We read with great interest the article about novel fistulotomy by Kuraishi et al.¹ In this article, the authors describe the novel fistulotomy technique named opening window fistulotomy, an initial procedure for securing biliary access in therapeutic endoscopic retrograde cholangiopancreatography (ERCP). This was a great initiative to establish a new technique for reducing the incidence of the most common post-ERCP adverse event.^2-4

In a prospective study, Jin et al.⁵ already deemed classic needle knife fistulotomy (NKF) as the primary biliary access for therapeutic ERCP in a high-risk post-ERCP pancreatitis (PEP) group safe and feasible. The European Society of Gastrointestinal Endoscopy also recommends NKF as the preferred precut technique in patients with a bile duct dilated down to the papilla.⁶

This novel technique fistulotomy (open window fistulotomy) has a comparative successful cannulation rate to that of classic NKF. However, the application of open window fistulotomy is low (27%) due to a smaller number of patients with long intraductal common bile duct (papilla roof size, >10 mm) as evident in this study.

Second, open window fistulotomy is better able to prevent PEP than the conventional method, while NKF has equal ability to open window fistulotomy to prevent PEP and a lower risk of perforation (1.8% vs. 3.3%), possibly due to the larger fistulotomy size and area.^1,2

Therefore, in our opinion, classic fistulotomy to establish primary biliary access not only reduces PEP but also has less serious adverse events and can be performed in most patients without a papilla roof size restriction.