Post written by Sho Takahashi, MD, from the Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan.

We report a case of the inside pancreatic stenting papillectomy method for the minor duodenal papilla using the EUS-guided rendezvous method.

Endoscopic papillectomy is a minimally invasive procedure for duodenal papillary tumors. However, it is often associated with adverse events, such as postprocedural pancreatitis, bleeding, and duodenal perforation.

Although postprocedural pancreatitis is a major problem, placement of a pancreatic plastic stent (p-PS) can reduce the risk of pancreatitis. Generally, a p-PS is inserted after endoscopic papillectomy, but the procedure can be unsuccessful.

We used the inside pancreatic stenting papillectomy method to insert a p-PS. This method involves placement of a p-PS tied to a suture above the papilla before endoscopic papillectomy. The p-PS is then placed in the appropriate position by pulling the suture attached to the stent after endoscopic papillectomy.

Endoscopic papillectomy has been performed for many tumors originating from a major duodenal papilla, but it is rarely performed for a tumor of the minor papilla.

In our case, a 65-year-old man had adenoma of the minor duodenal papilla. Magnetic resonance cholangiopancreatography revealed pancreatic divisum. If pancreatic juice does not flow through the duct of Wirsung because of pancreatic divisum, postprocedural pancreatitis may occur because of obstruction of the duct of Santorini caused by minor endoscopic papillectomy.

Thus, we decided to treat the patient using the inside pancreatic stenting papillectomy method combined with EUS-guided rendezvous. The procedure was successful, and the patient was discharged on postoperative day 7 without postprocedural pancreatitis or other adverse events.

In conclusion, postprocedural pancreatitis remains a challenge for endoscopists. We must take all measures to prevent postpapillectomy pancreatitis. This inside pancreatic stenting papillectomy method requires EUS-guided rendezvous. It is a highly technical procedure, but it is likely to ensure placement of pancreatic stents.

It was shown that it is possible to secure the pancreatic duct not only in the case of the usual papillectomy, but also in the case of minor papillectomy with divisum. We hope this report will help prevent postprocedural pancreatitis.

A, Create a slit on the tip of the catheter. B, Snap onto the rendezvous guidewire. C, Successful cannulation into the duct of Santorini using the hitch-and-ride method.

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