Post written by Go Endo, MD, and Naminatsu Takahara, MD, PhD, from the Department of Gastroenterology in Organ Pathophysiology Program, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
A 70-year-old woman developed acute cholangitis and pancreatitis 3 months after hybrid endoscopic papillectomy (EP) of a 25-mm ampullary adenoma. The papillary orifice was completely obstructed by a fibrotic post-EP stricture, and conventional ERCP failed. As a salvage approach, EUS-assisted rendezvous was performed: the distal bile duct was punctured from the duodenum with a 19-gauge needle (EZ Shot 3 Plus; Olympus, Tokyo, Japan), and a 0.025-inch guidewire (VisiGlide 2; Olympus) was advanced across the stricture into the duodenum.
After exchange to a duodenoscope, the guidewire was retrieved with biopsy forceps, and biliary access was established. The pancreatic duct was then cannulated through the same papillary access using a double-lumen papillotome (MagicTome; PIOLAX Inc, Yokohama, Japan). Balloon dilation and plastic stent placement were performed in both ducts without adverse events. All stents were removed at 12 months, and no recurrence was observed 12 months after removal.
Papillary stricture is a late adverse event of EP, with a reported incidence of 3.0% to 7.3%,1,2,3 and it may cause concurrent cholangitis and pancreatitis. Because these strictures consist of dense fibrotic tissue, standard ERCP access is often extremely difficult, and drainage of both the biliary and pancreatic ducts may be required at the same time. Salvage strategies in this setting have rarely been reported. To our knowledge, this is the first report in which dual-duct drainage was achieved with a single EUS-assisted rendezvous biliary puncture followed by pancreatic duct cannulation using a double-lumen papillotome. We believe this video offers a practical solution to a rare but troublesome scenario.
Several technical tips may be useful. When a guidewire cannot be advanced directly through the stricture, exchanging the needle for an ERCP catheter allows finer guidewire manipulation. Coiling the guidewire sufficiently within the duodenum prevents dislodgement during scope exchange. If cannulation alongside the guidewire fails, the over-the-guidewire technique, retrieving the floppy end with biopsy forceps while an assistant advances the opposite end, secures biliary access.
For pancreatic cannulation, the double-lumen papillotome is inserted partially into the bile duct and bowed gently upward so that the proximal lumen faces the pancreatic orifice; a second guidewire is then advanced under assistant manipulation. Notably, guidewire placement straightened a previously looped pancreatic duct, allowing easy stent placement.
The stricture was managed with staged stent exchanges at 4 and 8 months, and its resolution was confirmed at 12 months. This approach may also be applied to other situations of difficult cannulation requiring dual-duct access.
Endoscopic view of the ampullary adenoma. A 25-mm tumor with marked erythema was present at the major papilla, with a laterally spreading lesion of whitish, granular changes in the surrounding mucosa.
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- Nam K, Song TJ, Kim, RE, et al. Usefulness of argon plasma coagulation ablation subsequent to endoscopic snare papillectomy for ampullary adenoma. Dig Endosc 2018;30:485-92. ↩︎
- Yamamoto K, Itoi T, Sofuni A, et al. Expanding the indication of endoscopic papillectomy for T1a ampullary carcinoma. Dig Endosc 2019;31:188-96. ↩︎
- Catalano, MF, Linder, JD, Chak, A, et al. Endoscopic management of adenoma of the major duodenal papilla. Gastrointest Endosc 2004;59:225-32. ↩︎
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