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Endoscopic ultrasound‐guided rendezvous procedure for unidentifiable papilla and non‐dilated pancreatic duct (with video)

The pancreatic endoscopic ultrasound (EUS)-guided rendezvous procedure (RV) is a newly developed, yet challenging, access technique. It is useful for interventions when endoscopic retrograde pancreatography (ERP) fails or is not possible. Here, we present a patient who underwent pancreatic EUS-RV for a non-dilated pancreatic duct (PD). A 66-yearold man with recurrent pancreatitis was admitted to our department. Esophagogastroduodenoscopy revealed multiple duodenal Brunner’s gland tumors. EUS revealed hyperechoic foci in the pancreatic parenchyma and a non-dilated PD a maximum of 2.5 mm in diameter. ERP was not feasible because the Brunner’s gland tumors obscured identification of Vater’s papilla. Thus, we carried out EUS-RV in the shortscope position at the descending duodenum. The PD was punctured with a 19-gauge needle, confirmed by EUS-guided antegrade pancreatography (Fig. 1). A 0.025-inch, angled guidewire was advanced through the needle into the duodenum under fluoroscopic guidance (Fig. 1). After withdrawal of the EUS scope, a duodenoscope was advanced near Vater’s papilla (Fig. 2). Snare forceps were used to grasp the end of the guidewire. ERP revealed irregular ductal change consistent with chronic pancreatitis. Finally, a 5-Fr nasopancreatic drainage tube was placed in the PD without complication. This technique is generally carried out from the stomach to the body of the pancreas to allow for stable scope positioning. To our knowledge, this is the first report of pancreatic EUS-RV for non-dilated PD at the head of the pancreas. The advantages of a short-scope position are the short distance between the puncture site and Vater’s papilla and the ease of directing the guidewire. This optional shortscope position would be particularly useful for pancreatic EUS-RV when the PD of the body of the pancreas is not dilated by EUS.