S4172 Rendezvous-Assisted Endoscopic Retrograde Pancreatography Using a Novel Dual-Wire Balloon Technique for Stenotic Pancreaticojejunostomy in Post-Whipple Anatomy

Introduction: Pancreatic duct (PD) stones and a stenotic pancreaticojejunal anastomosis (PJA) can make standard endoscopic retrograde cholangiopancreatography (ERCP) extremely challenging, especially in post-Whipple anatomy. Endoscopic ultrasound (EUS)-assisted rendezvous (RV) can serve as a salvage approach, but severe stenoses may thwart cannulation. We describe a novel dual-wire balloon technique to achieve successful PD drainage under these circumstances. Case Description/Methods: A 67-year-old man with a history of Whipple procedure for Zollinger-Ellison syndrome developed recurrent pancreatitis due to stones obstructing the PJA. Multiple enteroscopy-assisted ERCP failed due to an inability to traverse the stenotic PJA, and an initial EUS-RV attempt was unsuccessful due to wire coiling around the stone. On repeat EUS-RV, a 22-gauge needle was used to puncture the PD, injecting contrast and methylene blue to localize the PJA. However, attempts to cannulate the PJA were unsuccessful. The PD was again injected in the tail, allowing duct distension and subsequent puncture closer to the PJA, which was initially very challenging due to the small caliber of the PD remnant (1.7 mm) and air within the duct. A straight 0.018-inch × 480-cm guidewire was then manipulated antegrade across the stenotic PJA into the jejunum and retrieved with forceps using a pediatric colonoscope. However, conventional cannulation remained impossible due to the severe stricture and a lack of compatible accessories. To overcome this, a therapeutic gastroscope was introduced over the rendezvous wire, allowing the passage of a small diameter 5.5-French balloon catheter for PJA dilation. After balloon dilation to 4 mm, the wire stiffener was removed and replaced with a second straight 0.021-inch × 480-cm guidewire, which was advanced alongside the rendezvous wire, providing a dual-wire configuration that finally permitted secure PD access. Two 5-French pancreatic stents were placed across the PJA into the PD, restoring ductal drainage. The patient had no adverse events and was discharged the same day, with a follow-up planned for stone extraction and further dilation if needed. Discussion: EUS-guided PD drainage is a viable salvage option when ERCP fails in altered anatomy. In the presence of a significantly stenosed PJA, utilizing a small diameter 5.5-French balloon catheter over a rendezvous wire and removing the stiffener to pass a second wire allows both dilation of stenoses and dual-wire access, facilitating stent placement and restoring ductal drainage. Watch the video: https://tinyurl.com/25ACGS4172