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
Endoscopy E-Videos is a free access online section, reporting on interesting cases and new techniques
in gastroenterological endoscopy. All papers include a high
quality video and all contributions are
freely accessible online.
This section has its own submission
website at
https://mc.manuscriptcentral.com/e-videos
