Endoscopic Dissection of The Papilla as Access to The Biliary Tract During ERCP

Access to the bile duct in endoscopic retrograde cholangiopancreatography (ERCP) can be done by cannulating the ostium of the papilla through the cannulotome with the aid of a guide wire. However, in about 18% of cases this access is not possible and the endoscopist uses alternative techniques such as precut, fistulotomy, the use of double guide wire or the placement of a pancreatic prosthesis [1]. We will describe the approach to access the bile duct through Endoscopic Dissection of the Papilla (EDP), a different method from conventional fistulotomy. ERCP is an important therapeutic method for clearing the extrahepatic bile duct. Access to the common bile duct is critical for the endoscopic treatment of biliary obstruction. The insistence on attempting cannulation through the ostium, with numerous attempts at progression of the guide wire and the injection of contrast in the pancreatic duct are responsible for most cases of pancreatitis [2, 3[. Thus, avoiding excessive trauma to the papillary ostium and biliopancreatic junction in cannulation attempts is of fundamental importance to avoid acute pancreatitis. We have been using early fistulotomy with endoscopic papilla dissection for a long time, with the technique detailed ahead. With this approach we observed that the success rate of deep bile duct cannulation improved and the cases of postERCP pancreatitis decreased. Work by Han SY (2021) showed that the rate of post-ERCP pancreatitis was significantly affected by the level of endoscopist experience in patients who underwent cannulation and conventional papillotomy, but there was no difference when the technique used was fistulotomy [4,5].