A Case Report of Minor Papilla Stenting with Extracorporeal Ultrasound Guidance underwent Percutaneous Pancreatic Ductal Drainage for Chronic Pancreatitis with Pancreas Divisum

Abstract

Recently endoscopic pancreatic stenting have been attempted for pancreatic duct strictures in chronic pancreatitis. But in technically difficult cases for stenting, the alternative methods such as surgical treatment have been selected. A 51-year-old male presented with severe epigastric pain radiating to the back since 1991. ERCP demonstrated chronic pancreatitis and pancreatic divisum. Then choledochojejunostomy and cholecystectomy was performed in 1995. In 1999 he was admitted because of the increasing frequency and intensity of abdominal pain. The extracorporeal ultrasonography and contrast-enhanced abdominal CT scan revealed dilated pancreatic duct, pancreatic calcification and large pancreatic pseudocyst without septations. Using curved linear array echoendoscope the cystic puncture was performed with the needle and the fluid was aspirated. The transgastric drainage with the stent was attempted for the cyst, but the stent could not be passed through the wall. Then the transpapillary stenting was attempted, but the minor papilla could not be identified. Therefore the percutaneous puncture for dilatated pancreatic duct was performed. Then the minorpapilla was identified endoscopically with the guidewire inserted via extracorporeal route. The percutaneous approach with extracorporeal ultrasound guidance could be considered as the alternative method with safty in case that minor papilla can not be identified in the patient with chronic pancreatitis.