Endoscopic ultrasound-guided rendezvous in pancreas divisum with a nondilated pancreatic duct

Pancreas divisum is the most common congenital malformation of the pancreas, in which a single pancreatic duct does not form in the 7th week of gestation. It usually causes no symptoms or complications, but a small percentage of persons with this malformation develop recurrent acute pancreatitis. Patients with recurrent acute pancreatitis may benefit from endoscopic sphincterotomy of the minor papilla to open up the outflow of the dorsal pancreatic duct [1] [2].

Here, we describe a case of pancreas divisum that was treated with minor papilla sphincterotomy and placement of a pancreatic duct stent through an endoscopic ultrasound (EUS)-guided rendezvous approach.

A 70-year-old man presented with recurrent acute pancreatitis. Pancreas divisum was diagnosed on EUS and magnetic resonance cholangiopancreatography.

Endoscopic retrograde cholangiopancreatography was attempted but the minor papilla could not be identified. EUS revealed a nondilated pancreatic duct 3.8 mm in diameter in the pancreatic body. The duct was punctured with a 22-gauge fine-needle aspiration needle through a transgastric approach. Pancreatography revealed no stone or stricture in the pancreatic duct. A 0.018-in. guidewire (Pathfinder; Boston Scientific, Massachusetts, USA) was advanced to the pancreatic duct, but it could not traverse the genu of the pancreatic duct in the pancreatic neck. The pancreatic duct in the pancreatic neck was then punctured, and the guidewire was advanced to the duodenum ([Fig. 1], [Fig. 2]). The needle and echoendoscope were withdrawn while the guidewire was left in place. A side-view duodenoscope was then advanced to the duodenum, and the tip of the rendezvous guidewire was visualized exiting from the minor papilla. Needle-knife papillotomy of the minor papilla was performed ([Fig. 3]), and cannulation of the Santorini duct was done alongside the rendezvous guidewire ([Fig. 4]; [Video 1]). After a minor papilla sphincterotomy, a 7-French plastic stent was placed in the pancreatic duct.

Fig. 1 Endoscopic ultrasound image showing the pancreatic duct in the pancreatic neck punctured with a 22-gauge fine-needle aspiration needle (arrow).

Fig. 2 Rendezvous guidewire entering the duodenum through the minor papilla.

Fig. 3 Needle-knife papillotomy of the minor papilla alongside the rendezvous guidewire.

Fig. 4 Deep cannulation of the pancreatic duct with the needle-knife catheter.

Video 1 Endoscopic ultrasound-guided rendezvous through the pancreatic duct followed by minor papilla sphincterotomy in a patient with pancreas divisum.

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Six months later, the patient remains well with no signs of recurrent pancreatitis. In conclusion, EUS-guided rendezvous is feasible even in a nondilated pancreatic duct in pancreas divisum, and a stiff type of guidewire is recommended in this situation.

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Competing interests

The authors declare that they have no conflict of interest.

• References

• 1 Heyries L, Barthet M, Delvasto C. et al. Long-term results of endoscopic management of pancreas divisum with recurrent acute pancreatitis. Gastrointest Endosc 2002; 55: 376-381
• 2 Tringali A, Voiosu T, Schepis T. et al. Pancreas divisum and recurrent pancreatitis: long-term results of minor papilla sphincterotomy. Scand J Gastroenterol 2019; 54: 359-364

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Artikel online veröffentlicht:
01. März 2023