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Pancreas - Dual Sphincterotomy with a Needle Knife Over a Stent in Billroth II Anatomy for Sphincter

abstract

This 48 year old woman has intractable post cholecystectomy pain with abnormal LFTs and chronic pancreatitis. She is post gastric bypass for obesity with Billroth II type gastrojejunostomy. On MRCP you can see fluid in her gastric pouch her efferent limb, and her afferent limb, leading up to a moder...

ately dilated bile duct and irregular pancreatic duct. ERCP is undertaken to perform biliary and pancreatic sphincterotomies. Luckily the duodenoscope enters the afferent limb. Here again from the fluoroscopic view. Now we see pylorus from the duodenal bulb, and pulling back slowly reveals the major papilla from the upside down view, again seen fluoroscopically. Our usual approach to Billroth II cannulation involves using a rotatable papillotome turned upside down. However here it over rotates and gives an awkward approach. We then go to a very straight dilating catheter with a stiff 0.035 guide wire to give as cephalad an approach as possible. You can see this on fluoroscopy. Fishing with the wire enters the orifice and pancreatic duct. This is good and we will use this to our advantage to place a pancreatic stent for safety and landmarks during the needle knife access. We switch the 035 wire for a very floppy tipped 0.018 Roadrunner wire to help negotiate the tortuous pancreatic duct. Here you see the very soft knuckled end of the wire beyond a tortuous alpha loop in the pancreatic duct. Here the knuckle and here the alpha loop. Advancing the wire deeper requires reducing this loop much like pulling back a colonoscope to straighten the sigmoid colon. Now seen in slow motion as the loop comes out and wire advances to the tail. Next we place a 4 French 9cm unflanged pancreatic stent, using the papillotome as a Rapid exchange pusher tube. Now the fun part – needle knife for biliary access. Initially we cut up towards the pancreatic stent, but don’t like this uncontrolled flip of the knife, which can be dangerous. We then switch to cutting from the top down, with gentle pressure. The pancreatic stent not only protects against pancreatitis but tells us how deep we can cut. We see the gush of golden bile, and then cut a bit further. For bile duct access, we use the straight 0.035 wire through the triple lumen needle knife Cholangiogram fills a dilated bile duct To extend the biliary sphincterotomy we reintroduce our twisted papillotome, which now orients nicely towards 6 o’clock. You can see the reverse bow on x-ray. I prefer this technique to needle knife over a biliary stent as I feel it gives better control of the depth. Next a pancreatic sphincterotomy is performed by cutting along the pancreatic stent with the needle knife. A short sphincterotomy is done because of limited control. Finally we place a long unflanged 7 F pancreatic type stent in the bile duct. You see pancreatic and biliary stents. Both fell out by plain x-ray at one week. Contributed by:

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