“HITCH AND RIDE” TECHNIQUE FOR BLIND PANCREATIC DUCT CANNULATION

Case:

A 72 year old patient suffered a biliary pancreatitis with wall-off pancreatic necrosis endoscopically drained and solved after two sessions of endoscopic necrosectomy. Biliary sphincterotomy was performed for suspected common bile duct stones. The transmural stent was retrieved and from then on the patient complained of epigastric pain with elevation of acute phase reactants. CT showed two new peripancreatic collections with mild dilation of the pancreatic duct, suggesting pancreatic duct disruption. Pancreatic ERCP was planned but the duodenal folds were edematous with stenosis of the duodenal lumen, precluding identification of the ampulla. The duodenoscope was placed facing the theoretical location of the ampulla under fluoroscopic control. Injecting contrast we could see a depression in the wall corresponding to the ampulla with the sphincterotomy which was blindly cannulated. Since we could see the biliary guidewire exiting the duodenoscope, a cannula with a preloaded guidewire and a slit on the tip was snapped onto the biliary guidewire and advanced over it (“hitch and ride” technique) until the theoretical location of the ampulla with fluoroscopic control. Once there, the preloaded guidewire was advanced exiting the cannula tip more caudally because of the slit, in a more convenient orientation for pancreatic duct cannulation. After a couple of attempts and blind adjustments of the cannula position we could easily cannulate the pancreatic duct with the second guidewire only under fluoroscopic control. Pancreatic ductography confirmed pancreatic duct disruption and a pancreatic stent was placed into the fistulous tract. The patient clinical status improved and was discharged asymptomatic (Video).

Conclusion:

The “hitch and ride” technique was initially described to facilitate biliary cannulation during EUS-guided rendezvous. After getting some experience in this setting we could successfully use it to cannulate blindly the pancreatic duct in this case of smoldering pancreatitis with difficult management.