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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  . While the double-guidewire (DGW) technique is one of the possible rescue techniques  , 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  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]).
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)  ([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.
This case illustrates that EUS-guided PD access can be used for biliary cannulation when ERCP or EUS-guided biliary access has failed.
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23 October 2020 (online)
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