Endoscopy 2021; 53(09): E320-E321
DOI: 10.1055/a-1275-9805
E-Videos

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

Rintaro Fukuda
1  Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
,
Tomotaka Saito
1  Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
,
Yousuke Nakai
1  Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
2  Department of Endoscopy and Endoscopic Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
,
Atsuo Yamada
1  Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
,
Hirofumi Kogure
1  Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
,
Kazuhiko Koike
1  Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
› Author Affiliations
 

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.


Quality:

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]).

Zoom Image
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.

Zoom Image
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.

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Competing interests

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


Corresponding author

Yousuke Nakai, MD, PhD
Department of Endoscopy and Endoscopic Surgery
Graduate School of Medicine, The University of Tokyo
7-3-1 Hongo, Bunkyo-ku
Tokyo 113-8655
Japan   
Fax: +81-3-38140021   

Publication History

Publication Date:
23 October 2020 (online)

© 2020. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany


Zoom Image
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.
Zoom Image
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.