A shot in the light: rendezvous endoscopic ultrasonography-guided pancreatic duct drainage in treatment of recurrent pancreatitis with pancreas divisum

 

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A 34-year-old man with recurrent pancreatitis was referred for endoscopic retrograde cholangiopancreatography (ERCP) [1], but cannulation of the main pancreatic duct (MPD) repeatedly failed at several teaching hospitals owing to pancreas divisum and invisible minor papilla orifice ([Fig. 1]) [2]. Thus, we decided to perform rendezvous endoscopic ultrasonography (EUS)-guided pancreatic duct drainage (EUS-PD-RV) ([Video 1]).

Video 1 The basic steps of rendezvous endoscopic ultrasonography-guided pancreatic duct drainage.

The dilated MPD was punctured using a 19-G needle ([Fig. 2]). Unfortunately, the guidewire wandered within MPD branches instead of advancing into the duodenum ([Fig. 3]). Magnetic resonance cholangiopancreatography (MRCP) was reviewed and indicated that the neck pancreatic duct connected with the minor papilla. Under combined navigation of MRCP and antegrade pancreatography, the guidewire was precisely maneuvered to rebound from the branch duct and drill into the duodenum ([Fig. 4]). Regular ERCP was attempted again but still failed due to the stenotic orifice of the minor papilla. Dilating bougies were used to expand the needle tract and the orifice of the minor papilla. The guidewire was then grasped and pulled into the duodenoscope; the guidewire was covered by the bougie during the whole rendezvous process ([Fig. 5]). Over the guidewire, the sphincterotome cannulated the MPD. After the MPD stricture was further dilated using an 8.5-Fr bougie, a 7-Fr pancreatic stent was placed across the body/tail of the MPD.

As initial passage of a guidewire across the papillae/anastomoses is the cornerstone of successful EUS-PD-RV [3] [4], we present a precise and safe guidewire maneuvering technique to tackle a really difficult EUS-PD-RV procedure. The technique has two benefits: 1) as the multiple dilated branches of the MPD make passage of the guidewire to the papillae difficult, our technique precisely directs the guidewire across the papilla under combined imaging navigation; 2) as the guidewire may split and bring transection injury to the pancreas during the rendezvous process, our technique safely covers the guidewire using the dilating bougie.

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Publication History

Article published online:
24 February 2023

© 2023. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

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