating the right and left mucosal flaps and puncturing the Oddi sphincter muscle. (C) Observation of the major papilla. (D) The length of the papillary roof, from the mucosal fold to the top edge of the infundibulum, is measured using a catheter. (E) Two parallel incisions on the infundibulum are made perpendicularly to the axis of the major papilla. The arrow shows incision direction. (F) An incision along the axis of the papilla is created to connect the two parallel incisions. The arrow shows incision direction. (G) An incision to the sphincter of Oddi along the axis of the papilla is made and whitish bile duct mucosa is evident. Arrowhead shows the fistula of the bile duct. (H) Selective biliary cannulation through the fistula was performed using a wire-guided technique.

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  Fig. 2. Flowchart of the selection of the biliary cannulation technique. The papillary roof size was measured as the length from the mucosal fold to the top of the infundibulum. If the size of the papillary roof was ≥10 mm, opening window fistulotomy was performed as the initial procedure for biliary access. If not, conventional biliary cannulation was conducted. Thirty and 80 patients had a papillary roof size of ≥10 mm and <10 mm, respectively.

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  Fig. 3. Endoscopic image of opening window fistulotomy. (A, B) Representative cases of opening window fistulotomy. This technique facilitates the observation of the submucosa and sphincter of the papilla in a wider field of view, providing more definite and safe access to the common bile duct. Arrowheads show the fistula of the bile duct.

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