An unusual case of recurrent acute pancreatitis successfully treated via precut papillotomy (with video)

Here we report a rare case of recurrent acute pancreatitis in a 34-year-old man caused by pancreatic stone impaction at the minor papilla rather than pancreas divisum (PD). Initial magnetic resonance cholangiopancreatography identified PD without pancreatic stones [Figure 1], but subsequent EUS revealed a protruding minor papilla and complete PD, with a 5 × 3-mm pancreatic stone impacted at the orifice of the dorsal pancreatic duct and diffuse ductal dilation [Figure 2]. Cannulation of minor papilla under endoscopic retrograde cholangiopancreatography failed, and the whitish stone was found embedded within the minor papilla [Figure 3]. A dual-knife papillotomy on minor papilla at the 12-o’clock position was used, exposing the impacted pancreatolith [Figure 4]. Precut papillotomy of minor papilla in the 4-o’clock direction was additionally performed, and the stone was successfully removed [Video 1]. The dorsal pancreatic duct was then cannulated easily, and a pancreatic stent was inserted into the duct for drainage. No postoperative complications occurred. Over 6 months of follow-up, the patient’s quality of life remained good.Figure 1: Magnetic resonance cholangiopancreatography showing pancreatic divisum and dorsal pancreatic duct dilatation but no evidence of pancreatic stone impaction at the orifice of dorsal pancreatic duct.Figure 2: A pancreatic stone impacted at the orifice of the dorsal pancreatic duct with associated dilation of the whole duct.Figure 3: Endoscopic views of the stone extraction showing whitish pancreatolith (yellow arrows) trapped in the minor papilla.Figure 4: The stone exposed after dual-knife cutting in the 12-oʼclock direction.This case also highlights that EUS has a superior diagnostic accuracy over magnetic resonance cholangiopancreatography for recurrent acute pancreatitis etiologies,[1] and the dual-knife precut papillotomy technique is safe and effective in such clinical conditions.[2] {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Supplementary Video","caption":"Video 1. Endoscopic extraction of a pancreatic stone encased in the minor papilla using dual-knife precut papillotomy technique allowing successful cannulation of the dorsal pancreatic duct. Videos are available only at the official website of the journal (www.eusjournal.com).","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_42f3yy2s"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]}