LAUSR

A pancreatic duct (PD) stent placement after endoscopic papillectomy (EP) is recommended to prevent papillary stenosis [1]. However, there are cases in which pancreatitis due to papillary stenosis develops after stent removal, making endoscopic PD drainage difficult [2, 3]. A 74-year-old man underwent EP for a duodenal papillary adenoma. After resection, a plastic stent was placed into the main PD and removed 8 days postoperatively (▶Fig. 1). Eight months later, the patient had sudden abdominal pain, and contrast-enhanced computed tomography showed inflammation extending from the peripancreatic to subrenal pole (▶Fig. 2). Endoscopic retrograde cholangiopancreatography was performed for PD drainage (▶Fig. 3, ▶Video 1). First, endoscopic transpapillary pancreatic duct stenting was attempted, but cannulation into the main pancreatic duct was difficult due to obstruction of the pancreatic duct orifice by post-EP scarring. We approached from the minor papilla but were unable to lead the guidewire into the tail side of the main PD. Therefore, we switched to stenting the main PD using the rendezvous technique from the minor to major papilla. We successfully approached the main PD via the Santorini duct and inserted the 0.025-inch guidewire through the stenosis of the pancreatic duct orifice into the duodenum. The guidewire was grasped with biopsy forceps, and finally a trans-papillary pancreatic stent was placed. The pancreatitis was quickly resolved. The treatment of papillary stenosis is generally performed by pancreatic sphincterotomy or stenting, both of which are difficult when the obstruction is severe, as in this case. The endoscopic ultrasound-guided rendezvous method for PD stenting [3] is also available, however it is difficult and has a high risk of complications. In terms of safety, the rendezvous technique from the minor papilla is one of the most useful methods in cases of a difficult approach due to papillary stenosis. Endoscopy_UCTN_Code_TTT_1AR_2AI E-Videos