Rajeev Attam, MD, from Kaiser Permanente, Downey, in Los Angeles, California, USA presents this video case “EUS-guided pancreatic duct access and wire placement to facilitate dorsal duct cannulation after failed ERCP.”
A 62-year-old woman was referred to us for management of recurrent pancreatitis in a setting of pancreatic divisum. Imaging confirmed pancreatic divisum and revealed mildly dilated pancreatic duct. Patient had undergone 2 failed attempts at cannulation of the dorsal duct by an endoscopist trained in advanced endoscopic procedures.
ERCP was attempted and the minor papilla was found to be at the edge of a duodenal diverticulum. Only superficial cannulation of dorsal duct with contrast injection could be performed. To obtain deeper access, a precut needle knife minor papillotomy was performed followed by repeat attempts at cannulation. At this time patient was found to have contrast extravasation from the papillotomy site.
As all attempts to gain retrograde access into the dorsal duct failed, we decided to proceed with EUS guided ante grade access and wire placement (Rendezvous procedure). The pancreatic duct was accessed with EUS and fluoroscopic guidance in the body of pancreas and with some difficulty a 0.025 wire was maneuvered across the minor papilla. The echoendoscope was removed after leaving the wire in place.
The dorsal duct was now cannulated besides the rendezvous wire (parallel rendezvous technique) and deep access into the pancreatic duct was obtained. The papillotomy was balloon dilated and a soft plastic stent placed into the pancreatic duct.
This case showcases the role of EUS guided ante grade duct access when conventional cannulation techniques fail. Once ductal access is obtained a wire can be passed across the papilla or anastomosis to facilitate retrograde cannulation. Retrograde cannulation can be performed over the rendezvous wire (classic rendezvous technique) or besides the rendezvous wire (parallel rendezvous technique).
Ante grade pancreatic duct access is an option in when conventional cannulation techniques fail. It is important for the endoscopist to be comfortable in maneuvering the wire in such situations.
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