Endoscopic ampullectomy has been considered a high risk procedure associated with a higher complication rate of bleeding, perforation and pancreatitis compared to conventional ERCP.
Much effort has been spent on using different technique, equipment and different power settings of the electrosurgical unit in an attempt to minimize complications. The most commonly employed approach is pancreatic stent placement which has been shown to significantly reduce the rate of post ampullectomy pancreatitis. However, a successful pancreatic duct cannulation after ampullectomy can be challenging at times. Loss of resected specimen due to rapid duodenal transit is another problem faced by many therapeutic endoscopists.
We hereby describe a twin-wire technique which, in our opinion, allows easier pancreatic duct cannulation while preserving the resected specimen for collection at the end of the ampullectomy procedure.
We have an 81 year old gentlemen with background hypertension and ischaemic heart disease diagnosed to have an ampullary adenoma proven on biopsy during a routine upper endoscopy. His liver biochemistry was normal. An endoscopic ultrasound performed earlier showed a normal common bile duct and pancreatic duct without intraductal involvement. He was referred to us for endoscopic ampullectomy after stopping his aspirin for a week.
Under the side-viewing scope, typical adenomatous tissue was seen involving the ampulla and some surrounding mucosa. The pancreatic duct was first cannulated with a sphincterotome loaded with a 0.035 jag wire and a pancreatogram was obtained to confirm our position.
The sphincterotome was then withdrawn, leaving the jag wire in the pancreatic duct and the sphincterotome was reinserted in a parallel fashion next to the jag wire. 0.5% indigo carmine solution was used to delineate the outer boarders of the adenoma.
An ordinary braided polypectomy snare was then back-loaded over the jag wire to capture the ampullary mass with the jag wire coursing through the ampulla in the pancreatic duct. We do not routinely perform a saline lift before ensnaring the ampulla as injection of saline may obliterate the tumour margin and make polypectomy more difficult to perform.
Polypectomy was performed using endocut mode as for ERCP sphincterotomy. With gentle jiggling while applying the cutting current, the ampullary mass was successfully resected from the base with the jag wire still residing within the pancreatic duct. The resected tissue dangled over the guide wire like a piece of meat on a skewer. This helped to retain the resected specimen for collection later on.
We then carefully release the snare and unlooped it over the resected tissue before removing it. With the first wire in the pancreatic duct, a sphincterotome loaded with a second jag wire was then inserted next to the resected tissue and parallel cannulation of the pancreatic duct was performed with the first wire serving as the guide as well as a splint for easier cannulation. The second wire was seen to form a loop near the pancreatic tail under fluoroscopy in this case.
The sphincterotome was removed leaving the twin wires in place and a 5F x 5cm pancreatic stent was back-loaded over the second wire and deployed into the pancreatic duct without any pancreatic sphincterotomy. A Roth net was then used to retrieve the resected specimen at the end of the procedure.
There was slight oozing from the resection site noted on reentry. Argon plasma coagulation was used to achieve haemostasis which also help to fulgurate any remnant adenomatous tissue. We decided not to proceed with biliary cannulation or sphincterotomy to minimize further bleeding and other complications.
An upper endoscopy was performed 10 days later and the pancreatic stent was removed.
A repeat ERCP done 3 months later showed scarring over the ampullectomy site without any residual adenomatous tissue. Two separate openings were noted which lead to the biliary and pancreatic duct respectively under fluoroscopy. Both the biliary and pancreatic ducts appeared normal.
We believe this twin-wire technique can ensure a faster more successful cannulation of the pancreatic duct after an ampullectomy, which hopefully translate to a lower post ampullectomy pancreatitis rate.
Dr. Quan Wai Leong, Tan Tock Seng Hospital, Singapore