Access fistulotomy: technical tips for success

BACKGROUND AND AIMS: Biliary cannulation, although critical to procedural success in ERCP, can be difficult and, if unsuccessful, can lead to longer hospital stays, repeat procedures, and increased costs. Expertise in adjunct techniques, including access fistulotomy, can increase success rates and potentially avoid these issues. The aim of this case series is to describe the technique of access fistulotomy and illustrate key points that are important for successful biliary access. METHODS: Three cases are reviewed in which access fistulotomy was used to achieve biliary access. The steps for the procedure are reviewed, and key technical tips and anatomic landmarks are illustrated in the video. RESULTS: Successful biliary access is obtained using fistulotomy in 3 cases. In each case, the anatomic landmarks of the papilla and intraduodenal biliary segment are reviewed. The first case illustrates a large papilla in which initial incision followed by careful exposure reveals a clear “onion ring” structure corresponding to the bile duct. The second case requires stepwise incision, each guided by anatomic landmarks before the biliary adventitia is identified, leading to biliary cannulation. In the third case, the utility of fistulotomy in a duodenal diverticulum is illustrated. Recognition of the distorted anatomy allowed precise, careful incision leading to biliary access. CONCLUSIONS: Access fistulotomy is an invaluable technique to aid in biliary access. Knowledge of key landmarks and careful evaluation of the incision are critical to successful biliary access when performing fistulotomy.