LAUSR

Repeated pancreatic juice cytology via a nasopancreatic drainage (NPD) catheter, known as serial pancreatic juice aspiration cytologic examination (SPACE), is reportedly useful for the diagnosis of earlystage pancreatic cancer [1]. When NPD catheter insertion through the major papilla is impossible due to main pancreatic duct (MPD) distortion, insertion through the minor papilla is attempted. Here, we describe antegrade dilation of the minor papilla using a balloon catheter inserted through the major papilla to facilitate minor papilla cannulation and NPD catheter insertion. A 76-year-old man was referred to our hospital due to main pancreatic duct (MPD) stenosis at the pancreatic tail. No pancreatic mass was revealed on endoscopic ultrasonography, and SPACE was attempted. Endoscopic retrograde pancreatography via the major papilla showed loop formation at the MPD in the head of the pancreas, thus a guidewire could not be inserted into the MPD in the tail of the pancreas (▶Fig. 1). Then, approach to the minor papilla was attempted. A 0.025-inch guidewire (JWIRE Prologue; J-MIT Co., Ltd, Kyoto, Japan) was successfully inserted into the accessory pancreatic duct and passed through the minor papilla (▶Fig. 2 a, b). Antegrade dilation of the minor papilla was performed using a 6-mm balloon catheter (REN; Kaneka Medix, Osaka, Japan), to facilitate cannulation (▶Fig. 3). Following guidewire removal, minor papilla cannulation was successfully performed, and a 5-Fr NPD catheter was inserted into the MPD at the pancreatic tail (▶Fig. 4, ▶Video 1). Pancreatic juice was collected six times for cytology, and the NPD catheter was removed the following day. Cytology revealed adenocarcinoma, and surgery was planned. The rendezvous technique is sometimes attempted for minor papilla cannulation using a guidewire inserted from the major papilla [2]. However, complicated steps including scope exchange, and grabbing and pulling the guidewire are required. Our method provides an alternative option for minor papilla cannulation.