Transpancreatic Precut Sphincterotomy (TPS) Technique for Failed Biliary Cannulation
After failed standard biliary cannulation, transpancreatic precut sphincterotomy involves creating an incision from the pancreatic orifice toward the bile duct orifice using a needle-knife, followed by immediate pancreatic duct stent placement to reduce post-ERCP pancreatitis risk.
Technical Approach
Pre-procedure Preparation
- Administer rectal NSAIDs (100 mg indomethacin or diclofenac) to all patients without contraindications to reduce post-ERCP pancreatitis (PEP) risk 1
- Verify coagulation parameters (FBC and INR/PT) prior to any sphincterotomy 1
Step-by-Step TPS Technique
Initial Setup:
- First achieve pancreatic duct access with a guidewire (this defines "difficult biliary cannulation")
- Position the needle-knife at the pancreatic orifice
Incision Strategy:
- Create a long incision extending beyond the midpoint of the papillary oral protrusion—this landmark is critical as longer incisions are independently associated with higher success rates (OR 3.71, p=0.010) 2
- Direct the incision from the pancreatic orifice toward the anticipated bile duct location
- The bile duct orifice typically appears in the upper-left region of the pancreatic orifice, usually within two sphincterotome widths distance (65.9% of cases) 2
Immediate Post-TPS Management:
- Place a 5F pancreatic stent immediately after completing the incision—this is essential for PEP prevention 1, 3
- Attempt biliary cannulation through the newly created access
Success Rates and Outcomes
The technique achieves:
- 93.5-100% overall biliary cannulation success across multiple studies 2, 4, 3
- First-attempt success rates of 69.6-85% 5, 3
- Comparable efficacy to alternative techniques like double-guidewire technique and precut fistulotomy 6
Critical Technical Factors
Papilla Morphology Matters:
- Haraldsson Type 2 papillae show reduced success rates and may require conversion to alternative techniques 2, 7
- Type 2 and Type 4 papillae have relatively high conversion rates to TPS 7
Incision Length is Key:
- Initiating TPS with a long/full incision (beyond the midpoint landmark) results in:
- Higher first-incision cannulation rates
- Shorter cannulation times
- No increase in adverse events 2
Safety Profile
Post-ERCP Pancreatitis:
- PEP rates range from 0-28.6% depending on operator experience 4, 3
- Most cases are mild severity 1
- Risk factors include younger age, end-stage renal disease, and less experienced operators 4
- Immediate pancreatic stent placement is mandatory to minimize this risk
Other Complications:
- Bleeding: 1.3% (mostly mild) 8
- Cholangitis: <1% 8
- Perforation: rare 8
- No significant difference in adverse events compared to alternative techniques 6, 5
Alternative Considerations
If TPS fails or is contraindicated:
- Precut over pancreatic duct stent (PPDS) may offer higher initial success (91.3% vs 69.6%) and potentially lower PEP risk, though it requires stent placement first 3
- Double-guidewire technique shows comparable efficacy with potentially lower PEP rates (10% vs 22%) 6, 5
- EUS-guided biliary drainage is reserved for complete ERCP failure in expert hands 8
Common Pitfalls to Avoid
- Inadequate incision length: Short incisions reduce success rates—use the midpoint landmark consistently 2
- Omitting pancreatic stent placement: Failed stent placement dramatically increases PEP risk 1
- Repeated pancreatic duct cannulation without stenting: If >1 pancreatic wire passage occurs, place a stent before continuing 1
- Excessive contrast injection: Avoid high-pressure contrast injection which can worsen outcomes 8
Operator Considerations
TPS is readily adoptable by endoscopists proficient in basic ERCP skills 4. Newly independent operators achieve comparable cannulation success (95.7-100%) but demonstrate longer procedure times initially 4. The technique is considered easier to learn than traditional precut fistulotomy approaches.