Ampullectomy: The use of methylene blue to aid in location of pancreatic orifice after ampullectomy
Comments: This 87-year-old female first presented to us with biliary obstruction 2 weeks after having aortic valve replacement. Plastic biliary stent was placed to relieve the obstruction and biopsies at the time revealed ampullary adenoma. Repeat ERCP with stent exchange and biopsies was performed confirming adenomatous tissue and EUS did not reveal any evidence of invasion of the adenoma. After multiple discussions with the patient and referring physicians she has chosen to undergo ampullectomy.
After removing the biliary stent, inspection of the ampulla shows an abnormal papilla with adenomatous growth. We were able to cannulate the pancreatic duct prior to ampullectomy and injected contrast mixed with methylene blue into the pancreatic duct to facilitate finding the pancreatic orifice after ampullectomy.
We believe starting from the top, at the proximal edge of the ampulla gives the best results for snare ampullectomy. During manipulation of the ampulla with the snare methylene blue can be seen coming from the pancreatic orifice. We took care trying to ensure an enbloc resection could be achieved with careful scope manipulation until we felt the snare was around the entire ampulla. Slow closure of the snare keeps it from slipping off of the ampulla. Ampullectomy was the next step. Combination of coagulation and cutting current was used with the ampullectomy. Immediately after resection removal of the specimen was undertaken with Roth retrieval net to ensure collection of the specimen for pathological review
Now with inspection of the ampullary bed the biliary orifice can easily be seen. A hint of the methylene blue is seen below and to the right of the biliary orifice. This will aid us in arguably the most important part of this procedure, ensuring pancreatic drainage. Using an ultra-tapered cannula and 0.025” jagwire the pancreatic duct is cannulated. Methlythene blue can be seen extruding from the pancreatic orifice. With endoscopic manipulation we were able to deeply cannulate this tortuous pancreatic duct for placement of a 5fr x 3cm pancreatic duct stent, which had been modified by cutting off the internal phalanges. Pancreatic secretions could be seen flowing from the stent after placement.
Here you can see the pancreatic stent in place and we are deploying a 10fr x 6cm plastic biliary stent in the common bile duct with good flow of bile and contrast after placement. There was some concern for residual tissue adenomatous tissue so APC was applied to the edge of the ampullary bed. We have protected both the pancreatic and biliary orifices from stricture by placing a stent in each.
The patient did well throughout the procedure. She did have some post procedure bleeding as evidenced by drop in HCT and melena. On EGD with duodenoscope there was no sign of bleeding and no intervention was needed. Pathology revealed ampullary adenoma without invasion. She will have KUB in 2 weeks to ensure migration of pancreatic stent and repeat ERCP with biliary sphincterotomy in 8 weeks. We feel this is a good example of the use of methlyene blue to facilitate locating the pancreatic duct orifice after ampullectomy, and should be considered if pancreatic cannulation can be achieved prior to ampullectomy.
| Contributed by: |
Bennett Hooks, MD Advanced Endoscopy Fellow University of Texas Health Science Center San Antonio Sandeep N. Patel, DO Director of Pancreatobiliary Endoscopy University of Texas Health Science Center San Antonio |
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Citation: Hooks, B. & Patel, DO, SN (Jun 01 2010). Ampullectomy: The use of methylene blue to aid in location of pancreatic orifice after ampullectomy. The DAVE Project. Retrieved Sep, 8, 2010, from http://daveproject.org/viewfilms.cfm?film_id=928 Times viewed since Feb 2006: 1643 |
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