Salvage antegrade endoscopic ultrasound-guided pancreatic guidewire placement allowing subsequent double-balloon ERCP

During endoscopic retrograde cholangiopancreatography (ERCP), biliary cannulation is still challenging in patients with anatomical variations, such as an intradiverticular ampulla or surgically altered anatomy [1] [2]. While the double-guidewire (DGW) technique is one of the possible rescue techniques [3] [4], pancreatic duct (PD) guidewire placement for DGW is sometimes impossible. Endoscopic ultrasound (EUS)-guided biliary access, such as the rendezvous technique, is increasingly used when cannulation has failed but this technique also needs a dilated biliary duct for EUS-guided puncture. We present a successful DGW biliary cannulation using PD guidewire placement under EUS guidance [5] in a patient with failed biliary access by ERCP and EUS ([Video 1]).

Video 1 Endoscopic ultrasound-guided pancreatic guidewire placement for the double-guidewire technique.

A 74-year-old man with a history of distal gastrectomy and Roux-en-Y reconstruction was admitted with cholangitis due to choledocholithiasis. Double-balloon endoscopy-assisted ERCP (DBE-ERCP) was attempted, but biliary cannulation failed owing to poor visualization of the ampulla. EUS-guided biliary access was then attempted but was unsuccessful because the intrahepatic bile ducts were not at all dilated.

We therefore proceeded to EUS-guided placement of a PD guidewire for subsequent DGW cannulation. Under EUS guidance, a 3-mm PD was punctured using a 19-gauge needle, which was followed by placement of a guidewire through the ampulla into the duodenum ([Fig. 1 a]). Leaving the guidewire in place, we changed the echoendoscope to a double-balloon endoscope. With the PD guidewire caught through the channel of double-balloon endoscope, the ampulla was facing the endoscope and well visualized ([Fig. 1 b]).

Fig. 1 Endoscopic ultrasound (EUS)-guided pancreatic guidewire placement for the double-guidewire technique showing: a the pancreatic duct punctured under EUS guidance and a guidewire placed through the ampulla into the duodenum; b the pancreatic duct guidewire caught through the double-balloon endoscope, making the ampulla well visualized.

Biliary cannulation was successfully achieved by the DGW technique using a double-lumen cannula with uneven outlets (Uneven Double Lumen Cannula; Piolax Medical Devices, Kanagawa, Japan) [4] ([Fig. 2 a]). Subsequently, biliary stones were removed after large-balloon papillary dilation and the procedure was completed ([Fig. 2 b]). A pancreatic drain was not placed, but no pancreatitis or pancreatic fistula was observed.

Fig. 2 Biliary cannulation using the double-guidewire technique showing: a selective biliary cannulation using the double-guidewire technique by inserting a double-lumen cannula over the pancreatic guidewire; b removal of biliary stones via double-balloon endoscopy-assisted endoscopic retrograde cholangiopancreatography using a basket catheter after large-balloon papillary dilation.

This case illustrates that EUS-guided PD access can be used for biliary cannulation when ERCP or EUS-guided biliary access has failed.

Endoscopy_UCTN_Code_TTT_1AR_2AK

Competing interests

Dr. Nakai received research grants from Fujifilm and Piolax. The remaining authors declare that they have no conflict of interest.

• References

• 1 Amer S, Horsley-Silva JL, Menias CO. et al. Endoscopic retrograde cholangiopancreatography in patients with surgically altered gastrointestinal anatomy. Abdom Imaging 2015; 40: 2921-2931
• 2 Shimatani M, Hatanaka H, Kogure H. et al. Diagnostic and therapeutic endoscopic retrograde cholangiography using a short-type double-balloon endoscope in patients with altered gastrointestinal anatomy: a multicenter prospective study in Japan. Am J Gastroenterol 2016; 111: 1750-1758
• 3 Sasahira N, Kawakami H, Isayama H. et al. Early use of double-guidewire technique to facilitate selective bile duct cannulation: the multicenter randomized controlled EDUCATION trial. Endoscopy 2015; 47: 421-429
• 4 Takenaka M, Minaga K, Kamata K. et al. Efficacy of a modified double-guidewire technique using an uneven double lumen cannula (uneven method) in patients with surgically altered gastrointestinal anatomy (with video). Surg Endosc 2020; 34: 1432-1441
• 5 Nakai Y, Kogure H, Isayama H. et al. Endoscopic ultrasound-guided pancreatic duct drainage. Saudi J Gastroenterol 2019; 25: 210-217

Publication History

Article published online:
23 October 2020