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DOI: 10.1055/a-2709-7289
From failure to success: endoscopic management of difficult pancreatic cannulation after ampullary adenoma resection
Autoren
Endoscopic papillectomy is a standard treatment for ampullary adenomas, especially those with high-grade dysplasia [1] [2]. Prophylactic pancreatic stenting is recommended to prevent postprocedural pancreatitis [1] [2]. However, achieving deep pancreatic duct cannulation through the major papilla may be technically challenging, particularly after ampullectomy due to mucosal bleeding or anatomic variations such as pancreas divisum.
This report demonstrates a rescue approach using needle-knife fistulotomy at the minor papilla to overcome failed pancreatic access via the major papilla after endoscopic ampullectomy ([Video 1]). A 59-year-old woman presented with a duodenal ampullary adenoma with high-grade intraepithelial neoplasia. Preoperative MRCP showed no evidence of ductal invasion ([Fig. 1]). Endoscopic papillectomy was performed using a snare without submucosal injection, and hemostasis was achieved with coagulation forceps. Biliary cannulation was successful, but repeated pancreatic cannulation attempts failed, as the guidewire consistently exited through the minor papilla and could not reach the pancreatic tail, suggesting the possibility of incomplete pancreas divisum. Following biliary stenting, an ultra-precise needle-knife incision was performed at the minor papilla over the guidewire under direct endoscopic visualization. The guidewire was advanced into the pancreatic body and tail, enabling successful pancreatic stent placement.
Guidewire-assisted minor papilla fistulotomy enabled successful pancreatic stenting after failed major papilla cannulation post-ampullectomy.Video 1
This case highlights the utility of minor papilla needle-knife fistulotomy as a salvage technique for deep pancreatic access when major papilla cannulation fails. Guidewire-assisted minor papilla access provides real-time orientation, minimizes blind manipulation, and may reduce the risk of post-ERCP pancreatitis. It offers a technically feasible and safe strategy for pancreatic stenting in anatomically altered or complex cases following ampullectomy.
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Publikationsverlauf
Artikel online veröffentlicht:
14. November 2025
© 2025. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/).
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References
- 1 Itoi T, Ryozawa S, Katanuma A. et al. Clinical practice guidelines for endoscopic papillectomy. Digestive Endoscopy 2022; 34: 394-411
- 2 Vanbiervliet G, Strijker M, Arvanitakis M. et al. Endoscopic management of ampullary tumors: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2021; 53: 429-448