Antegrade balloon dilation of the minor duodenal papilla to facilitate serial pancreatic juice aspiration cytology

Repeated pancreatic juice cytology via a nasopancreatic drainage (NPD) catheter, known as serial pancreatic juice aspiration cytologic examination (SPACE), is reportedly useful for the diagnosis of early-stage pancreatic cancer [1]. When NPD catheter insertion through the major papilla is impossible due to main pancreatic duct (MPD) distortion, insertion through the minor papilla is attempted. Here, we describe antegrade dilation of the minor papilla using a balloon catheter inserted through the major papilla to facilitate minor papilla cannulation and NPD catheter insertion.

A 76-year-old man was referred to our hospital due to main pancreatic duct (MPD) stenosis at the pancreatic tail. No pancreatic mass was revealed on endoscopic ultrasonography, and SPACE was attempted. Endoscopic retrograde pancreatography via the major papilla showed loop formation at the MPD in the head of the pancreas, thus a guidewire could not be inserted into the MPD in the tail of the pancreas ([Fig. 1]). Then, approach to the minor papilla was attempted. A 0.025-inch guidewire (J-WIRE Prologue; J-MIT Co., Ltd, Kyoto, Japan) was successfully inserted into the accessory pancreatic duct and passed through the minor papilla ([Fig. 2 a, b]). Antegrade dilation of the minor papilla was performed using a 6-mm balloon catheter (REN; Kaneka Medix, Osaka, Japan), to facilitate cannulation ([Fig. 3]). Following guidewire removal, minor papilla cannulation was successfully performed, and a 5-Fr NPD catheter was inserted into the MPD at the pancreatic tail ([Fig. 4], [Video 1]). Pancreatic juice was collected six times for cytology, and the NPD catheter was removed the following day. Cytology revealed adenocarcinoma, and surgery was planned.

Fig. 1 Endoscopic retrograde pancreatography via the major papilla showed loop formation at the main pancreatic duct in the head of the pancreas (yellow curved line).

Fig. 2 a Fluoroscopic image shows a 0.025-inch guidewire inserted into the accessory pancreatic duct (yellow arrow) and passed through the minor papilla (red arrow). b Endoscopic image shows a 0.025-inch guidewire passed through the minor papilla into the duodenum.

Fig. 3 Endoscopic image shows minor papilla dilation using a 6-mm balloon catheter inserted from the major papilla.

Fig. 4 Fluoroscopic image showing a 5-Fr nasopancreatic drainage catheter inserted into the main pancreatic duct at the pancreatic tail.

Video 1 Antegrade dilation of the minor duodenal papilla using a balloon catheter inserted through the major papilla to facilitate minor papilla cannulation and insertion of a nasopancreatic drainage catheter.

The rendezvous technique is sometimes attempted for minor papilla cannulation using a guidewire inserted from the major papilla [2]. However, complicated steps including scope exchange, and grabbing and pulling the guidewire are required. Our method provides an alternative option for minor papilla cannulation.

Endoscopy_UCTN_Code_TTT_1AR_2AI

Publication History

Article published online:
25 August 2022

• References

• 1 Mikata R, Ishihara T, Tada M. et al. Clinical usefulness of repeated pancreatic juice cytology via endoscopic naso-pancreatic drainage tube in patients with pancreatic cancer. J Gastroenterol 2013; 48: 866-873
• 2 Song MH, Kim MH, Lee SK. et al. Endoscopic minor papilla interventions in patients without pancreas divisum. Gastrointest Endosc 2004; 59: 901-905