Abstract
Several precut techniques have been proposed to increase the success rate of biliary cannulation with either a needle-knife sphincterotome or a standard traction sphincterotome. However, the gold standard of precut methods has not yet been established. Transpancreatic precut sphincterotomy is an option after failure of pancreatic duct guidewire placement for patients with difficult biliary cannulation. A sphincterotome is subsequently inserted into the pancreatic duct over the guidewire placed into the pancreatic duct, and cuts the papilla through the sphincter associated with the biliary orifice, drawing a fluent arc from the pancreatic orifice to the biliary orifice from the 11 o'clock to noon position on the papilla. The goal is to create a small incision of no more than 5 to 8 mm, because the priority of this method is to improve the accessibility of the bile duct via pancreatic duct guidewire placement rather than exposing the biliary orifice. The use of a soft guidewire permits to control the direction and depth of the incision. Understanding both the anatomy of the papilla and the precut methodology leads to the application of a safe and reliable precut technique.
