EUS-guided rendezvous technique for pancreas divisum

A 64-year-old woman with a history of known pancreatic divisum, coronary artery disease, congestive heart failure, hypertension, type II diabetes mellitus, and opioid use disorder (on suboxone) presented to the emergency department with epigastric pain for the past few days. She was diagnosed with acute pancreatitis based on a lipase level of >600 U/L (normal is <50 U/L). She denied any history of heavy alcohol use. She reported history of smoking a pack of cigarettes per day for 20 years. She underwent a contrast CT scan of her abdomen (Fig. 1) that demonstrated interstitial pancreatitis with multiple obstructing stones in the proximal dorsal pancreatic duct with upstream dilation up to 7.8 mm. The gallbladder was distended without any evidence of cholelithiasis. She was treated with intravenous fluids and supportive care but continued to have ongoing symptoms with significant abdominal pain and nausea. Thus, the decision was made to pursue ERCP for pancreatic duct decompression (Video 1, available online at www.giejournal.org).

During her ERCP, traditional retrograde cannulation was deemed not feasible because of severe edema obscuring the major and minor papillae. The decision was then made to attempt an EUS-guided rendezvous technique to access the pancreatic duct (Fig. 2). Using a therapeutic echoendoscope, we punctured the pancreatic duct (Fig. 3) in the pancreatic body using a 19-gauge needle via a transgastric approach. Multiple filling defects consistent with stones within the main pancreatic duct were seen during the contrast study. A 0.025-inch hydrophilic guidewire was then advanced antegrade through the needle into the dorsal pancreatic duct, which was challenging because obstructing stones were present. This was complicated by shearing of the hydrophilic tip of the wire in the pancreatic duct; however, using a second 0.025-inch wire, we eventually were able to pass the wire into the duodenum (Fig. 4). The duodenoscope was then used to complete the rendezvous by grabbing the duodenal end of the wire with biopsy forceps and pulling it through the working channel (Fig. 5). Using a double-lumen cytology brush introducer, we advanced a second 0.035-inch guidewire through the open catheter lumen into the dorsal pancreatic duct to secure the access. The main pancreatic duct was then balloon-dilated to 4 mm (Fig. 6) and several stone fragments were swept. Minor papillotomy was avoided because of the risk for worsening pancreatitis. A single 10F × 17 cm plastic wedge stent was placed into the dorsal pancreatic duct (Figs. 7 and 8) through the minor papilla. The total duration of the procedure was 129 minutes. After the procedure, the patient reported improvement of symptoms and was discharged within 24 hours. She had 4 subsequent ERCPs within 9 months after her initial procedure for further dilation of the pancreatic duct up to 6 mm, with replacement of the stents and findings of pancreatic duct stricture. No adverse events were noted on follow-up imaging at 6 months (Fig. 9). During her last ERCP, the majority of the sheared wire was removed as well as her pancreatic duct stents, with improvement of the pancreatic duct stricture.

Pancreas divisum is the most common pancreatic congenital anomaly and occurs in up to 10% of the population, resulting from failed fusion of the dorsal pancreatic duct and ventral pancreatic duct. Whether or not pancreas divisum alone can cause acute pancreatitis is controversial; however, a randomized trial has demonstrated clinical improvement with endoscopic therapy in patients with pancreas divisum who develop recurrent pancreatitis. In cases of complicated pancreatic anatomy or severe pancreatitis, traditional retrograde cannulation can be challenging or unsuccessful. We describe a case of successful endoscopic stenting of the minor papilla using a rendezvous maneuver in a patient with obstructing pancreaticolithiasis and pancreatic divisum.