Impact of Duodenal Papilla Morphology on the Success of Transpancreatic Precut Sphincterotomy

<b>Background</b>: This study aimed to evaluate whether the morphology of the duodenal major papilla is linked to transpancreatic precut sphincterotomy (TPS) failure. <b>Methods</b>: We conducted a retrospective review of patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) at our institution. The inclusion criteria involved patients with a naïve major duodenal papilla who required TPS due to difficult biliary cannulation. Papilla morphology was classified using Haraldsson's system, as follows: regular (Type 1), small (Type 2), protruding or pendulous (Type 3), and creased or ridged (Type 4). The analysis focused on identifying risk factors for TPS failure and related complications. <b>Results</b>: A total of 103 cases were analyzed, with an overall TPS success rate of 85.44%. There were no significant differences in age, gender, ERCP indications, or the prevalence of juxtapupillary diverticula across the four papilla types. The TPS failure rates by papilla type were Type 1 (10.53%), Type 2 (0%), Type 3 (16.67%), and Type 4 (28%). Type 4 papilla had a significantly higher failure rate compared to Type 1 and Type 2 in the univariate analysis (<i>p</i> = 0.028), but this was not statistically significant in the multivariate analysis (<i>p</i> = 0.052). Age emerged as an independent risk factor for TPS failure. <b>Conclusions</b>: Duodenal papilla morphology may influence the success rate of TPS, with advanced age being a key risk factor for failure. Identifying high-risk factors such as Type 4 papilla and older age can help endoscopists adjust their techniques early, potentially improving outcomes and minimizing complications.