In patients in whom biliary access is still not achieved often another type of sphincterotome or cannulatome will be used. If this does not work a wire or pancreatic stent will often be placed in the pancreatic duct ideally to change the orientation of the papilla in a favorable way.12 The latter strategy will also decrease the risk of post ERCP pancreatitis in difficult cases including those who have undergone multiple cannulation attempts.13 If these approaches fail an access or precut papillotomy may be performed using a needle knife. Precut sphincterotomy in the direction of the bile duct can either be performed from the orifice (gough) or above the orifice (fistulotomy).12, 14