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Case report| Volume 1, ISSUE 1, P22-24, September 2016

Think opposite: biliary guidewire-assisted pancreatic cannulation in chronic pancreatitis for transpapillary pseudocyst drainage

Open AccessPublished:September 02, 2016DOI:https://doi.org/10.1016/j.vgie.2016.07.010
Think opposite: biliary guidewire-assisted pancreatic cannulation in chronic pancreatitis for transpapillary pseudocyst drainage
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      Pancreatic duct cannulation in chronic pancreatitis fails in up to 10% to 30% of cases because of difficult guidewire or catheter manipulation.
      • Will U.
      • Reichel A.
      • Fueldner F.
      • et al.
      Endoscopic ultrasonography-guided drainage for patients with symptomatic obstruction and enlargement of the pancreatic duct.
      World J Gastroenterol. 2015; 21: 13140-13151
      Synthetic porcine secretin
      • Devereaux B.M.
      • Lehman G.A.
      • Fein S.
      • et al.
      Facilitation of pancreatic duct cannulation using a new synthetic porcine secretin.
      Am J Gastroenterol. 2002; 97: 2279-2281
      and more challenging techniques such as EUS-guided drainage or dorsal duct cannulation have been proposed.
      • Will U.
      • Reichel A.
      • Fueldner F.
      • et al.
      Endoscopic ultrasonography-guided drainage for patients with symptomatic obstruction and enlargement of the pancreatic duct.
      World J Gastroenterol. 2015; 21: 13140-13151
      , 
      • Devereaux B.M.
      • Lehman G.A.
      • Fein S.
      • et al.
      Facilitation of pancreatic duct cannulation using a new synthetic porcine secretin.
      Am J Gastroenterol. 2002; 97: 2279-2281
      , 
      • Dumonceau J.M.
      • Delhaye M.
      • Tringali A.
      • et al.
      Endoscopic treatment of chronic pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline.
      Endoscopy. 2012; 44: 784-796
      Pancreatic guidewire-assisted biliary cannulation, also known as the double-guidewire (DGW) technique, after failure of deep cannulation of the common bile duct (CBD) was first described in 1998 by Dumonceau et al.
      • Dumonceau J.M.
      • Delhaye M.
      • Tringali A.
      • et al.
      Endoscopic treatment of chronic pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline.
      Endoscopy. 2012; 44: 784-796
      , 
      • Dumonceau J.M.
      • Devière J.
      • Cremer M.
      A new method of achieving deep cannulation of the common bile duct during endoscopic retrograde cholangiopancreatography.
      Endoscopy. 1998; 30: S80
      The aim of the DGW technique is to obstruct the pancreatic orifice and facilitate deep biliary cannulation.
      We report the case of a 40-year-old man with chronic alcoholic pancreatitis presenting with a dilation of the Wirsung duct complicated by a 4-cm fluid pseudocyst in the body of the pancreas in communication with the pancreatic duct (Fig. 1A, B, Fig. 2). Deep cannulation of the main pancreatic duct failed despite several attempts with different angles of cannulation. Cannulation of the CBD was eventually achieved. Therefore, we decided to leave the guidewire in the CBD (Fig. 3). Afterward, because of obstruction of the biliary orifice, a more precise cannulation of the pancreatic orifice was possible, obtaining selective Wirsung duct cannulation (Fig. 4). Pancreatography showed major duct dilation coupled with a stricture and spillage of contrast inside the pseudocyst (Fig. 5). Pancreatic sphincterotomy was performed (Fig. 6), followed by hydrostatic 6-mm dilation (Fig. 7). A stent with multiple side holes (10F, 14 cm) was then deployed with the distal end inside the cavity and the proximal end transpapillary to achieve internal drainage and calibration of the pancreatic duct (Figure 8, Figure 9, Video 1, available online at www.VideoGIE.org). Recovery was uneventful, and stent replacement was scheduled in 3 months.
      Figure thumbnail gr1
      Figure 1A and B, CT scan showing chronic pancreatitis with dilation of the Wirsung duct (W) complicated by a 4-cm fluid pseudocyst (PK) communicating with the main pancreatic duct (arrow).
      Figure thumbnail gr2
      Figure 2Radial EUS showing a 4-cm fluid pseudocyst communicating with the Wirsung duct (arrow).
      Figure thumbnail gr3
      Figure 3Pancreatic cannulation adopting a reversed double-guidewire technique.
      Figure thumbnail gr4
      Figure 4Fluoroscopic image showing pancreatic cannulation after guidewire placement in the common bile duct.
      Figure thumbnail gr5
      Figure 5Dilated Wirsung duct communicating with the pseudocyst.
      Figure thumbnail gr6
      Figure 6Pancreatic sphincterotomy.
      Figure thumbnail gr7
      Figure 7Balloon dilation of the Wirsung duct.
      Figure thumbnail gr8
      Figure 8Deployment of a pancreatic plastic stent with the distal end inside the pseudocyst.
      Figure thumbnail gr9
      Figure 9Fluoroscopic image showing drainage of the pseudocyst inside the duodenum.
      The DGW technique is a useful tool for the management of difficult cannulation. Guidewire cannulation of the CBD to achieve pancreatic cannulation in cases of difficult pancreatic access is a feasible and effective technique.

      Disclosure

      All authors disclosed no financial relationships relevant to this publication.

      Supplementary data

      • Download .mp4 (37.48 MB)
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        Video 1

        Biliary guidewire-assisted pancreatic duct cannulation, endoscopic pancreatic sphincterotomy, hydrostatic dilation, and plastic stenting of the main pancreatic duct to achieve internal drainage of pseudocyst and calibration of the pancreatic duct.

      References

        • Will U.
        • Reichel A.
        • Fueldner F.
        • et al.
        Endoscopic ultrasonography-guided drainage for patients with symptomatic obstruction and enlargement of the pancreatic duct.
        World J Gastroenterol. 2015; 21: 13140-13151
        View in Article
        • Devereaux B.M.
        • Lehman G.A.
        • Fein S.
        • et al.
        Facilitation of pancreatic duct cannulation using a new synthetic porcine secretin.
        Am J Gastroenterol. 2002; 97: 2279-2281
        View in Article
        • Dumonceau J.M.
        • Delhaye M.
        • Tringali A.
        • et al.
        Endoscopic treatment of chronic pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline.
        Endoscopy. 2012; 44: 784-796
        View in Article
        • Dumonceau J.M.
        • Devière J.
        • Cremer M.
        A new method of achieving deep cannulation of the common bile duct during endoscopic retrograde cholangiopancreatography.
        Endoscopy. 1998; 30: S80
        View in Article

      Article info

      Publication history

      Published online: September 02, 2016

      Footnotes

      Written transcript of the video audio is available online at www.VideoGIE.org.

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      DOI: https://doi.org/10.1016/j.vgie.2016.07.010

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      Copyright © 2016 The Authors. Published by Elsevier, Inc. on behalf of the American Society for Gastrointestinal Endoscopy.

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