Reverse bougienage of the major papilla via the minor papilla followed by conventional sphincterotomy

I read with great interest the paper and skillful E-video by Chavan et al. on “Reverse sphincterotomy of the minor papilla via the major papilla for chronic pancreatitis with incomplete pancreas divisum” [1]. I would like to highlight a slightly different approach in a similar patient who was admitted for management of suspected necrotizing pancreatitis (confirmed by endoscopic ultrasound) in incomplete pancreas divisum with chronic pancreatitis (these data have not been published previously).

Access through a severely strictured major papilla into the pancreatic duct was not possible. Access through the minor papilla encountered infected intraparenchymal necrosis upstream of a dilated duct of Santorini. A 0.035 inch guidewire was navigated with a sphincterotome through the minor papilla so that exit through the major papilla was achieved. After conventional minor sphincterotomy, retrograde bougienage of the major papilla via the minor papilla with 6 to 7 Fr was obtained. The Duct of Wirsung could then be intubated in an antegrade fashion, and major pancreatic sphincterotomy with subsequent drainage of the necrosis could be achieved by insertion of an 8.5 Fr stent (major papilla) and 5 Fr stent (minor papilla). The patient recovered quickly.

Trials comparing both approaches are not conceivable, and reverse ductal access will probably only be performed by very well trained endoscopists. Although reverse sphincterotomy is a very elegant approach, we believe that it may be more controlled to perform a reverse bougienage followed by an antegrade (i. e. conventional) sphincterotomy, as sphincterotomy is a critical step responsible for most of the complications of endoscopic retrograde cholangiopancreatography.

Fig. 1 Reverse bougienage of the major papilla via the minor papilla. a A guidewire was navigated via minor papillary access toward the major orifice. The pancreatic duct was dilated upstream of an intraparenchymal pancreatic necrosis (contrast cloud in projection onto the spine). b The tip of the bougie (metal ring) exited at the major papillary orifice.

• Reference

• 1 Chavan R, Kalapala R, Nabi Z. et al. Reverse sphincterotomy of the minor papilla via the major papilla for chronic pancreatitis with incomplete pancreas divisum. Endoscopy 2017; 49 (Suppl. 01) E119-E120