LAUSR

Sometimes, older technology and techniques deserve a second look, but the time has to be right. Consider electric cars, which have been around longer than automobiles powered by internal combustion engines [1, 2], and at the turn of the twentieth century, there were nearly twice as many battery-powered electrics as internal combustion engine (ICE)-powered vehicles on American roads. But ICE vehicles, mostly due to their superior power and range, quickly overtook the electrics and, for the past 100 years, have been overwhelmingly dominant. Yet, a century later, electric cars are becoming all but commonplace and, due to their many superiorities, are predicted to surpass ICE autos rapidly to become the mainstream vehicles of the foreseeable future. There are different reasons as to why the time can be right for a second look at a technology or a technique. Sometimes, a technology was not adequately developed, was too expensive, or was too complex for general acceptance. In other cases, society or culture simply was not ready for the idea. In yet other cases, there simply were not convincing data that a technique was safe enough to justify using, even though it was technically simpler to perform than some existing alternatives. Why did electric cars fail to be commercial successes at the turn of the century? Rudimentary batteries that could not hold enough of a charge for adequate range or power, lack of adequate infrastructure for efficient battery recharging, and even advertising campaigns suggesting that clean electric cars were “ideal for women” all combined to undermine widespread adoption of electric cars [3]. Of course, today, these concerns are vanishing and a growing environmental consciousness is converging with accelerated improvement in battery technology and a proliferation of charging stations. Consequently, electric cars are gaining traction, with > 300,000 sold in the USA in 2019. While ERCP is likewise “old tech”—it is 52 years old— its popularity has thankfully never experienced a decline and remains a remarkably robust and essential medical technique and technology today. That is saying a lot for a medical technology that was first described by McCune in 1968 [4]. Less than two decades ago, some predicted that EUS, and then MRCP, would sideline ERCP. Instead, these new technologies simply soaked up some of the burdensome diagnostic work previously relegated to ERCP, such as diagnosing chronic pancreatitis and PSC, and advanced ERCP as an essential therapeutic tool. In ERCP, as with most mature technologies, novel major advances are infrequent. Sometimes, however, older ideas, as was the case with electric vehicles, are worthy of a second look and old techniques may become new again. Such is the case for transpancreatic septotomy, a technique that has been revived as a salvage technique for difficult biliary cannulation for biliary obstruction and related pathology [5]. Although numerous noninvasive techniques have improved biliary cannulation success rates, including wire-guided biliary cannulation, sphincterotome-guided cannulation, double-wire cannulation, and cannulation beside a pancreatic stent [6–12], there are still times when invasive biliary access techniques, such as precut papillotomy using a needle knife or entry cut using a traction sphincterotome, are necessary. Alternative methods include suprapapillary fistulotomy and several rendezvous techniques. Nobody, or almost nobody, talks about transpancreatic septotomy (TPS), a technique described by John Goff in 1995 for difficult biliary access that uses a traction sphincterotome guided by a pancreatic guidewire to electrosurgically incise the pancreatic septum...until now. TPS has only rarely been taught during fellowship or post-training in recent years despite being introduced over two decades ago. To paraphrase the standup comedian Rodney Dangerfield (1921–2004), “I don’t get no respect.” TPS always seemed to be a bit of an outcast when it came to invasive entry techniques. Has the time finally come to give TPS some respect? In order to do so, there needs to be convincing data demonstrating that the technique is safe enough to justify using, even though it is technically simpler * John A. Martin [email protected]