A stepwise cannulation strategy for conservative endoscopists: the clinical impact of transpancreatic precut after pancreatic stenting in a retrospective study from Taiwan

BACKGROUND: 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.