Practical Gastroenterology and Hepatology Board Review Toolkit

Nicholas J. Talley , Kenneth R. Devault, Michael B. Wallace, Bashar A. Aqel, Keith D. Lindor


62.1 Minor papillotomy in a patient with acute recurrent pancreatitis and pancreas divisum with Santorinicele

The patient presented with relapsing acute pancreatitis. MRCP without secretin demonstrated pancreas divisum with cystic dilation consistent with a Santorinicele at the terminus of the dorsal duct. At ERCP, major papilla was normal, and minor papilla was located but was small and flat, inverted, with no visible orifice. For localization of minor papilla we sprayed methylene blue onto the area and administered intravenous secretin. After a few minutes, the bulge of the minor papilla Santorinicele was clearly visible and this allowed a safe precut papillotomy with a needle knife. After precut, cannulation of the minor papilla with the papillotome was not difficult. At fluoroscopy you can see the guide wire passing through the dorsal duct to the body of the pancreas. Next, we extended the minor papillotomy, followed by pancreatic stenting with a 4 Fr 9 cm soft unflanged single pigtail pancreatic stent using the papillotome as a pusher tube. The video clip has an audio commentary.