Reverse sphincterotomy assisted accessory pancreatic duct cannulation

Reverse sphincterotomy assisted accessory pancreatic duct cannulationA 61-year-old woman admitted to our hospital with pancreatic duct stones.She underwent extracorporeal shockwave lithotripsy followed by endoscopic retrograde cholangiopancreatography (ERCP).Pancreatography demonstrated significant tortuosity of the main pancreatic duct (MPD) ( Fig. 1 a) and acute angle between the ventral and proximal pancreatic duct which created technical difficulty in advancing the guidewire into the proximal pancreatic duct ( Fig. 1 b).In this context, we attempted cannulation via minor papilla.However, the inconspicuous orifice of the minor papilla rendered cannulation challenging.Ultimately, we advanced the guidewire retrogradely through the MPD into the accessory pancreatic duct (APD) and finally into the duodenal lumen via the minor papilla ( Fig. 2 a).A sphincterotome was then passed retrogradely through a minor papilla along the guidewire.Reverse sphincterotomy was performed with the orientation toward 6-8 o'clock and enabled cannulation without any intraoperative complications ( Fig. 2 b, c).Successful cannulation of APD was achieved through minor papilla ( Fig. 3 a).Following dilation of APD with a balloon catheter ( Fig. 3 b), the Fig. 1 a Pancreatography demonstrated significant tortuosity of the main pancreatic duct (marked by the white arrows).b A schematic diagram demonstrating the acute angle between the ventral and proximal pancreatic duct (marked by the *) and showing of passage of the guidewire through the main pancreatic duct into the accessory pancreatic duct and subsequent retrograde passage through the minor papilla. Fig. 2 a The guidewire passed retrogradely through the main pancreatic duct into the accessory pancreatic duct and coiled in the duodenal lumen.b A sphincterotome passed reversely through the minor papilla along the guidewire and performed reverse sphincterotomy.c The orifice of minor papilla after reverse sphincterotomy. Fig. 3 a Pancreatography showed successful cannulation through the accessory pancreatic duct.b A balloon catheter was used to dilate the accessory pancreatic duct.c A retrieval basket was used to clear the pancreatic duct stones.d Two plastic stents (10 Fr, 5 cm and 7 Fr, 10 cm) were placed in the accessory pancreatic duct.