Skip Navigation
Skip to contents

Clin Endosc : Clinical Endoscopy

Search
Advanced Search
OPEN ACCESS
mobile search button mobile menu button

Articles

Page Path
HOME > Clin Endosc > Volume 59(1); 2026 > Article
Original Article A stepwise cannulation strategy for conservative endoscopists: the clinical impact of transpancreatic precut after pancreatic stenting in a retrospective study from Taiwan
Wei-Chih Su1,2orcid, Chia-Chi Wang1,2orcid, Tsung-Hsien Hsiao1orcid, Hung-Da Chen1,2orcid, Tzu-Hsiang Kung1orcid, Chih-Hsiang Chen1orcid, Jiann-Hwa Chen1,2orcid
Clinical Endoscopy 2026;59(1):132-141.
DOI: https://doi.org/10.5946/ce.2025.241
Published online: January 12, 2026

1Department of Gastroenterology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan

2School of Medicine, Tzu Chi University, Hualien, Taiwan

Correspondence: Jiann-Hwa Chen Department of Gastroenterology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Number 289, Jianguo Road, Xindian District, New Taipei City 23142, Taiwan E-mail: jhctylci@gmail.com
• Received: July 23, 2025   • Revised: August 24, 2025   • Accepted: August 26, 2025

© 2026 Korean Society of Gastrointestinal Endoscopy

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

  • 582 Views
  • 46 Download
prev next
Full Article

Download PDF Download PDF

  • Background/Aims
    Pancreatic stenting reduces post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) and aids in cannulation in difficult cases. However, conservative endoscopists may stop at this step, resulting in suboptimal outcomes. This study assessed the efficacy of transpancreatic precut sphincterotomy (TPS) as a rescue procedure following pancreatic stenting.
  • Methods
    Between March 2013 and November 2018, 82 patients underwent pancreatic stenting at our institution prior to successful biliary cannulation. TPS was introduced in April 2016, and patients were divided into Before TPS and After TPS groups. The outcomes included cannulation success, PEP incidence, and predictors of TPS conversion.
  • Results
    There were 43 and 39 patients in the Before TPS and After TPS groups, respectively. Twenty-two patients (56.4%) underwent conversion to TPS in the After TPS group. The After TPS group had a higher bile duct cannulation rate (89.7% vs. 72.1%) than the Before TPS group, but this difference was not statistically significant (p=0.054). Multivariate analysis showed that age >50 years (odds ratio [OR], 0.181; p=0.021) and being in the After TPS group (OR, 0.712; p=0.039) were independently associated with reduced PEP risk. Haraldsson Type 2 and Type 4 papillae carried a relatively high TPS conversion rate.
  • Conclusions
    A stepwise cannulation strategy that incorporates TPS after pancreatic stenting minimizes the need for advanced techniques and improves PEP outcomes.
  • Keywords: Cholangiopancreatography, endoscopic retrograde; Pancreatitis; Sphincterotomy, endoscopic; Stents; Transpancreatic precut sphincterotomy
Endoscopic retrograde cholangiopancreatography (ERCP) is a widely used procedure for diagnosing and treating biliary tract disorders, including stone removal, stenting, and tissue sampling. However, ERCP is associated with a high risk of complications, particularly post-ERCP pancreatitis (PEP), which is strongly associated with prolonged cannulation attempts1 and unintended pancreatic duct cannulation.2 Therefore, the development of effective cannulation strategies is essential for optimizing procedural success while minimizing complications.
Unintended pancreatic duct cannulation is common during ERCP, particularly in cases of difficult biliary cannulation.2 To reduce the risk of PEP in such settings, the European Society of Gastrointestinal Endoscopy (ESGE) recommends the placement of a prophylactic pancreatic stent.3 The ESGE also endorses the use of advanced cannulation techniques, such as the double-guidewire technique (DGT), needle-knife precut (NKP), and transpancreatic precut sphincterotomy (TPS), when standard methods fail. Although these techniques have demonstrated efficacy in improving biliary cannulation rates, their technical complexity and increased complication risk4,5 often limit their adoption, especially among less experienced6,7 or more conservative endoscopists. In real-world practice, some procedures may be prematurely terminated after pancreatic stent placement if cannulation remains unsuccessful, potentially missing an opportunity for definitive therapy.
Among the available rescue options, the pancreatic stent-assisted technique, which is performed via a standard cannulation maneuver alongside a pancreatic stent, is often favored because of its relative simplicity. First described in 1996,8 this technique offers several advantages. The pancreatic stent can straighten the pancreatic duct and common channel, stabilize any papillae, and widen the papillary orifice, thereby facilitating biliary access and potentially reducing the need for precut techniques.9 However, previous studies have reported suboptimal outcomes in terms of success rates and complication profiles.10 When the pancreatic stent-assisted technique fails, TPS is the next logical step. TPS mimics standard wire-guided sphincterotomy but is performed over a pancreatic duct guidewire and has been shown to be technically feasible with a favorable safety profile, even in the hands of less-experienced operators.11 Therefore, TPS may serve as an effective and accessible rescue strategy, allowing endoscopists to maintain a stepwise approach without resorting to more technically demanding or high-risk methods.
At our institution, minimizing ERCP-related complications has been a top priority. In cases of difficult cannulation, prophylactic pancreatic stenting is commonly used, and the pancreatic stent-assisted technique is routinely employed as the first-line advanced approach. In April 2016, TPS was introduced and has since become the preferred rescue strategy when stent-assisted cannulation fails because of its technical feasibility and favorable safety profile. This study aimed to evaluate the clinical impact of incorporating TPS as a rescue technique following unsuccessful pancreatic stent-assisted biliary cannulation in patients with unintended pancreatic duct access. By comparing outcomes before and after TPS became part of our standard approach, we sought to determine whether TPS improved success rates while maintaining patient safety, particularly for endoscopists who favor stepwise and conservative strategies.
Patient data collection
To assess the impact of TPS as a rescue strategy following the use of the pancreatic stent-assisted technique, we conducted a retrospective analysis of patients who had not previously undergone ERCP and who underwent ERCPs for biliary indications between March 2013 and November 2018 at our institution. During this period, prophylactic pancreatic stenting was the primary strategy for PEP prevention, whereas pharmacological prophylaxis was not routinely used until November 2018.
Patients were included if they had a pancreatic stent placed before any further attempt at biliary cannulation. ERCP procedures involving advanced cannulation techniques other than TPS or those in which pharmacological prophylaxis for PEP was used were excluded from the analysis. The collected clinical data included age, sex, relevant medical history, ERCP findings, and procedural outcomes. The ERCP indications were categorized into four groups: biliary stones, distal common bile duct obstruction, proximal bile duct obstruction, and other indications. The macroscopic morphology of the ampulla of Vater was classified into four types according to the criteria proposed by Haraldsson et al.12: regular papillae (type 1), small papillae (type 2), enlarged or protruding papillae (type 3), and creased or ridged papillae (type 4) (Fig. 1). The presence of periampullary diverticulum was also documented and categorized based on the classification system described by Shi et al. in 2023.13 Both papillary and diverticular classifications were determined retrospectively by reviewing the archived duodenoscopic images. To ensure classification accuracy, two experienced endoscopists (W.C.S. and T.H.H.) independently reviewed and categorized the images. When these endoscopists disagreed, a third endoscopist (J.H.C.) adjudicated the final classification through consensus.
ERCP procedures
All ERCP procedures were initiated using standard cannulation techniques under monitored anesthesia. The procedures were performed by one of the four experienced ERCP endoscopists at our institution, each with 18, 9, 6, and 5 years of experience at the time of data collection (endoscopists A, B, C, and D, respectively).
Prophylactic pancreatic stenting was considered for PEP prevention in cases involving more than one unintended pancreatic duct cannulation. The timing of stent placement was left to the discretion of the endoscopist. Following pancreatic stent placement, attempts at biliary cannulation were continued until success was achieved or until further attempts were deemed unfeasible. Before April 2016, advanced cannulation techniques were rarely used at our center, with only 10 NKP and 3 DGT procedures performed among 359 ERCPs. In April 2016, TPS was introduced as a rescue technique, and its use was determined by the performing endoscopist. TPS was performed as follows: In patients in whom selective bile duct cannulation could not be achieved after pancreatic stent placement, a guidewire was advanced deep into the pancreatic duct. Wire-guided sphincterotomy was performed using a standard sphincterotome oriented in the 11 o’clock direction relative to the pancreaticobiliary septum. Following the incision, further attempts to perform bile duct cannulation were made on the left side of the sphincterotomy site.
Definitions and data measurement
The included ERCP procedures were categorized into two groups based on whether TPS was available as a rescue technique: Before TPS (procedures performed before April 2016) and After TPS (procedures performed from April 2016 onward) groups. Data collected included the timing of pancreatic stenting initiation, bile duct cannulation time, total ERCP duration, and post-ERCP adverse events. According to the consensus of Cotton et al.,14 PEP was defined as clinical pancreatitis with a serum lipase level at least three times the upper limit of normal more than 24 hours after the procedure that required a prolongation of planned hospital admission. Cholangitis was defined as a body temperature exceeding 38 °C attributed to a biliary cause without evidence of acute cholecystitis. Bleeding was defined as “immediate” if it was during the procedure or immediately afterward, and as “delayed” if it occurred hours to several weeks after the procedure. ERCP-related perforations are limited to sphincterotomy-related ones, which are identified by the presence of extraluminal air on radiological imaging. At our institution, endoscopic and fluoroscopic images are routinely captured during key procedural milestones, including initial papillary visualization, stent placement, successful cannulation, and procedure completion. The timing of pancreatic stent placement, biliary cannulation, and total ERCP duration was retrospectively determined based on timestamped image records, with the moment of initial papilla visualization used as the starting point.
Statistical analyses
Categorical variables are presented as absolute numbers with corresponding percentages, whereas continuous data are reported as means with standard deviations. For between-group comparisons, the chi-squared test or Fisher exact test was performed as appropriate for categorical variables, whereas the Student t-test was performed for continuous variables. Logistic regression analysis was performed to identify the factors associated with PEP. All statistical analyses were performed using the IBM SPSS ver. 27.0 for Windows (IBM Corp.). The reported p-values were two-tailed, and statistical significance was set at p<0.05.
Ethical considerations
The study was approved by the Institutional Review Board of Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation (14-IRB049).
Between March 2013 and November 2018, 920 ERCP procedures for biliary diseases were performed at our center, of which 668 were performed in patients with naive papillae. Among these, 108 underwent prophylactic pancreatic stenting to prevent PEP. Eighteen patients were excluded because advanced cannulation techniques were used before pancreatic stenting (TPS, 10; NKP, 5; and DGT, 3). Additionally, five patients underwent NKPs after pancreatic stenting, two underwent prophylactic pancreatic stenting after successful bile duct cannulation, and two received pharmacological prophylaxis for PEP. Finally, 82 ERCP procedures met the inclusion criteria and were included in the final analysis. The data collection process is illustrated in Fig. 2. Endoscopist A performed 58 procedures; the remaining 24 procedures were almost evenly distributed among endoscopists B, C, and D. As summarized in Table 1, 43 patients (41.5%) were male, and 66 (80.5%) were over 50 years of age. The most common ERCP indication was biliary stones (87.8%), followed by distal (8.5%) and proximal (1.2%) biliary obstructions; two cases involved bile leakage. Type 1 papillae were the most common (43.9%), followed by Types 3 (22.0%), 4 (20.7%), and 2 (13.4%). Ten patients had a history of biliary pancreatitis, and two had end-stage renal disease. Difficult cannulation (cannulation time >10 minutes) occurred in 86.6% of the patients. Among the 82 procedures, 43 were performed in the After TPS group and 39 in the Before TPS group. There were no significant differences in baseline characteristics between the two groups.
As shown in Table 2, TPS was employed as a rescue technique in 22 patients whose procedures were included in the After TPS group. There were no significant differences in bile duct cannulation times or total ERCP durations between the two groups. However, pancreatic stenting was initiated significantly earlier in the After TPS group than in the Before TPS group (9.13±5.53 vs. 15.91±11.18 minutes, p=0.001). Although the After TPS group demonstrated a higher bile duct cannulation success rate (Before TPS, 72.1%; After TPS, 89.7%; p=0.054) and a lower PEP rate (Before TPS, 20.9%; After TPS, 5.1%; p=0.051), the difference was not significant according to Fisher exact test. No statistically significant differences were observed between the two groups in terms of bleeding complications or cholangitis. No perforations were observed during any procedure.
Table 3 presents the results of the univariate and multivariate logistic regression analyses for the risk factors associated with PEP. According to the univariate analysis, the older (age >50 years) group had a lower risk of developing PEP (odds ratio [OR], 0.220; p=0.028). The other patient-related and procedural variables were not significantly associated with PEP. Multivariate logistic regression analysis revealed that age >50 years (OR, 0.181; 95% confidence interval [CI], 0.012–0.774; p=0.021) and inclusion in the After TPS group (OR, 0.172; 95% CI, 0.032–0.918; p=0.039) were significantly associated with a reduced incidence of PEP.
As shown in Table 4, 22 of the 39 ERCP procedures (56.4%) required conversion from the pancreatic stent-assisted technique to TPS. A significant difference in the conversion rate was observed among patients with different macroscopic papilla appearances (p=0.034). Type 4 (85.7%) and type 2 (83.3%) papillae showed the highest conversion rates, followed by type 3 (58.3%) and type 1 (28.6%) papillae. No significant differences were found in diverticulum type or ERCP indications.
In this study, the addition of TPS as a rescue technique following a pancreatic stent-assisted approach significantly reduced the incidence of PEP. Moreover, macroscopic papillary morphology was significantly associated with conversion to TPS, with Types 2 and 4 papillae showing the highest conversion rates.
Among the techniques used for difficult biliary cannulation, the pancreatic stent-assisted approach is technically simple, requires no additional accessories, and can be performed using standard cannulation methods, making it particularly suitable for less-experienced endoscopists or trainees. Avoiding complex guidewire manipulation or cutting may theoretically reduce procedure-related trauma. Although the success rate of bile duct cannulation is relatively low, and the associated PEP incidence is relatively high,10 this approach offers a practical and accessible entry point for trained endoscopists. Despite the well-established influence of procedural volume and experience on ERCP outcomes, most studies evaluating advanced cannulation techniques have been conducted by expert operators, despite the well-established influence of procedural volume and experience on ERCP outcomes.7,15 For those less familiar with freehand NKP or DGT, the pancreatic stent-assisted method is a reasonable first-line strategy. Prior studies have also suggested that it may reduce the immediate need for more complex techniques.9
However, our data revealed that the pancreatic stent-assisted technique alone resulted in a cannulation success rate of only 72.1% and a PEP rate as high as 20.9%, both of which are below the ESGE-recommended quality indicators of ≥90% for cannulation success and ≤6% for PEP incidence.16 In this context, TPS serves as an effective and practical next-step rescue method. When standard wire-guided sphincterotomy is performed after guidewire insertion into the pancreatic duct, TPS is technically easier when a pancreatic stent has already been placed. In our study, the sequential use of pancreatic stenting followed by TPS improved the biliary cannulation success rate to 89.7% and reduced the incidence of PEP to 5.1%, thus meeting the guideline standards without introducing additional complexity.
Although TPS was first introduced in 1995,17 it remains relatively underutilized and is assigned a lower priority among ESGE-recommended techniques.3 In addition to being relatively understudied, TPS is a concern regarding the long-term outcomes of pancreatic sphincterotomy. However, a large-scale study involving 369 patients over an 11-year period18 and a long-term follow-up study of 134 patients over 4–10 years (median follow-up, 6 years)19 reported no late complications related to TPS. In our study, TPS was not used as a first-line method but rather as a rescue technique after pancreatic stent-assisted cannulation. This strategy not only maintained a high success rate but also limited the overall use of TPS, with a conversion rate of approximately 60% in the After TPS group. Macroscopic papillary morphology is a key predictor of conversion, with type 2 and 4 papillae showing the highest likelihood of requiring TPS. For these subtypes, early consideration of TPS, particularly after repeated unintended pancreatic cannulations, may increase procedural efficiency and safety. Nevertheless, our study did not include long-term follow-up; thus, we could not directly evaluate the long-term safety of TPS in our cohort. Although prior evidence suggests favorable long-term outcomes, future prospective studies with extended follow-up periods are needed to confirm its safety profile in diverse clinical settings.
Because radiological and surgical alternatives are available for biliary decompression, some endoscopists may adopt a more conservative strategy and refrain from pursuing technically advanced endoscopic interventions owing to the perceived procedural risks. However, premature termination after pancreatic stent placement alone may not ensure patient safety and may result in missed opportunities for definitive endoscopic treatment. A stepwise strategy that incorporates pancreatic stent-assisted cannulation, followed by TPS as a rescue method, is a practical and effective alternative. This approach increases the likelihood of successful biliary access while avoiding more complex and high-risk techniques, such as freehand NKP or DGT. This sequential approach improves the procedural success and reduces the risk of PEP by combining the protective benefits of pancreatic stenting with the technical accessibility of TPS. Importantly, the role of TPS should not be overlooked after failed pancreatic stent-assisted cannulation. Underutilization of this technique may result in avoidable therapeutic failure and compromised patient outcomes. Future prospective, randomized controlled studies directly comparing standard precut sphincterotomy and TPS are warranted to validate these findings and clarify their respective roles in the management of difficult biliary cannulation.
This study had several limitations. First, as this was a retrospective, single-center study, our analysis was inherently limited by potential selection bias. The decision to perform pancreatic duct stenting and proceed to TPS was made at the discretion of the individual endoscopist, which could have influenced the procedural outcomes. Notably, TPS was applied in less than 60% of patients in the After TPS group, indicating that the decision remained selective rather than systematic. This selective application may reflect real-world practice patterns, particularly among conservative endoscopists; however, it also underscores the need for future prospective studies with standardized decision-making criteria to reduce this bias. Second, pancreatic duct stent placement tended to be earlier in the After TPS group than in the Before TPS group, possibly reflecting a more proactive approach facilitated by the availability of TPS as a rescue technique. However, according to logistic regression analyses, this factor was not significantly associated with the PEP rate. Third, in line with the current guidelines recommending pancreatic stent placement after more than one unintended pancreatic duct cannulation, our study categorized patients based on whether they underwent more than one such cannulation without recording the exact number of pancreatic duct cannulations. In clinical practice, unsuccessful pancreatic stent-assisted cannulation is often attributed to unintended pancreatic duct cannulation during repeated attempts. This may partially explain the limited protective effect of pancreatic stenting against PEP observed in the Before TPS group because multiple attempts at pancreatic stent-assisted cannulation may have led to cumulative pancreatic duct trauma. The optimal timing for transitioning to TPS warrants further investigation in future studies.
In conclusion, the addition of TPS after pancreatic stent-assisted cannulation reduces the risk of PEP. Papillary morphology may help guide its timely application. This stepwise strategy minimizes the need for advanced techniques and is well-suited for conservative endoscopists to manage difficult biliary cannulation.
Fig. 1.
(A) Type 1. Regular papilla, with no distinctive features. (B) Type 2. Small papilla, often flat, with a diameter not greater than 3 mm (approximately 9 Fr). (C) Type 3. Protruding or pendulous papilla. The papilla is standing out, protruding or bulging into the duodenal lumen or sometimes hanging down, pendulous, with the orifice oriented caudally. (D) Type 4. Creased or ridged papilla, where the ductal mucosa seems to extend distally out of the orifice either on a ridge or in a crease.
ce-2025-241f1.jpg
Fig. 2.
Flow chart of data collection. ERCP, endoscopic retrograde cholangiopancreatography; TPS, transpancreatic precut sphincterotomy.
ce-2025-241f2.jpg
ce-2025-241f3.jpg
Table 1.
Characteristics of patients undergoing ERCP with continued biliary cannulation after pancreatic stent placement before and after TPS introduction
Characteristic All (n=82) Before TPS (n=43) After TPS (n=36) p-valueb)
Male 34 (41.5) 17 (39.5) 17 (43.6) 0.710
Age >50 yr 66 (80.5) 35 (81.4) 31 (79.5) 0.828
Indication 0.553
 Biliary stones 72 (87.8) 36 (83.7) 36 (92.3)
 Distal obstruction 7 (8.5) 5 (11.6) 2 (5.1)
 Proximal obstruction 1 (1.2) 1 (2.3) 0 (0)
 Others 2 (2.4) 1 (2.3) 1 (2.4)
Macroscopic appearance of the ampulla of Vater 0.239
 Type 1 36 (43.9) 22 (51.2) 14 (35.9)
 Type 2 11 (13.4) 5 (11.6) 6 (15.4)
 Type 3 18 (22.0) 6 (14.0) 12 (30.8)
 Type 4 17 (20.7) 10 (23.3) 7 (17.9)
Periampullary diverticuluma) 0.392
 No diverticulum 50 (61.0) 28 (65.1) 22 (56.4)
 Type I 1 (1.2) 0 (0) 1 (2.6)
 Type IIa 5 (6.1) 1 (2.3) 4 (10.3)
 Type IIb 13 (15.9) 8 (18.6) 5 (12.8)
 Type III 13 (15.9) 6 (14.0) 7 (17.9)
History of biliary pancreatitis 10 (12.2) 3 (7.0) 7 (17.9) 0.181c)
ESRD 2 (2.4) 1 (2.3) 1 (2.6) 0.995c)
Difficult cannulation (>10 min) 71 (86.6) 38 (88.4) 33 (84.6) 0.749

Values are presented as number (%).

ERCP, endoscopic retrograde cholangiopancreatography; TPS, transpancreatic precut sphincterotomy; type 1, regular papilla; type 2, small papilla, often flat, with a diameter ≤3 mm; type 3, protruding or pendulous papilla; type 4, creased or ridged papilla; ESRD, end-stage renal disease.

a)Papilla located completely inside the diverticulum (type I), papilla located in the inner (type IIa) and outer (type IIb) margins of the diverticulum; papilla located outside the diverticulum (type III).

b)Chi-squared test.

c)Fisher exact test.

Table 2.
Outcomes of patients undergoing ERCP with continued biliary cannulation after pancreatic stent placement before and after TPS introduction
All (n=82) Before TPS (n=43) After TPS (n=39) p-value
Conversion to TPS from pancreatic stent-assisted technique 22 (26.8) 0 (0) 22 (56.4) <0.001a)
Successful cannulation 66 (80.5) 31 (72.1) 35 (89.7) 0.054a)
Time of successful bile duct cannulationc) 23.20±14.01 24.37±13.14 21.90±15.00 0.428b)
Time of pancreatic stent initiationc) 12.68±9.53 15.91±11.18 9.13±5.53 0.001b)
Total procedural timec) 36.72±14.02 37.67±13.70 35.67±14.47 0.521b)
Post-ERCP pancreatitis 11 (13.4) 9 (20.9) 2 (5.1) 0.051a)
Immediate bleeding requiring hemostasis 2 (2.4) 0 (0) 2 (5.1) 0.223a)
Delayed bleeding 2 (2.4) 0 (0) 2 (5.1) 0.223a)
Cholangitis 3 (3.7) 2 (4.7) 1 (2.6) 1.000a)

Values are presented as number (%) or mean±standard deviation. Time variables are expressed in minutes.

ERCP, endoscopic retrograde cholangiopancreatography; TPS, transpancreatic precut sphincterotomy.

a)Fisher exact test. b)Student t-test. c)Time variables are expressed in minutes.

Table 3.
Univariate and multivariate analyses of the factors associated with post-ERCP pancreatitis
Variable Category Univariate analysis Multivariate analysis
OR (95% CI) p-value OR (95% CI) p-value
Age (yr) >50 0.220 (0.057–0.848) 0.028 0.181 (0.012–0.774) 0.021
<50 Reference Reference
Sex Female 3.692 (0.744–18.323) 0.110
Male Reference
After TPS group Yes 0.201 (0.041–1.013) 0.052 0.712 (0.032–0.918) 0.039
No Reference Reference
Endoscopist A 1.120 (0.270–4.640) 0.867
B, C, D Reference
Biliary stone Yes 1.452 (0.166–12.730) 0.737
No Reference
Distal bile duct stricture Yes 1.083 (0.118–9.967) 0.944
No Reference
Macroscopic appearance of papilla Type 1 Reference
Type 2 1.778 (0.279–11.323) 0.542
Type 3 2.286 (0.499–10.467) 0.287
Type 4 0.500 (0.052–4.849) 0.550
Periampullary diverticulum No 7.317 (0.888–60.285) 0.064
Yes Reference
Cannulation method Pancreatic stent assisted 1.765 (0.350–8.891) 0.491
TPS Reference
Difficult cannulation (min) >10 1.639 (0.189–14.238) 0.654
<10 Reference
Time of pancreatic stent initiation 1.043 (0.986–1.103) 0.139
Successful cannulation Yes 1.105 (0.214–5.697) 0.905
No Reference
Papilla interventiona) Yes 0.594 (0.156–2.269) 0.447
No Reference

ERCP, endoscopic retrograde cholangiopancreatography; OR, odds ratio; CI, confidence interval; TPS, transpancreatic precut sphincterotomy; type 1, regular papilla; type 2, small papilla, often flat, with a diameter ≤3 mm; type 3, protruding or pendulous papilla; type 4, creased or ridged papilla.

a)Papilla intervention including endoscopic sphincterotomy and endoscopic papillary balloon dilation.

Table 4.
Conversion rates and biliary cannulation success after TPS introduction
Total Pancreatic stent-assisted (n, success rate %)a) TPS (n, success rate %)a) Convert rate (%) p-value
All ERCPs 39 17 (82.4) 22 (95.5) 56.4
Papilla type 0.034
 Type 1 14 10 (80.0) 4 (100.0) 28.6
 Type 2 6 1 (100.0) 5 (80.0) 83.3
 Type 3 12 5 (80.0) 7 (100.0) 58.3
 Type 4 7 1 (100.0) 6 (100.0) 85.7
Periampullary diverticulumb) 0.311
 No diverticulum 22 11 (81.8) 11 (90.9) 50.0
 Type I 1 0 (0) 1 (100.0) 100.0
 Type IIa 4 0 (0) 4 (100.0) 100.0
 Type IIb 5 2 (100) 3 (100.0) 60.0
 Type III 7 4 (75.0) 3 (100.0) 42.9
Indication 0.501
 Bile stone 36 15 (88.2) 21 (95.2) 58.3
 Distal stricture 2 1 (100.0) 1 (100.0) 50.0
 Others 1 1 (0) 0 (0) 0 (0)

TPS, transpancreatic precut sphincterotomy; ERCP, endoscopic retrograde cholangiopancreatography; type 1, regular papilla; type 2, small papilla, often flat, with a diameter ≤3 mm; type 3, protruding or pendulous papilla; type 4, creased or ridged papilla.

a)No. of ERCPs performed (successful bile duct cannulation rate);

b)papilla located completely inside the diverticulum (type I), papilla located in the inner (type II a) and outer (type II b) margins of the diverticulum; papilla located outside the diverticulum (type III).

  • 1. Dumonceau JM, Kapral C, Aabakken L, et al. ERCP-related adverse events: European Society of Gastrointestinal Endoscopy (ESGE) guideline. Endoscopy 2020;52:127–149.ArticlePubMed
  • 2. Phillip V, Schwab M, Haf D, et al. Identification of risk factors for post-endoscopic retrograde cholangiopancreatography pancreatitis in a high volume center. PLoS One 2017;12:e0177874.ArticlePubMedPMC
  • 3. Testoni PA, Mariani A, Aabakken L, et al. Papillary cannulation and sphincterotomy techniques at ERCP: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy 2016;48:657–683.ArticlePubMed
  • 4. Tse F, Yuan Y, Moayyedi P, et al. Double-guidewire technique in difficult biliary cannulation for the prevention of post-ERCP pancreatitis: a systematic review and meta-analysis. Endoscopy 2017;49:15–26.ArticlePubMed
  • 5. Zhou W, Li Y, Zhang Q, et al. Risk factors for postendoscopic retrograde cholangiopancreatography pancreatitis: a retrospective analysis of 7,168 cases. Pancreatology 2011;11:399–405.ArticlePubMed
  • 6. Akaraviputh T, Lohsiriwat V, Swangsri J, et al. The learning curve for safety and success of precut sphincterotomy for therapeutic ERCP: a single endoscopist’s experience. Endoscopy 2008;40:513–516.ArticlePubMed
  • 7. Lee MH, Huang SW, Lin CH, et al. Predictive factors of needle-knife pre-cut papillotomy failure in patients with difficult biliary cannulation. Sci Rep 2022;12:4942.ArticlePubMedPMCPDF
  • 8. Slivka A. A new technique to assist in bile duct cannulation. Gastrointest Endosc 1996;44:636.Article
  • 9. Coté GA, Ansstas M, Pawa R, et al. Difficult biliary cannulation: use of physician-controlled wire-guided cannulation over a pancreatic duct stent to reduce the rate of precut sphincterotomy (with video). Gastrointest Endosc 2010;71:275–279.ArticlePubMed
  • 10. Facciorusso A, Ramai D, Gkolfakis P, et al. Comparative efficacy of different methods for difficult biliary cannulation in ERCP: systematic review and network meta-analysis. Gastrointest Endosc 2022;95:60–71.ArticlePubMed
  • 11. Su WC, Wang CC, Hsiao TH, et al. The impact of transpancreatic precut sphincterotomy on the quality of ERCP in a low-volume setting. Gastrointest Endosc 2024;99:747–755.ArticlePubMed
  • 12. Haraldsson E, Kylänpää L, Grönroos J, et al. Macroscopic appearance of the major duodenal papilla influences bile duct cannulation: a prospective multicenter study by the Scandinavian Association for Digestive Endoscopy Study Group for ERCP. Gastrointest Endosc 2019;90:957–963.ArticlePubMed
  • 13. Shi HX, Ye YQ, Zhao HW, et al. A new classification of periampullary diverticulum: cannulation of papilla on the inner margins of the diverticulum (Type IIa) is more challenging. BMC Gastroenterol 2023;23:252.ArticlePubMedPMCPDF
  • 14. Cotton PB, Lehman G, Vennes J, et al. Endoscopic sphincterotomy complications and their management: an attempt at consensus. Gastrointest Endosc 1991;37:383–393.ArticlePubMed
  • 15. Saito H, Kadono Y, Shono T, et al. Factors predicting difficult biliary cannulation during endoscopic retrograde cholangiopancreatography for common bile duct stones. Clin Endosc 2022;55:263–269.ArticlePubMedPDF
  • 16. Domagk D, Oppong KW, Aabakken L, et al. Performance measures for ERCP and endoscopic ultrasound: a European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative. Endoscopy 2018;50:1116–1127.ArticlePubMed
  • 17. Goff JS. Common bile duct pre-cut sphincterotomy: transpancreatic sphincter approach. Gastrointest Endosc 1995;41:502–505.ArticlePubMed
  • 18. Barakat MT, Girotra M, Huang RJ, et al. Goff septotomy is a safe and effective salvage biliary access technique following failed cannulation at ERCP. Dig Dis Sci 2021;66:866–872.ArticlePubMedPDF
  • 19. Koskensalo V, Udd M, Rainio M, et al. Transpancreatic biliary sphincterotomy for biliary access is safe also on a long-term scale. Surg Endosc 2021;35:104–112.ArticlePubMedPMCPDF

Figure & Data

REFERENCES

    Citations

    Citations to this article as recorded by  

      • PubReader PubReader
      • ePub LinkePub Link
      • Cite
        CITE
        export Copy Download
        Close
        Download Citation
        Download a citation file in RIS format that can be imported by all major citation management software, including EndNote, ProCite, RefWorks, and Reference Manager.
        Format:
        • RIS — For EndNote, ProCite, RefWorks, and most other reference management software
        • BibTeX — For JabRef, BibDesk, and other BibTeX-specific software
        Include:
        • Citation for the content below
        A stepwise cannulation strategy for conservative endoscopists: the clinical impact of transpancreatic precut after pancreatic stenting in a retrospective study from Taiwan
        Clin Endosc. 2026;59(1):132-141.   Published online January 12, 2026
        DOI: https://doi.org/10.5946/ce.2025.241
        Close
      • XML DownloadXML Download
      Figure
      • 0
      • 1
      • 2
      Related articles
      A stepwise cannulation strategy for conservative endoscopists: the clinical impact of transpancreatic precut after pancreatic stenting in a retrospective study from Taiwan
      Image Image Image
      Fig. 1. (A) Type 1. Regular papilla, with no distinctive features. (B) Type 2. Small papilla, often flat, with a diameter not greater than 3 mm (approximately 9 Fr). (C) Type 3. Protruding or pendulous papilla. The papilla is standing out, protruding or bulging into the duodenal lumen or sometimes hanging down, pendulous, with the orifice oriented caudally. (D) Type 4. Creased or ridged papilla, where the ductal mucosa seems to extend distally out of the orifice either on a ridge or in a crease.
      Fig. 2. Flow chart of data collection. ERCP, endoscopic retrograde cholangiopancreatography; TPS, transpancreatic precut sphincterotomy.
      Graphical abstract

      Fig. 1.

      Fig. 2.

      Graphical abstract

      A stepwise cannulation strategy for conservative endoscopists: the clinical impact of transpancreatic precut after pancreatic stenting in a retrospective study from Taiwan
      Characteristic All (n=82) Before TPS (n=43) After TPS (n=36) p-valueb)
      Male 34 (41.5) 17 (39.5) 17 (43.6) 0.710
      Age >50 yr 66 (80.5) 35 (81.4) 31 (79.5) 0.828
      Indication 0.553
       Biliary stones 72 (87.8) 36 (83.7) 36 (92.3)
       Distal obstruction 7 (8.5) 5 (11.6) 2 (5.1)
       Proximal obstruction 1 (1.2) 1 (2.3) 0 (0)
       Others 2 (2.4) 1 (2.3) 1 (2.4)
      Macroscopic appearance of the ampulla of Vater 0.239
       Type 1 36 (43.9) 22 (51.2) 14 (35.9)
       Type 2 11 (13.4) 5 (11.6) 6 (15.4)
       Type 3 18 (22.0) 6 (14.0) 12 (30.8)
       Type 4 17 (20.7) 10 (23.3) 7 (17.9)
      Periampullary diverticuluma) 0.392
       No diverticulum 50 (61.0) 28 (65.1) 22 (56.4)
       Type I 1 (1.2) 0 (0) 1 (2.6)
       Type IIa 5 (6.1) 1 (2.3) 4 (10.3)
       Type IIb 13 (15.9) 8 (18.6) 5 (12.8)
       Type III 13 (15.9) 6 (14.0) 7 (17.9)
      History of biliary pancreatitis 10 (12.2) 3 (7.0) 7 (17.9) 0.181c)
      ESRD 2 (2.4) 1 (2.3) 1 (2.6) 0.995c)
      Difficult cannulation (>10 min) 71 (86.6) 38 (88.4) 33 (84.6) 0.749
      All (n=82) Before TPS (n=43) After TPS (n=39) p-value
      Conversion to TPS from pancreatic stent-assisted technique 22 (26.8) 0 (0) 22 (56.4) <0.001a)
      Successful cannulation 66 (80.5) 31 (72.1) 35 (89.7) 0.054a)
      Time of successful bile duct cannulationc) 23.20±14.01 24.37±13.14 21.90±15.00 0.428b)
      Time of pancreatic stent initiationc) 12.68±9.53 15.91±11.18 9.13±5.53 0.001b)
      Total procedural timec) 36.72±14.02 37.67±13.70 35.67±14.47 0.521b)
      Post-ERCP pancreatitis 11 (13.4) 9 (20.9) 2 (5.1) 0.051a)
      Immediate bleeding requiring hemostasis 2 (2.4) 0 (0) 2 (5.1) 0.223a)
      Delayed bleeding 2 (2.4) 0 (0) 2 (5.1) 0.223a)
      Cholangitis 3 (3.7) 2 (4.7) 1 (2.6) 1.000a)
      Variable Category Univariate analysis Multivariate analysis
      OR (95% CI) p-value OR (95% CI) p-value
      Age (yr) >50 0.220 (0.057–0.848) 0.028 0.181 (0.012–0.774) 0.021
      <50 Reference Reference
      Sex Female 3.692 (0.744–18.323) 0.110
      Male Reference
      After TPS group Yes 0.201 (0.041–1.013) 0.052 0.712 (0.032–0.918) 0.039
      No Reference Reference
      Endoscopist A 1.120 (0.270–4.640) 0.867
      B, C, D Reference
      Biliary stone Yes 1.452 (0.166–12.730) 0.737
      No Reference
      Distal bile duct stricture Yes 1.083 (0.118–9.967) 0.944
      No Reference
      Macroscopic appearance of papilla Type 1 Reference
      Type 2 1.778 (0.279–11.323) 0.542
      Type 3 2.286 (0.499–10.467) 0.287
      Type 4 0.500 (0.052–4.849) 0.550
      Periampullary diverticulum No 7.317 (0.888–60.285) 0.064
      Yes Reference
      Cannulation method Pancreatic stent assisted 1.765 (0.350–8.891) 0.491
      TPS Reference
      Difficult cannulation (min) >10 1.639 (0.189–14.238) 0.654
      <10 Reference
      Time of pancreatic stent initiation 1.043 (0.986–1.103) 0.139
      Successful cannulation Yes 1.105 (0.214–5.697) 0.905
      No Reference
      Papilla interventiona) Yes 0.594 (0.156–2.269) 0.447
      No Reference
      Total Pancreatic stent-assisted (n, success rate %)a) TPS (n, success rate %)a) Convert rate (%) p-value
      All ERCPs 39 17 (82.4) 22 (95.5) 56.4
      Papilla type 0.034
       Type 1 14 10 (80.0) 4 (100.0) 28.6
       Type 2 6 1 (100.0) 5 (80.0) 83.3
       Type 3 12 5 (80.0) 7 (100.0) 58.3
       Type 4 7 1 (100.0) 6 (100.0) 85.7
      Periampullary diverticulumb) 0.311
       No diverticulum 22 11 (81.8) 11 (90.9) 50.0
       Type I 1 0 (0) 1 (100.0) 100.0
       Type IIa 4 0 (0) 4 (100.0) 100.0
       Type IIb 5 2 (100) 3 (100.0) 60.0
       Type III 7 4 (75.0) 3 (100.0) 42.9
      Indication 0.501
       Bile stone 36 15 (88.2) 21 (95.2) 58.3
       Distal stricture 2 1 (100.0) 1 (100.0) 50.0
       Others 1 1 (0) 0 (0) 0 (0)
      Table 1. Characteristics of patients undergoing ERCP with continued biliary cannulation after pancreatic stent placement before and after TPS introduction

      Values are presented as number (%).

      ERCP, endoscopic retrograde cholangiopancreatography; TPS, transpancreatic precut sphincterotomy; type 1, regular papilla; type 2, small papilla, often flat, with a diameter ≤3 mm; type 3, protruding or pendulous papilla; type 4, creased or ridged papilla; ESRD, end-stage renal disease.

      Papilla located completely inside the diverticulum (type I), papilla located in the inner (type IIa) and outer (type IIb) margins of the diverticulum; papilla located outside the diverticulum (type III).

      Chi-squared test.

      Fisher exact test.

      Table 2. Outcomes of patients undergoing ERCP with continued biliary cannulation after pancreatic stent placement before and after TPS introduction

      Values are presented as number (%) or mean±standard deviation. Time variables are expressed in minutes.

      ERCP, endoscopic retrograde cholangiopancreatography; TPS, transpancreatic precut sphincterotomy.

      a)Fisher exact test. b)Student t-test. c)Time variables are expressed in minutes.

      Table 3. Univariate and multivariate analyses of the factors associated with post-ERCP pancreatitis

      ERCP, endoscopic retrograde cholangiopancreatography; OR, odds ratio; CI, confidence interval; TPS, transpancreatic precut sphincterotomy; type 1, regular papilla; type 2, small papilla, often flat, with a diameter ≤3 mm; type 3, protruding or pendulous papilla; type 4, creased or ridged papilla.

      Papilla intervention including endoscopic sphincterotomy and endoscopic papillary balloon dilation.

      Table 4. Conversion rates and biliary cannulation success after TPS introduction

      TPS, transpancreatic precut sphincterotomy; ERCP, endoscopic retrograde cholangiopancreatography; type 1, regular papilla; type 2, small papilla, often flat, with a diameter ≤3 mm; type 3, protruding or pendulous papilla; type 4, creased or ridged papilla.

      No. of ERCPs performed (successful bile duct cannulation rate);

      papilla located completely inside the diverticulum (type I), papilla located in the inner (type II a) and outer (type II b) margins of the diverticulum; papilla located outside the diverticulum (type III).

      Table 1.

      Table 2.

      Table 3.

      Table 4.

      Clin Endosc : Clinical Endoscopy Twitter Facebook
      © Korean Society of Gastrointestinal Endoscopy.
      Close layer
      TOP