Transpancreatic precut sphincterotomy during ERCP: Learnability and outcomes across operator volumes and experience

Transpancreatic precut sphincterotomy (TPS) is an advanced option for difficult biliary cannulation during endoscopic retrograde cholangiopancreatography (ERCP) and is thought to be easier to learn than other techniques. We assessed TPS learnability across operators with differing volumes and experience levels.

TPS was introduced in April 2016. We retrospectively analyzed ERCPs performed thereafter (April 2016-March 2023) by three endoscopists: high-volume senior (~80/year), low-volume senior (~30/year), and low-volume newly independent (~30/year; since October 2020). Outcomes were successful common bild duct cannulation after TPS; cannulation/total ERCP times; and adverse events, including post-ERCP pancreatitis (PEP).

Among 539 ERCPs in patients with naïve papillae, TPS was used in 69 procedures (12.8%; 46, 16, and 7 for the high-volume senior, low-volume senior, and newly independent operators, respectively). Cannulation success after TPS was uniformly high (95.7%, 100%, and 100%, respectively). PEP occurred in 8.7%, 6.3%, and 28.6%, respectively, all mild. The newly independent operator had longer cannulation times (median [interquartile range] 35 [15] min vs. 22 [17] and 25 [12] min; P = 0.016) and total ERCP times (54 [42] vs. 42 [19] and 49 [32] min; P = 0.013). In multivariable analysis, older age was associated with lower PEP odds (odds ratio [OR] 0.936; P = 0.033), whereas end-stage renal disease (OR 47.433; P = 0.024) and procedures performed by the newly independent operator (OR 14.879; P = 0.028) were associated with higher odds.

TPS is a readily adoptable advanced option for endoscopists proficient in basic ERCP skills. Newly independent operators can achieve comparable cannulation success but demonstrate early-proficiency patterns that may inform training, supervision, and procedure standardization.