The urgency of dealing with impacted ampullary stones is underlined in the first case reported by Opie6 at the autopsy of a young woman. Impacted ampullary stones that prevent papillary cannulation and standard sphincterotomy make up less than 5% of common bile duct stones seen at ERCP.3 Several series suggest the safe use of needle-knife sphincterotomy to create a choledochoduodenal fistula or to allow subsequent standard sphincterotomy in this situation. These series have also reported failure to extract the stone so that surgical removal was required.3,4Successful sphincterotomy may facilitate the early diagnosis of tumors that cause the ampulla to bulge. However, the endoscopist who creates a choledochoduodenal fistula must be aware that the patient may require subsequent open surgery. This technique to harpoon the exposed but impacted stone with the needle tip of the sphincterotome may prevent that eventuality.