Rendezvous-assisted endoscopic retrograde pancreatography in a patient with annular pancreas and coexisting pancreas divisum

An 18-year-old female was hospitalized for chronic pancreatitis of unknown origin. No history of alcohol abuse and hereditary diseases were found. Enhanced computed tomography (CT) and magnetic resonance cholangiography revealed dilated pancreatic duct system and abnormal pancreatic tissue incompletely wrapping around the second portion of the duodenum ([Fig. 1], [Fig. 2]). Endoscopic retrograde pancreatography (ERP) with intended minor papilla cannulation was attempted and yet failed due to the polypoid nodular papilla ([Fig. 3]).

Fig. 1 Abdominal computed tomography showed abnormal pancreatic tissue incompletely wrapped around the second portion of the duodenum.

Fig. 2 Magnetic resonance cholangiography revealed both the dorsal pancreatic duct and side branches were irregular and dilated.

Fig. 3 Endoscopic appearance of major and minor papilla.

Rendezvous-assisted ERP (RV-ERP) was performed ([Video 1]). The main pancreatic duct was punctured with 19-G needle (Echotip Ultra, Cook, Limerick, Ireland) via gastric access. Contrast injection showed that the dilated dorsal pancreatic duct opened into the minor papilla without communication with the ventral duct, and irregular side branches partially encircled the duodenum, which confirmed diagnosis of annular pancreas (AP) and complete pancreas divisum (PD) ([Fig. 4]). Then a 0.035-inch guidewire (Jagwire, Boston Scientific, Marlborough, USA) was advanced from the pancreatic duct into the duodenum and the echoendoscope was exchanged for a duodenoscope, leaving the coiled guidewire in place ([Fig. 5]). Using a snare, the guidewire was grasped and pulled out of the working channel. Then a sphincterotome was inserted over the guidewire for minor papilla sphincterotomy. Finally, two 7- and 5-Fr plastic stents (Zimmon, Cook, Limerick, Ireland) were placed successfully for ductal decompression.

Video 1 Rendezvous-assisted endoscopic retrograde pancreatography in a patient with annular pancreas and coexisting pancreas divisum.

Fig. 4 After successful puncture with a 19-G needle, contrast was injected to provide a clear map of the pancreatic duct.

Fig. 5 A 0.035-inch guidewire was successfully advanced from the pancreatic duct into the duodenum and coiled, providing a stable platform for rendezvous procedures.

As a congenital anomaly, AP often occurs in children presenting with duodenal obstruction [1]. Symptomatic adult patients are rare, among whom 29 % have concurrent PD [2]. From another aspect, endoscopists should notice whether AP coexists in the management of common PD. In the case, EUS-assisted rendezvous served as an invaluable rescue procedure when conventional ERP failed [3]. To our best knowledge, this is the first case of RV-ERP for AP and coexisting PD.

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Competing interests

The authrors declare that they have no conflict of interest.

• References

• 1 Gromski MA, Lehman GA, Zyromski NJ. et al. Annular pancreas: endoscopic and pancreatographic findings from a tertiary referral ERCP center. Gastrointest Endosc 2019; 89: 322-328
• 2 Zyromski NJ, Sandoval JA, Pitt HA. et al. Annular pancreas: dramatic differences between children and adults. J Am Coll Surg 2008; 206: 1019-1025
• 3 van der Merwe SW, van Wanrooij RLJ, Bronswijk M. et al. Therapeutic endoscopic ultrasound: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2022; 54: 185-205

Publication History

Article published online:
23 March 2023