Pancreatic duct rendezvous with pancreatoscopy via the minor papilla.
An 18-year-old Asian female with a history of pancreatitis presented with nausea, worsening abdominal pain, and new onset ascites. A CT of the abdomen and pelvis showed marked dilation of the pancreatic duct measuring up to 1.1 cm with a subtle, hypodense filling defect within the distal pancreatic duct near the head of the pancreas.A circumscribed cystic lesion containing simple fluid along the undersurface of the pancreatic tail measuring 7.9 cm in largest diameter was seen.MRCP also revealed a filling defect in the pancreatic duct as well as marked ascites and a pseudocyst compressing the stomach. Diagnostic paracentesis was performed revealing pancreatic ascities with ascitic fluid amylase of 3485 U/L.
An endoscopic ultrasound was performed. A hypoechoic, heterogeneous intraluminal lesion was seen within the genu of the pancreas in the main pancreatic duct. The lesion measured 16mm in largest diameter. The common bile duct was non-dilated at 4 mm. An endoscope was advanced to the duodenum which revealed an edematous major ampulla. Initial attempts to cannulate the pancreatic duct resulted in CBD wire insertion. However, after several attempts the distal pancreatic duct was cannulated with wire. A limited pancreatogram was obtained and demonstrated pancreatic duct dilation to 10 mm in the body and a large filling defect of the distal body occupying the majority of the pancreatic duct lumen. However, the wire could not be advanced beyond the distal genu around the pancreatic lesion. The limited length of wire insertion into the pancreatic duct did not allow for pancreatic duct stent placement or pancreatoscopy. Cytology aspirate was obtained and was negative for malignancy. Cannulation and pancreatoscopy via the minor papilla was not initially attempted given the small orifice of the minor papilla on endoscopic assessment.
The pancreatic duct was punctured proximal to the intraluminal lesion with a 19-gauge FNA needle through the stomach wall. EUS directed pancreatogram revealed a diffusely dilated pancreatic duct. The blush seen superior to the main pancreatic duct was due to inadvertent injection into the retroperitoneal space prior to needle access into the pancreatic duct.
A 0.035-inch hydrophilic guidewire was then advanced through the needle into the pancreatic duct, traversed through the intraluminal lesion and exited into the duodenum through the minor papilla.The minor papilla was used as the site for cannulation as the wire did not pass through the major papilla, and the duct of Santorini was mildly dilated to 5mm, which would allow for later insertion of a pancreatoscope.
On endoscopy, the rendezvous wire was seen exiting through the minor papilla.Using the rendezvous wire as a guide, the Pancreatic duct was then cannulated with a guidewire to allow for the insertion of a sphincterotome.A small minor papillotomy was performed with a sphincterotome. White stone fragments were observed exiting through the minor papilla. The sphincterotome was then removed and the cholangiopancreatoscope was inserted into the PD over the wire.
A large, white PD stone was visualized. The stone was fragmented with an electrohydraulic lithotripsy catheter with a power level of 70%, a frequency of 30 shots per second, and number of shots of 5. The PD was swept multiple times using a 9 mm extraction balloon. The epithelial lining of the PD appeared normal without fish egg appearance or villous features. The rendezvous wire puncture site is visualized here on pancreatoscopy.This rendezvous wire was left in place after the successful placement of the second guidewire so in the event that the retrograde therapy of the pancreatic duct stone was unsuccessful, an anterograde trans-gastric approach would then be possible.
Occlusion pancreatogram confirmed clearance of the stone and a 10F 5 cm plastic pancreatic duct stent was placed. Additionally, the pancreatic pseudocyst was drained via a cystogastrostomy using a 15-mm lumen-opposing metal stent.
An occulsion pancreaticogram 4 weeks later showed no filling defect within the pancreatic duct. The duct of Wirsung was opacified and terminated at the level of the major ampulla. The lumen apposing metal stent was removed and the patient had clinicalresolution of ascites.
Obstructing pancreatic duct stones were previously treated with a surgical lateral pancreaticojejunostomy and open duct stone removal.However, endoscopic techniques to remove main pancreatic duct stones have been developed and include pancreatic sphincterotomy, stone retrieval, stent placement, and mechanical lithotripsy.Endoscopic extraction of pancreatic duct stones is often more difficult than removing biliary calculi as pancreatic duct stones are usually harder and located behind strictures.EUS guided pancreatic duct rendezvous can assist in removing larger stones when deep cannulation of the pancreatic duct via the major papilla is not feasible.
We report a unique use of a rendezvous procedure to remove an obstructing pancreatic duct stone in the setting of pancreatic ascites and a symptomatic pseudocyst.