Pancreatic endoscopic ultrasound-assisted rendezvous procedure to facilitate drainage of nondilated pancreatic ducts.

scopic ultrasound−assisted rendezvous procedures has been reported previously in patients with obstructive chronic pan− creatitis [1 ± 5]. However, there have been no reports describing the use of this tech− nique in patients with normal pancreatic duct dimensions. We present two patients, a 42−year−old woman with a history of recurrent acute pancreatitis and a tight, inaccessible pan− creatic duct stricture seen at endoscopic retrograde cholangiopancreatography which was associated with an upstream fluid collection (patient A), and a 37− year−old woman with postsurgical Whip− ple anatomy who presented with persist− ent abdominal pain, in whom endoscopic retrograde cholangiopancreatography confirmed the presence of a widely pat− ent hepaticojejunostomy but failed to identify the pancreatic duct orifice, de− spite the administration of secretin (pa− tient B). A transgastric approach using a 22−gauge endoscopic ultrasound needle allowed access to the pancreatic duct upstream from the stricture (l" Fig. 1). A 0.018− inch guide wire was advanced across the pancreatic duct stricture and was coiled in the duodenum under endoscopic ultra− sound and fluoroscopic guidance (l" Fig. 2). After withdrawal of the echo endoscope, a gastroscope was advanced in patient A and a colonoscope in patient B. A biopsy cable within an Oasis system sheath (Cook Medical, Ireland) was used to grasp and stabilize the leading end of the guide wire. By withdrawing the endo− scope, both ends of the guide wire were identified exiting from the patient’s mouth. A dilating balloon was advanced over the guide wire, within the pancreatic head, under fluoroscopic guidance but without endoscopic assistance. Balloon dilation was performed, followed by placement of a pancreatic duct stent using the same technique (l" Fig. 3, l" 4). In this report we have described two pa− tients with pancreatic duct strictures that were inaccessible using traditional techniques, but which were managed using a combined endoscopic, endosono− graphic, and fluoroscopic pancreatic ren− dezvous technique. The unique technical aspects of these procedures included the achievement of endoscopic ultrasound access to diminutive pancreatic ducts, and the use of a biopsy cable within a catheter to “snag” the slippery guide wire, followed by balloon dilation and over−the−wire stent placement with lim− ited endoscopic guidance.