Transpancreatic precut sphincterotomy (transpancreatic precut papillotomy)

This patient with obstructive jaundice from pancreatic cancer was referred for repeat ERCP following unsuccessful biliary cannulation at an outside hospital. On examination with a side viewing endoscope, the papilla was distorted by tumor (A). Initial cannulation showed that the pancreatic duct was completely obstructed by tumor. After a wire was passed into the pancreatic duct (D), a transpancreatic precut sphincterotomy was performed to expose the bile duct by directing the incision up the middle of the papilla (B,E). With the catheter in the pancreatic duct, the bile duct (blue circle) was exposed as a nipple-like structure in the center of the incision, to the left of the pancreatic duct (C). A wire was then passed deeply into the bile duct (F). For patients with a completely obstructed pancreatic duct, pancreatic stent placement is not necessary.