Technical factors associated with biliary cannulation success after transpancreatic precut sphincterotomy

Abstract Transpancreatic precut sphincterotomy (TPS) is a rescue technique for difficult biliary cannulation, but the factors associated with its success remain incompletely defined. In this study, patient-related and technical variables associated with biliary access after TPS were evaluated. We retrospectively reviewed 92 endoscopic retrograde pancreatography (ERCP) procedures requiring TPS between 2016 and 2023. Because additional incisions could be created after unsuccessful attempts, a total of 115 TPS sessions were analyzed. Patient characteristics and technical parameters, including papilla morphology, incision extent, and exposure, were assessed. Incision extent was categorized using the midpoint of the papillary oral protrusion as a visual landmark and the post-TPS orientation of bile and pancreatic orifices was documented. The overall biliary cannulation success rate was 93.5%. In the session-level analyses, Haraldsson type 2 papillae were associated with lower success, whereas long incisions, defined as those extending beyond the midpoint, were independently associated with higher success (odds ratio 3.71, P = 0.010). At the ERCP level, initiating TPS with a long/full incision was associated with a higher first incision cannulation rate and shorter cannulation time without an increase in adverse events. After the TPS, the bile duct orifice was most often located in the upper-left region of the pancreatic orifice with a distance less than two sphincterotome widths (65.9%). TPS outcomes are associated mainly with technical factors, with type 2 papillae showing reduced success. Longer incisions were associated with higher biliary access rates and the bile duct orifice typically was upper-left of the pancreatic orifice after TPS.