The first patient had two failed attempts at minor papilla access at an expert center, in the setting of acute recurrent pancreatitis. There was no visual clue as to the whereabouts of the minor papilla. That clip at the bottom was from a prior biliary sphincterotomy bleed over one year earlier. In this case, it is indispensable to spray methylene blue and give IV secretin to locate the minor papilla. You can see the area of clearing indicating flow of pancreatic juice from the minor papilla even though there are no papillary landmarks or visible orifice. Prodding with catheters is not advisable as it causes oozing and obscures landmarks. A 0.021 hybrid wire pops into the orifice but it does not sink deeply. We then open up the orifice with a needle knife over the guidewire. We then get better access using a 0.018 wire, avoiding sidebranches carefully. The 018 wire platinum tip knuckles in the duct, and as always the knuckle stays in the main duct, and advances to the tail without contrast. A 4F 2cm pancreatic stent is placed.
This next patient has pancreas divisum as shown by secretin MRCP. Although she does have acute recurrent pancreatitis, she also has subtle evidence of chronic pancreatitis with decreased T1 signal on axial MR. Using high definition, narrow band imaging ERCP, it is absolutely impossible to locate the minor papilla, here even using NBI. Again, key is not to probe the mucosa with a catheter as that creates traumatic artifacts. After we have given secretin IV and topical methylene blue, you see a blush where the minor papilla orifice must be. Using a 0.018 platinum tipped wire, we carefully probe at the area of the orifice. Eventually we see the wire tip drop into the orifice. Wire passage is visible by fluoroscopy. In this case we are using absolutely no contrast injection as it is unnecessary, passing the wire to the tail of the pancreas, and placing a 4F 11cm unflanged stent. We will then perform a needle knife papillotomy over the stent.
This next case reemphasizes the importance of advanced imaging in guiding ERCP, just like using a GPS system for your car. In this patient with acute recurrent pancreatitis, secretin MRCP shows pancreas divisum with an obvious Santorinicele, or cystic dilation of the terminus of the dorsal duct, which sometimes has no apparent orifice. When secretin is given, the dorsal duct becomes dilated and the sac at the minor papilla inflates with pancreatic juice. Endoscopically, minor papilla is very flat, almost collapsed. There is no visible orifice, so we try only very briefly to wire cannulate. Once we give secretin and methylene blue, the minor papilla turns from an “inny” to an “outy”. Now we are fairly comfortable needle-knifing the orifice as we know we are unroofing a cyst-like structure. We are just going to open it enough to get access with a 0.021 wire and a papillotome. Notice that we use no contrast as we know where the duct runs by secretin MRCP. We perform a traction pull type minor papillotomy, then place a long unflanged spontaneously dislodging stent, as the patient lives in a rural area far from the referring center.
In the final case, we will perform needle knife precut for access in a patient without a bulging Santorinicele. We do this very rarely and with some trepidation. Again, we know in advance this patient has pancreas divisum by secretin MRCP and EUS, but has no Santorinicele. This patient has well documented acute recurrent pancreatitis, and a prior failed attempt at minor papilla access by a truly expert endoscopist. We tried a wire probe, but it is not going deep. We tried giving secretin, but still no success. Then using an angled tip 0.020 glidewire, we get the upwards angle we need but the wire just stops at the papillary orifice. We particularly want to avoid intramural injections. Here we are going a needle knife precut up the middle of the papilla. It is pretty much the same as orientation for a biliary sphincterotomy, towards 11:00 o’clock. Then, we are going to give methylene blue spray, and watch for a clue to the location of the orifice. By the secretin blush, you can see the orifice is closer to the bottom than expected. With careful probing, the wire and catheter go in. Look closely here – even with this high resolution fluoroscopy, you can barely see this tiny wire exiting the sidebranch. If we had pushed any further, the wire would have perforated the sidebranch duct. After redirecting the wire into the main duct, we exchange for a more stable wire. That means pushing all the contrast in the catheter into the duct. In general, it is advisable to use a single wire for access, stenting and papillotomy.
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Martin L. Freeman, M.D., University of Minnesota