Axis fistulami approach for selective biliary cannulation. Palpation the intraduonal biliary segment prior to needle knife instrumentation, a case series. Axis fistulami involves using a needle knife to cut into the intraduonal segment of the bile duct, thereby avoiding the papilla. Prior studies suggest the same rates as traditional cannulation with early fistulami potentially leading to decreased risk of pancreatitis. Here we describe using a Toman needle knife to palpate for the bile duct. This helps us visualize the guardrails in the optimal position for needle knife access. Careful dissection is then performed along this axis prior to achieving biliary cannulation with the guide wire. Here is case one. We show a 58 year old male who presented with a 2.6 centimeter pancreatic head mass and biliary obstruction. Here we are using the sphincter tome to prod the intraduodenal segment of the biliary bowel duct to delineate where the bowel duct is in terms of the intraduodenal portion. The tome is seen going to the left and to the right of the intraduodenal segment. Here you can see a frozen picture of where the actual intraduodenal segment is with the arrow assigned. Circle is where the papilla is. To perform the axis sphincterotomy we will then cut along this biliary access direction and peel back the layers of the duodenum to find the bowel duct. We will next exchange to a needle knife to start axis fistulami. Prior to the actual fistulami we will use the knife to once again prod to make sure that we are cutting along the biliary access. The pipe itself can be palpated with the needle knife. By palpating we can help to avoid cutting into the submucosal space and thereby decreasing our chance of perforation. Here the needle knife is cutting through the intraduodenal segment of the bowel duct while avoiding the papilla. We then retract the needle knife. We then use the blunt end of our cannula to push away the sides after our fistulotomy to help us visualize the area. We then see the white strands of the biliary muscle and then we perform a further dissection to help enter the bowel duct. Here the green arrow shows the appropriate area to insert the wire for cannulation. We then switch to a tome and then help advance the wire into the bowel duct. We can then perform an extend sphincterotomy after gaining biliary access. Subsequently a fully covered metal stent is placed. Case 2. An 86 year old male presenting with obstructive jaundice. Imaging was suggestive of biliary dilation in distal common bowel duct structure. Here the needle knife is seen prodding for the duodenal bowel duct as well. Here in this still shot we can see that the circle is the papilla. Red lines are the borders of the bowel duct. Borders were deduced by using the needle knife. The green arrow shows the direction of the axis fistulotomy and the exact location. Now that we know where we want to perform the axis fistulotomy, the knife is advanced and the axis fistulotomy is started. One should carefully peel back the layers like peeling the layers of an onion, carefully and slowly and examining under visualization the entire time. We now switch over to a sphincter tome and proceed to cannulae. A 67-year-old female presents with abdominal pain and imaging confirming choledocal lithiasis. The box here shows the biliary segment. The red box shows the intraduino-bioduct borders. 67-year-old male presents with painless jaundice with imaging showing a 1cm pancreatic head mass. EUS ERCP is subsequently performed. Here we show the FMB of an intraductal ampullary adenocarcinoma. The neonife here is prodding around trying to delineate the borders of the bowel duct. After careful dissection, we then switch to the sphincter tome for cannulation. After the sphincterotomy, we can actually see the tumor inside of the bile duct. This is shown by the green arrow. Clinical Implications. Prior palpation for the bile duct may aid endoscopists with axis fistulotomy. This may lead to wider adoption of axis fistulotomy. Further perspective research is needed. All four patients shown were discharged the next day with no evidence of delayed bleeding or pancreatitis with downtrending liver enzymes. Preparation of the bile duct may help guide endoscopists with axis fistulotomy. Here we present a case series showing how this technique can be utilized in this pre-cut technique.

Axis Fistulami approach

needle knife

bile duct

pancreatitis risk

biliary cannulation