Precutting of the Minor Papilla for Pancreatic Duct Cannulation in Pancreas Divisum Patients

 

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Therapeutic endoscopic interventions such as pancreatic sphincterotomy of the minor papilla, dilation of the minor papilla, and stent insertion are alternatives to surgical sphincteroplasty in patients with pancreas divisum - particularly in patients with acute recurrent pancreatitis, chronic pancreatitis, and chronic pancreatic pain [1]. Minor papilla sphincterotomy can be carried out using a pull-type sphincterotome or needle-knife sphincterotome, with guidance from a previously inserted stent [1]. Cannulation of the pancreatic duct via the minor papilla is necessary with both of these techniques. Once the pancreatic duct has been cannulated, the procedure can be carried out successfully in almost all patients. The limiting factor in therapeutic endoscopic interventions is cannulation of the minor papilla. Cannulation rates of between 73.5 % and 83.3 % have been reported in several studies [2] [3] [4]. A needle-tipped catheter, a highly tapered catheter, or a guide wire are routinely used for cannulation of the minor papilla [1]. We describe here a technique for cannulation of the minor papilla involving precutting with a needle-knife sphincterotome. So far as we are aware, this technique has not previously been described.

In this technique, the needle of the sphincterotome is inserted 1-2 mm into the minor papilla. Depending on its size, the minor papilla is then cut 2-4 mm in the 10-12-o’clock direction. This makes cannulation of the pancreatic duct easier (Figure [1] [2] [3]).

Figure 1 Papillary edema due to previous attempts at cannulation. The needle-knife sphincterotome is ready for precutting.

Figure 2 The incision is made after insertion of the sphincterotome needle 1-2 mm in the 11-o’clock direction.

Figure 3 The minor papilla orifice is now open.

During the last 8 years, we have carried out 13 cannulations of the minor papilla in 155 patients requiring therapeutic interventions in the pancreatic duct (8.4 %). Seven of the 13 patients underwent cannulation without precutting, and cannulation with precutting was carried out in six (46.2 %). Three patients underwent cannulation during the same procedure, two patients during the second procedure, and one patient during the third procedure (the period between procedures was approximately 3-5 days, and the overall success rate was 100 %). There were no complications such as pancreatitis, perforation, or bleeding, including patients in whom precut sphincterotomy of the minor papilla was carried out.

We consider that precutting of the minor papilla is an efficient and safe method of cannulating the minor papilla.

References

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B. Şahin, M. D.

Dept. of Gastroenterology

Türkiye Yüksek İhtisas Hospital
Sihhiye
Ankara, 06100
Turkey

Fax: +90-3123124122

Email: Eparlak@tr.net