EUS-guided rendezvous cannulation of minor papilla for recurrent pancreatitis due to pancreatic diffism. These are the disclosures. This is a 65-year-old gentleman, a non-drinker with history of DM and hypertension. He presented with recurrent acute pancreatitis since 2002. Back then, ERCP and MRCP were performed, which were normal. Liposcopic cholecystectomy was performed despite not having any gallstones in 2004. He continued to have repeated attacks every year, and the most recent attack was in July this year, 2022. He presented with typical epigastric pain and a serum amylase of over 2000. At that point, his liver function, calcium, and lipids were normal. A CT scan done one month after the attack, which showed a 4.5 times 6 centimeter pseudocyst in the pancreatic body. The scan was repeated three months later, which showed spontaneous resolve of the pseudocyst. An MRCP was subsequently performed, which showed a type 2 pancreatic diffism with an absent ventral duct. ERCP was attempted, but failed to identify the minor papilla despite repeated attempts. Papillary stenosis of the minor papilla was suspected. This is why we proceeded to this procedure, EOS-guided Honde-Wu cannulation of the minor papilla. The procedure started with a linear echoendoscope. The scope now is in the stomach at the pancreatic neck level, showing a dilated pancreatic duct, measuring 3.8 millimeters. The pancreatic duct was punctured with a 19-gauge FNA needle. As you can see on the video, the needle is within the pancreatic duct. A contrast injection confirmed the position of the needle in the pancreatic duct and showed a single pancreatic duct. A cuff tip 025 guide wire was inserted. After repeated attempts, the guide wire finally traversed the papilla into the duodenum. The scope was then changed from a linear echoendoscope to a duodenoscope. The guide wire was then grasped with a biopsy forceps. As you can see on the fluoroscopy films here, the scope now is in a long-loop position in D1, which is an unstable scope position. With the guide wire in situ in the pancreatic duct, the scope was then inserted deeper into the second part of the duodenum and reduced for a better scope position. A sphincter tome was subsequently inserted on wire and the guide wire exchanged. So the previous 0.025 guide wire was removed and reinserted with a flexible tip forward into the pancreatic duct. The next step then is a minor papillotomy. The papillotomy was performed over the 10 to 12 o'clock region of the minor papilla. The sphincterotome was then tightened to gauge the size and adequacy of the papillotomy. The last step then is the insertion of the pancreatic stent. In this case, a 5-fringe, 5-centimeter single-picture was inserted. Majority of patients with pancreatic diffusome are asymptomatic. In 25 to 38% of them, however, they suffer from recurrent acute pancreatitis, which may finally lead to chronic pancreatitis. For patients with recurrent acute pancreatitis or an episode of severe pancreatitis, endoscopic sphinctrotomy of the minor papilla should be considered. For patients who are asymptomatic, conservative treatment can be considered. Pancreatic diffusome is a rare but known cause of recurrent acute pancreatitis, especially in young patients. This is an important differential diagnosis that has to be actively looked for during MRCP. The first-line treatment is for ERCP and minor papillotomy. In case that fails, as in this case, an alternative is for EOS-guided rendezvous cannulation of the minor papilla to facilitate the minor papillotomy. Thank you.

pancreatitis

pancreatic diffism

recurrent attacks

ERCP

MRCP