Post written by Darshan Parekh, MS, from Mumbai Institute of Gastroenterology, Mumbai, India, and Ken Ohata, MD, PhD, from NTT Medical Center Tokyo, Tokyo, Japan.

An 80-year-old man underwent resection of an approximately 30-mm ampullary tumor by endoscopic submucosal dissection (ESD). Post-ESD biliary and pancreatic diversion was attempted, but the ampullary opening could not be visualized in the post-ESD ulcer.

Hence, EUS-guided rendezvous technique was used, and a guidewire was negotiated into the biliary system in the antegrade direction to identify the opening. Subsequently, cannulation of the common bile duct and pancreatic duct was achieved, and diversion was possible.

Endoscopic retrograde stenting is reported to be fairly easy after ampullary resection because of distinct visibility of the opening. This case highlights an unfamiliar challenge of an obscured post-ESD ampullary opening, probably because of it being undermined below the edge of the ulcer.

In conclusion, expert technical skill and equipment in therapeutic EUS along with ESD are imperative to perform ampullary resections.

Ampullary tumor on forward-viewing endoscope. A, White light. B, Narrow-band imaging.

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