Hello, I am Kapil Gupta along with my colleagues Tim Kinney and Marty Freeman. In this DVD, we will be discussing various topics related to endotherapy in pancreatic diseases. In the introduction section, we will cover the indications and appropriate use of endoscopic techniques in pancreatic diseases, the basics of pancreatic ductal anatomy, pancreatic duct access, imaging modalities available, and the tools and devices needed. Following that, we will be going over clinical cases with videos and still images and walk through each case. Indications and key elements of techniques and devices in pancreatic endotherapy. Pancreatic endotherapy can be effective in various disease processes. Before we actually discuss pancreatic endotherapy, we will like to stress on the fact that these interventions should be performed by an endoscopist with expertise and comfort in pancreatic therapy. Further, it is very important to note that such interventions are performed at advanced centers which have multidisciplinary approach with availability of good surgical backup, advanced imaging modalities, and other techniques like SWAL. We need to remember the caveats in endoscopic therapy in pancreatic diseases need to stress particularly the risk of complications and specially careful patient selection. The common indications for pancreatic endotherapy are acute recurrent pancreatitis from sphincter of OD dysfunction, recurrent acute pancreatitis from pancreas divisum, chronic pancreatitis with stones and strictures, fistulas and leaks, for management of pseudocysts, organized pancreatic necrosis, and some special case scenarios like post-vipal surgery patients. There has been more data available supporting the efficacy of endotherapy. The recent study comparing surgery to pancreatic endotherapy for chronic pancreatitis has to be interpreted carefully as this study was performed in a special subset of patients with markedly dilated pancreatic duct. The results from this study cannot be generalized to the broad diagnosis of chronic pancreatitis as many patients present with small duct disease, stones, less severe disease, and surgical option may not be the right option due to their underlying comorbidities. Briefly discussing the basic pancreatic ovulary anatomy, the pancreatic duct starts from the papillary orifice and runs through the length of the pancreas. On direct view of the papillary orifice, the pancreatic orifice is usually located to the right at 3 to 4 o'clock. The bile duct runs cephalot and the biliary orifice is usually located at around 11 o'clock. You can encounter various alterations in the anatomy of the ducts at the level of the papilla. There can be completely separate openings for the bile duct and the pancreatic duct or there could be a very long common channel. Also, the pancreatic duct can be in different shapes, can be a very straight duct or it can have a very tortuous course with an alpha loop or sharp bend at the genu. This is important to understand when passing a guide wire and attempting to place a pancreatic duct stent. Pancreas devisum is a normal variant in which the ventral and the dorsal pancreas fail to fuse embryologically and hence the main pancreatic duct drains via the minor papilla. Pancreas devisum is believed to be the cause of acute recurrent pancreatitis. In carefully selected patients, this can be treated by accessing the pancreatic duct from the minor papilla and performing minor papillotomy. This procedure will be discussed in a different section of this DVD. To access the pancreatic duct from the major papilla, the endoscope is usually kept more in a straight position so the catheter is oriented in a more straight line. An upward hook may lead to orientation towards the bile duct. Due to a more narrow caliber of the pancreatic duct, we recommend using taper-tip devices or pure wire-guided cannulation. It is sometimes very difficult to visualize the orifice. In such cases, spraying methylene blue with subsequent administration of secretin is very helpful. The sudden bolus release of pancreatic juices due to secretin clears the methylene blue and the orifice can be clearly visualized as seen here. It is important to understand the role of imaging for pancreatic endotherapy. A right imaging can help in judicious choice of the intervention and also avoid unnecessary interventions. High-resolution triple-phase CAT scans provide excellent images. Here a well-defined pseudocyst can be noted. MRI with MRCP, especially secretin-enhanced MRCP, along with endoscopic ultrasound can provide with excellent imaging alone or as a combination of different modalities. We often use secretin MRCP as it provides us with a roadmap of the pancreatic duct and decreases the need of injecting extra contrast. EOS is very helpful to assess strictures, identifying intra-ductal location of pancreatic duct stones, and also assists in identifying solid component in pseudocysts and organized necrosis. Interventional EOS also assists drainage of pancreatic collections and pancreatic duct access. When considering pancreatic endotherapy, it is advisable to understand and have some specific catheters, guide wires, and stents available in your endoscopy suite. An O1-8 guide wire is very helpful in pancreatic duct as it can form a loop and stays in the main duct and does not go into side branches. Smaller-sized dilating balloons like a 5-fringe dilating balloon, smaller 5-fringe stone removal baskets are essential to have in your endoscopy suite. Pancreatic duct stents play an important role in pancreatic endotherapy. A wide variety of stents are available for pancreatic duct and understanding what type of stents is to be used in which situation is very important. The stents vary from different lengths starting from 2 centimeters and longer, different size 3-fringe and upwards, and in different materials, hard materials or soft materials. We usually use hard stents in patients with severe chronic calcific pancreatitis where we are not worried about injuring the pancreatic duct and ducts which have stones and strictures. When a pancreatic duct stent is placed in a normal duct to decrease the risk of post-ERCP pancreatitis, we recommend using soft stents. In therapy of pancreas divisum or difficult-to-access papilla, a thinner caliber duodenoscope can be considered. Routine use of general anesthesia or MAC for all complex ERCPs and patients requiring pancreatic endotherapy is very helpful. The primary reason for endoscopic intervention in the setting of acute pancreatitis is to treat patients with suspected bile duct stones. Endoscopic treatment of bile duct stones falls outside the scope of this video. Instead, this section will focus on patients with non-biliary pancreatitis who may benefit from endoscopic therapy directed at the pancreas itself. After common etiologies of pancreatitis such as gallstones, alcohol, and medications have been excluded, a more thorough and exhaustive evaluation for the cause of pancreatitis should be undertaken. This is especially true in the patient with severe pancreatitis, prolonged symptoms, or recurrent disease. Important etiologies such as occult malignancy or aberrant anatomy must be considered. This can usually be identified by advanced imaging techniques. If an etiology has not been identified despite an extensive workup, biliary microlithiasis or sphincter of ODE dysfunction should be considered. When there is concern for sphincter of ODE dysfunction, it's best to avoid cutting the biliary and pancreatic sphincter empirically without first performing careful manometry, as these patients are at very high risk of post-ERCB pancreatitis and other complications, making it difficult to justify empiric therapy. This was clearly stated in recent NIH consensus guidelines. Techniques for pancreatic sphincterotomy. Pancreatic sphincterotomy is a bit more challenging than a typical biliary sphincterotomy with greater risks, so the first question to ask is whether pancreatic sphincterotomy is truly indicated. One of the primary differences in performing pancreatic sphincterotomy is the absence of typical landmarks that are used for biliary sphincterotomy. A pancreatic sphincterotomy is typically performed following a biliary sphincterotomy. This exposes the common channel and exposes the pancreatic orifice, making the pancreatic landmarks more visible. Pancreatic sphincterotomy can be performed using either the traction technique or with a needle knife. After the biliary orifice is identified and the pancreatic duct is successfully cannulated, a traction sphincterotome is directed towards the biliary orifice, and the pancreatic sphincterotomy is performed in the direction of the bile duct. Similarly, a needle knife can be used to cut the pancreatic sphincter, directing the needle knife towards the biliary orifice. The needle knife technique is typically performed over a pancreatic stent. This helps with orientation, helps to identify the sphincter, and likely adds a measure of safety to this technique. This technique has gained favor among many endoscopists after a recent study suggested a lower pancreatitis complication rate using the needle knife over a stent technique. Complications from sphincterotomy include, of course, pancreatitis and perforation, and a pancreatic stent should always be considered after performing a pancreatic sphincterotomy. Another fairly common and potentially quite serious complication from pancreatic sphincterotomy is re-stenosis of the pancreatic orifice at the sphincterotomy site, with subsequent pain or recurrent pancreatitis. It has been postulated that excessive coagulation current at the time of the sphincterotomy may contribute to re-stenosis. There is some evidence that the use of a pure cut current results in a lesser degree of post-pancreatic sphincterotomy complications. Many endoscopists will use either a pure cut or a blended current. This may also be due to an inappropriately deep-seated traction sphincterotome that cuts too deeply into the pancreatic parenchyma during sphincterotomy, instead of cutting just the sphincter muscle fibers at the pancreatic orifice. Great care should be taken when performing pancreatic sphincterotomies to cut only the superficial sphincter fibers along the septum, rather than a deep cut into the pancreatic parenchyma. This is a patient with severe right upper quadrant pain that is exacerbated by PO intake. Pancreatic ultrasound showed only 3 out of 9 criteria for chronic pancreatitis, which is non-diagnostic, and liver and pancreatic enzymes were normal. She is suspected of sphincterotomy dysfunction type 3. In this case, you can see a very small papillary orifice. In order to first identify the anatomy, a small amount of contrast is injected to pacify the main pancreatic duct. Here, a manometry cannula is inserted initially into the biliary orifice and then into the pancreatic orifice. The manometry cannula is then carefully withdrawn and pressures are measured, at first the proximal and then the distal sensors on the cannula. Pressure readouts, both from the proximal and distal sensors, show readings greater than 40 millimeters of mercury. A soft, small diameter wire is then carefully passed to the tail of the pancreas, following the path of the main pancreatic duct, as seen on pancreatogram. Again, care is taken to inject enough contrast to identify the main pancreatic duct, however not enough contrast to lead to acinarization. The biliary orifice is quite small and indistinct in this patient. After a pancreatic stent is passed into the pancreatic duct, the bile duct is now cannulated and a cholangiogram is performed. A biliary sphincterotomy is now performed using a standard sphincterotome. Notice after placement of the pancreatic stent and the cannulation of the bile duct how the papilla seems to grow larger and landmarks are more identifiable, even in this patient with a very small papilla initially. Here you can see a widely patent biliary orifice at the end of the procedure. Cholangiogram at the end of the sphincterotomy shows obvious drainage of contrast, suggesting complete ablation of the biliary sphincter. Here a needle knife is used to perform the pancreatic sphincterotomy. The needle knife is placed along the pancreatic stent and the sphincterotomy is performed using short bursts of primarily cut current, directing the sphincterotomy towards the biliary orifice seen at 12 o'clock. As you see, it can be difficult to identify the pancreatic sphincter fibers, but the use of a pancreatic stent can assist with this. The pancreatic stent also adds some safety measures so that the sphincterotomy is not performed too deep. Pancreatic stent placement. The importance of prophylactic pancreatic stenting cannot be overemphasized when performing pancreatic endotherapy. Risk factors for post-ERCP complications have been carefully analyzed and are likely due to both the risk categorization of the patient pre-procedure as well as to the risk of the procedure itself. Pancreatic stent placement should be a standard skill set that is available to any endoscopist performing ERCP, whether or not pancreatic therapy is performed. Even in difficult biliary cases in which multiple inadvertent pancreatic cannulations or wire passes have been performed, a pancreatic stent can reduce the risk of procedure-related pancreatitis. After the pancreatic duct has been identified and a pancreatogram has been performed, a wire is then passed into the pancreatic duct for stent placement. Gentle injection of contrast into the pancreas should be performed to reduce the risk of acinarization as well as procedure-related complications. Of course, this should be tailored to the patient and the indication for the procedure. In a young woman with acute recurrent pancreatitis and suspected sphincter voti dysfunction, a delicate technique and likely smaller amounts of contrast should be utilized when compared to a patient with longstanding burnt-out chronic pancreatitis who is likely at much lower risk of having severe post-ERCP pancreatitis. It is our preference to use a very small caliber, soft, flexible wire such as an 018-inch diameter wire. You can see in this video the tip of the wire is initially passed outside of the main pancreatic duct in a fairly tortuous duct. In this case, the tip of the soft, flexible pancreatic wire has become somewhat bent during the procedure. This can be used to our advantage as a bent-tip wire is much more likely to form a knuckle and then can make it around curves and corners in the main pancreatic duct rather than passing out through small side branches as demonstrated in this video. You can see the bent knuckle of the wire nicely follows along the main branch of the pancreatic duct. A 3-French stent is then placed. Here you can see a black mark that was placed with a marker at the end of the 3-French stent to help identify where the loop is formed, preventing accidental passage of the stent all the way into the duct. While passage of the wire to the tail of the pancreas can add to stability of the wire, this is not always required for placement of a pancreatic stent. As you can see in this case, there is a tight ansa loop. After a few attempts at navigating the pancreatic wire around the ansa loop, a decision was made to pass the wire just out to the loop and place a shorter 2-centimeter stent into the head of the pancreas. These shorter pancreatic stents can also be quite effective in reducing post-ERCP pancreatitis. Selection of the proper pancreatic stent is important, as is having a wide variety of stents available. Pancreatic stent-related injuries can result in severe or long-term pancreatic strictures potentially requiring surgical resection. While stiff stents have a role for treatment of strictures in the setting of chronic pancreatitis, care should be taken so that these stiffer pancreatic stents end in a straight portion of the duct rather than poking at or angulating into the wall around an ansa loop. Of course, it is also important to offer careful follow-up on pancreatic stents to ensure that temporary prophylactic stents either fall out spontaneously or are removed in a few weeks of the procedure time before they can result in longer-term complications. Again, in this case, you can see the pancreatic wire tends to go out a side branch. But with careful manipulation of the wire, it can be passed around the ansa loop and out to the tail of the gland. Here a long pancreatic stent is passed around the ansa loop out to the body tail. In this case, a tight ansa loop is identified pre-procedure on secretin-stimulated MRCP. A cannula is used to opacify the pancreatic duct, and the ansa loop is seen on endoscopic pancreatogram. In this case, it was quite difficult to pass the wire around the initial turn of the ansa loop and only a short segment of wire is passed into the pancreas. A short 2 cm stent is then placed over a short segment of wire to the head of the gland. Great care must be taken in this setting to maintain the scope position so that the wire stays in place. While this technique can be challenging, it is sometimes required or preferable to spending a great deal of time and potentially traumatizing the pancreas in attempts to pass a wire around a torturous pancreatic duct all the way out to the tail. In this case, the pancreatic duct stent is used to facilitate biliary cannulation in a patient with a very small papilla. After the pancreatic duct is stented, a biliary wire is used to pass alongside the pancreatic stent and selectively cannulate the bile duct using the wire guided technique. The rest of this procedure is fairly straightforward after the pancreatic duct is stented. Biliary sphincterotomy is performed. A limited pancreatic sphincterotomy is then performed over the previously placed pancreatic stent. Pancreas Divisum, minor papilla therapy. First we should ask ourselves, does it need to be done? Should I be the one to do it? And am I in the right place to do it? Minor papilla therapy in patients with pancreas divisum is one of the most challenging and risky procedures in ERCP. It requires a high degree of expertise, not only of the endoscopist, but of the nursing team and very high resolution fluoroscopy. Whether or not to do minor papillotomy or other therapy is a complex and controversial decision. Pancreas divisum can be associated with acute recurrent pancreatitis, chronic pancreatitis, possibly chronic pain only, or no symptoms. Many patients have overlap between these patterns, bouts of pain with elevated amylase, but also have chronic pain between attacks. They also may have evidence of chronic pancreatitis by endoscopic ultrasound, or MRCP. Response to intervention varies, and particularly resolution of any chronic pain component independent of acute episodes can be quite disappointing. Because minor papilla access can be difficult and risky, it's important to define anatomy in advance with non-invasive imaging and to plan therapy accordingly. Secretin MRCP and EUS are both very useful and complementary and avoid the risk of direct pancreatography. MRCP can be very accurate and provides a nice roadmap. Secretin improves diagnostic accuracy of MRCP and can be the only way to identify a Santorini seal. Here are a number of examples of secretin MRCP before and after secretin, where you can't really see the dorsal duct until you give the secretin. Here you see incomplete pancreas devisum. Here complete pancreas devisum. Here a Santorini seal. Here are examples of moderate and severe chronic pancreatitis. EUS is the best available tool to assess for chronic pancreatitis, especially for small stones and an expert hands to detect the presence of devisum as well. Here you see a clear-cut example of the pancreatic duct draining through the minor papilla. Here is a small intraductal stone not seen at CT scan. For the ERCP shown in every one of the following cases, MRCP or EUS have demonstrated pancreas devisum in advance, and a plan for minor papilla therapy has been made after informed discussion with the patient. There are two main techniques for minor papillotomy. Some do needle knife over a pancreatic stent, while others do traction papillotomy. First, you must obtain deep wire access to the minor papilla. This case demonstrates a fairly classic technique. We have injected a ventral duct to show that there is pancreas devisum, which is really unnecessary in most cases with adequate imaging. When accessing the minor papilla, the key is to do pure wire cannulation without touching the papilla with a catheter. If you do poke at the papilla, the orifice can close up like a frightened clam or get edematous. Here we are using an 018 wire with a very soft platinum tip, angled upwards towards 11 o'clock, somewhat like a bile duct. We inject minimal contrast into this very small dorsal duct. We are not able to deeply cannulate without deep wire passage first. As often happens, the wire goes out of side branch. It is very important not to push the wire any further and thus avoid side branch perforation. Rather, pull it back, redirect the catheter, shorten the scope position a little bit, and again, no side branch perforation here. We want to pull back a little more. Notice we have not injected very much contrast, and with some repositioning, we'll float the wire out to the tail. When doing minor papillotomy, it is very important to use a minimal length of cutting wire in contact with a tissue. This is so that we don't fry the duct, cause strictures, scarring, or restenosis. Landmarks are often unclear. Now you can see up the duct rather nicely, indicating epatulous papillotomy. The stent typically placed by many advanced endoscopists is this 8 to 10 centimeter long three French unflanged stent with a big pigtail. I must admit, we haven't had such good results with these stents as some others. Although this case took only 20 minutes to do, the patient was in the hospital for five days afterwards with posterior CP pancreatitis. Our preference now is to use soft material, shorter stents, although data are not there to support this choice. What is really important is to avoid duct injury. Here is an unfortunate young man whose dorsal duct was destroyed by placing a five French two centimeter flanged polyethylene stent on two different occasions for two weeks at a time, done at an expert center. He ended up referred to our center for total pancreatectomy with islet auto-transplantation when repeated endoscopic therapy failed to resolve this stricture. We generally recommend either short 2 to 3 centimeter soft material stents or very long 8 to 10 centimeter very small caliber three French or soft material four French stents in order to minimize the risk of duct injury, especially in small caliber or normal dorsal ducts. What we really want to avoid with minor papilla access is this kind of situation that you see here in this patient who had minor papillotomy done elsewhere, where the pancreas is filled out to the secondary and even tertiary branch ducts and even acinarized. This is not ideal. The logical conclusion of precise advanced knowledge of the pancreatic anatomy from MRCP and EUS is not to use contrast at all if we can. In this case, in this patient with acute recurrent pancreatitis, secretin MRCP has conclusively shown presence of pancreas devicem. We use pure wire cannulation with an O2-1 hybrid wire. The papilla is too stenotic to allow a five French paplitome to enter, therefore we unroof the papilla with a needle knife over the secure wire access. We then perform a pull-type traction sphincterotomy, cut effect one, and not cut too deep. Then we place a soft material four French, two centimeter, single inner flange stent. Look ma, no contrast. Now granted, this isn't always possible. Now finding minor papilla and its orifice can be very difficult at times. If the orifice isn't clear, spraying methylene blue and giving IV secretin, as in this case, will identify and open up the orifice. In this still image sequence, in a patient with known Santorini seal from MRCP, there is no clue as to the location of the minor papilla or its orifice. After the combination of the two, you will see a fish mouth opening. This next patient had two failed attempts at minor papilla access at a very expert center. There is no visual clue as to the whereabouts of the minor papilla or its orifice. That clip at the bottom was from a prior biliary sphincterotomy bleed. In this case, it's indispensable to spray methylene blue and give IV secretin. If you watch very closely, you can see the blush of clearing indicating pancreatic juice drainage, even though there is absolutely no papillary landmark. Trotting is not so good, as it caused a little oozing here. An O2-1 hybrid pops into the orifice, however, it is still not going in deep. We then open up the orifice with a needle knife over the guide wire. Then we get better access. Here again, avoiding side branches carefully. This next case re-emphasizes the importance of advanced imaging, just like using a GPS system for your car. In this lady with acute recurrent pancreatitis, secretin MRCP shows pancreas divisum with an obvious Santorini seal or cystic dilation at the terminus of the duct. When you give secretin, you can see how fat the dorsal duct gets and see how the sac at the minor papilla inflates. Endoscopically, minor papilla is very flat, almost collapsed, and there is no orifice. So, we try very briefly to wire cannulate it, but once we give secretin and spray methylene blue, the Santorini seal turns from an innie to an outie. Now we are fairly comfortable needle knifing it as we know we are unroofing a cystic structure. We are just going to open it enough to get access with a papiltome and an O2-1 wire. Notice that we use almost no contrast in this patient as we know exactly where the duct goes by secretin MR. In this case, of a patient who lived in rural North Dakota, we wanted to put in a self-ejecting stent. We also did not feel this was a terribly high-risk procedure, so in this case we are using a long, soft, four-french, unflanged, single-pigtail stent, which should not injure the duct but will stay in for at least a day or two and then will pass out within a few weeks. Here, we will perform a needle knife pre-cut for minor papilla access on a patient without a bulging Santorini seal. We do this very rarely and with some trepidation. Again, we know in advance the patient has pancreas divisum by secretin MRCP and EUS, but this patient has no Santorini seal. This patient has well-documented acute recurrent pancreatitis and a prior failed attempt at minor papilla access by a truly expert endoscopist. We try to cut the wire, but it's just not going deep. After giving secretin to help open things up, the same thing is happening here. We're just not getting anywhere with the wire. This angled O2O wire gives us the upwards curve we need, but the wire just goes in and stops. We want to avoid intramural injection. So here, we are doing a needle knife pre-cut very carefully up the middle of the minor papilla. It is pretty much the same orientation as a biliary sphincterotomy towards 11 to 12 o'clock. Then we are going to spray methylene blue and give secretin and watch. You would think the orifice would be at the top, but by this secretin blush, you can see it is closer to the bottom and with some careful probing, the wire and catheter goes in. Look closely here. Even with a super high resolution fluoroscopy, you can barely see this tiny wire exiting a side branch. If we had pushed any further, it would have perforated the duct. After redirecting the wire into the main duct, once we are in deeply, we have to exchange to a more stable wire and that means pushing all that contrast from the catheter into the duct. To avoid this, it is ideal to use one guide wire from start to finish to avoid intraductal exchange. Chronic Pancreatitis may lead to pain from a number of mechanisms, one of which is duct obstruction and hypertension due to strictures in stones. These are potential candidates for endoscopic therapy. Complications of chronic pancreatitis, such as duct disruption, pseudocyst, and biliary obstruction are covered elsewhere in this DVD. Adjunct therapy should be done in the context of all available therapies, including medical, endoscopic, and surgical, and the decision for therapeutic approach should be individualized to the patient. Availability of adjunct techniques, such as ESWL, and advanced pancreatic surgery is critical. For surgery, the classic concept has been for dilated ducts that pusto pancreaticogenostomy drainage procedures are preferable. And for small ducts, Whipple or distal pancreatectomy is done. Our approach at the University of Minnesota and the Minnesota Pancreas and Liver Center is a bit different. For severe head-dominant disease, we will sometimes offer Whipple resection. In most patients, however, we offer aggressive endoscopic therapy. We avoid surgical drainage operations, such as pusto, even though a recent small randomized trial suggested superiority of surgical drainage. This is because drainage operations, or tail resections, eventually fail in about half of the patients and severely compromise the ability to retrieve islet cells in case of a future resection with islet auto-transplantation. In the event that the patient fails other treatments, total pancreatectomy with islet cell auto-transplantation is, in our opinion, the ultimate therapy for refractory pain of chronic pancreatitis. This procedure, developed and pioneered at the University of Minnesota, preserves islet cell function and reduces or eliminates the otherwise inevitable surgical diabetes, does not require immunosuppression, and is sometimes the only way to relieve intractable pain. Pancreatic stone extraction. Perhaps the most effective thing we do in endoscopic therapy of chronic pancreatitis is to remove main pancreatic duct stones. This is in a meta-analysis of ESWL published by Nalini Gupta and our group. Pain relief occurred in about two-thirds of patients. Choose your targets well. With an inflammatory mass and complex stones in the head, in general, endoscopic therapy is going to be pretty futile. This patient will probably be better served with a Whipple resection. In some patients with pancreatic duct stones and associated peripapillary stenosis, endotherapy consisting of pancreatic sphincterotomy and stone removal can be quite effective. It's relatively uncommon, though, to be able to clear a pancreatic duct of substantial stone burden at a single session. Here's an example where one session was adequate. The basic approach to pancreatic stones is to perform usually a biliary, then a pancreatic sphincterotomy. Here you can see a patient with double duct dilation but no biliary stricture. The reason for biliary sphincterotomy is just to make room for the pancreatic septum to be cut, although it is not essential to cut the biliary sphincter prior. Here is an example where just the pancreatic sphincter has been cut, leaving the biliary sphincter intact. Dual sphincterotomy with lithotripsy basket extraction allows complete clearance in one session. In our experience, this is more feasible in patients with hereditary and idiopathic pancreatitis than in alcoholic pancreatitis, but this is just an impression. In general, we don't recommend balloons to remove pancreatic stones, except at the very end of the procedure, because they tend to break, and they also tend to push stones out the side branches. Here after stone extraction, we've placed a couple of long, soft, self-ejecting stents. Here's an unusual example of a patient who is a college student with hereditary pancreatitis who has relapsing bouts of pancreatitis and chronic pain. MRCP after secretin shows dorsal dominant drainage with a prominent minor papilla and possibly a small stone in the distal pancreatic duct, which you can't really see very well. EUS shows us that in fact she does have a small stone in the distal MPD. At ERCP, MPD is too tortuous to allow meaningful therapy. Instead, we approach the minor papilla, knowing from MRCP that it is large and dominant. This patient has done very well for two years since this minor papillotomy was done, with spontaneous passage of the stone, presumably back out the minor papilla. Here are a few examples of sizable pancreatic stones that can be removed through a pancreatic sphincterotomy with additional balloon dilation of a stricture. Sometimes mechanical lithotripsy will allow crushing and extraction of a stone too large to remove through a narrowed or strictured distal duct. The problem with basket lithotripsy is that PD stones are often impacted and they prevent capture with the basket. Sometimes just to get a catheter and stent past a stone, a screw dilator is necessary. For about half of pancreatic stones, standard endoscopic techniques are not adequate. ESWL is indispensable and almost a prerequisite for effective treatment. This picture shows our setup for ESWL. General anesthesia, prone position, and in this 12-year-old with hereditary pancreatitis and non-radio-opaque stones, targeting is done by using the stents as a landmark. You can imagine that a stone like this monster in a renal transplant patient with intractable pain will not be amenable to endoscopic techniques. One session of ESWL and the duct was cleared with complete resolution of pain. ESWL can also be necessary for completely impacted stones such as this one in an elderly male with idiopathic chronic pancreatitis presenting with acute intermittent episodes of pain and pancreatitis. Only a 3 French stent could be placed. After ESWL, fragments were cleared easily. Another approach to refractory stones, which is increasingly in vogue but very laborious, is intraductal EHL lithotripsy through a baby scope. Here is a short clip courtesy of Doug Howell. While sometimes possible, obtaining adequate visualization and targeting of a stone without hitting duct wall is unusual, as pancreatic stones are often impacted above a quite narrow duct. We generally prefer ESWL. With a very dilated duct, spyglass can be used to inspect the duct for clearance. The new spy allows steering all the way to the tail. Small fragments of residual stone can be seen here that were not apparent by fluoroscopy after endoscopic clearance of a rather large pancreatic stone. Dilating strictures which are below stones is essential not only for stone extraction but probably for drainage and clinical efficacy as well. In this case of an alcoholic patient with dorsal-dominant drainage, otherwise known as pseudodevesin, minor papilla is accessed using the new loop wire. Stents are placed through the tight downstream stricture. ESWL is performed and the duct is cleared. Stents are then removed after the stricture is resolved. Unfortunately, despite a good technical result, this patient did not respond well with any improvement in pain and was referred for total pancreatectomy with islet auto-transplantation. It's thought by some that the principal endoscopic therapy for chronic pancreatitis consists of pancreatic stent placement. In fact, stenting alone is probably the least effective thing we do, particularly in patients with chronic pain. Remember that isolated strictures may actually be due to an inflammatory mass for which endotherapy is futile, but they also may be due to tumors and increasingly now autoimmune pancreatitis. Before embarking on a potentially endless series of ERCPs in an otherwise good surgical candidate with head-dominant disease, consider alternatives such as Whipple resection. There are situations where stricture therapy with dilation and stenting are appropriate. They should be approached, like benign biliary strictures, with aggressive dilation and placement of increasing numbers of stents. This one looks like the hand of the grim reaper. Note that we use single pigtail long stents, not straight long stents, because those can ratchet themselves up inside the duct and cause problematic migration. There are often situations where surgery might be ideal, but patients refuse to have an operation or have contraindications such as portal hypertension. This 40-year-old otherwise healthy man has a dominant stricture in the head with chronic pain that responded dramatically to stents. He refused any kind of surgery because it would have meant six weeks off from his self-employed floor finishing business. Instead, he comes back to us every six months. We prefer to use multiple stents, in this case, four seven-french stents rather than one or two big 10-french stents, because the side branches drain better around small stents, and the small stents provide drainage between the stents should the lumen become occluded. This sequence shows techniques of stricture dilation and stent exchange. This patient had a difficult-to-access stricture, which we are treating because he responds very well to stents with dramatic improvement in pain, allowing him to work and function well. He's been unable to have surgery because he has portal hypertension due to a thrombosed portal vein. At his six-month stent exchanges, we put in three to four five-french stents. Here you can see they are rather crusty. To maintain access, we put a guide wire up through the stents, pull out the stents, and make sure to cover him with intravenous antibiotics. We then clear out any stone debris through the stricture. Then we place multiple soft stents, here one beside the other. I don't think we are ever going to fix this stricture, but he certainly has been doing well clinically. It is not infrequent to require a screw dilator to get any catheter or balloon through a stricture. When managing chronic pancreatitis with endoscopic therapy, it's very important to have a strategy as well as an exit strategy. Don't repeat ERCPs endlessly if the patient doesn't respond or is a good surgical candidate. Don't just be a scoped doctor. Bill restrictors can occur due to extrinsic compression of the bile ducts by chronic and or acute pancreatitis. If they result in significant choastasis, treatment may be indicated. Don't forget that they may be due to cancer or autoimmune pancreatitis. Also, in some cases, surgical management may be in order. Don't forget that simply draining a biliary stricture will seldom provide pain relief, so that Whipple resection may be considered for patients with head-dominant disease who have biliary and pancreatic strictures. Endoscopic therapy of biliary strictures consists of temporizing for good surgical candidates. Excessive endotherapy may be indicated in patients who are poor candidates for any kind of surgery due to comorbidity, portal hypertension, or who have a difficult surgical abdomen due to severe prior inflammatory disease or multiple other operations. Choices for endoscopic drainage include a single 10-fringe stent of limited benefit or balloon dilation with multiple plastic stents. Double pigtail stents are immune to inward or outward migration. After balloon dilation, multiple 10-fringe straight stents can be placed. This looks very dramatic. Intervals between ERCPs can be as long as 6 to 12 months. It is a poor idea to place uncovered metal stents for benign strictures, as tissue ingrowth and hyperplasia are almost inevitable. Look at this buried stent. A novel strategy, though, is to place fully covered, removable metallic stents. Here is a patient with advanced cardiopulmonary disease. You can see the filter, who presented with biliary sepsis due to a distal stricture. Here he is receiving a trimmed, covered wall stent with the bare top wires cut off. Unfortunately, this stent migrated out of the duct and passed out of his bowel uneventfully. To prevent migration, fully covered stents with anchors can be used. Here is an elderly, poor surgical candidate with idiopathic chronic pancreatitis and a biliary stricture causing cholestasis. A covered metal stent was placed. She was followed expectantly, and two years later, she returned with mild cholangitis. Here you can see the stent being removed. The stent is completely occluded by stones and sludge. Yuck! Pretty good resolution of the stricture is noted, and the patient has done well since removal. Palliation of biliary stents is a common problem. The main indication for endoscopic pancreatic duct drainage in cancer is for patients with a recurring acute pancreatitis or duct disruption above a malignant stricture. Pancreatic duct obstruction as a cause of pain in advanced cancer is quite unpredictable, and we tend to avoid pancreatic stenting for that indication alone. Here is a very unusual case of pancreatic duct obstruction. The patient has been treated for pancreatic duct obstruction, and we tend to avoid pancreatic stenting for that indication alone. Here is a very unusual case of a young man with relentless smoldering pancreatitis due to metastatic melanoma to the head of the pancreas. He has an obvious pancreatic duct stricture and has smoldering pancreatitis with intractable pain. He responded very well to placement of a stent. In this case from about 15 years ago, note how much contrast we injected. We generally don't do that anymore. Here is a patient who had an IPMN that degenerated into a frank unresectable carcinoma just above the minor papilla. She happened to have pancreas divisum and presented with a disrupted pancreatic duct and a liver abscess. After treatment with a pancreatic stent through the minor papilla resolved her symptoms, the persistent fistula leaking up to the hepatic abscess was treated by bridging the minor papilla with a metallic stent. Interestingly, that patient went on later to have biliary and duodenal stents for jaundice and then gastric outlet obstruction. But she survived two years after the initial diagnosis with very good quality of life. And as I recall, she lived independently and took care of her ailing husband for the last year of her life. Finally, here is another patient with unresectable pancreatic cancer who had a large pseudocyst caused by surgical exploration that was drained endoscopically a month earlier. However, she still has a chronic fistula from the pancreatic duct one month later. This was treated by placing metallic stents through the obstructed pancreatic and biliary strictures. A niche opportunity for endoscopic therapy for acute recurrent pancreatitis is type 3 coledocal cyst or coledococel. In this unique case, a 17-year-old with recurrent acute pancreatitis has a secretin MRCP showing a double-barrel coledococel. MRCP done elsewhere failed because no biliary orifice was seen, which we confirmed. When we come back to the minor papilla, you can see bile coming out of it. Therefore, we access it and see that the coledococel doesn't empty into the duodenum. We unroof the major pancreas and see that the coledococel doesn't empty into the duodenum. We unroof the major papilla with a needle knife followed by pancreatic stent to reduce risk of pancreatitis. And then we inject the bile duct to prove that the ducts have now been separated. Our theory here was that all of his biliary and pancreatic secretions were refluxing through the minor papilla. Our theory here was that all of his biliary and pancreatic secretions were refluxing through the minor papilla. or liquefy completely over time with a well-defined wall forming what is known as a pseudocyst. Many times, severe acute pancreatitis can just present as a large pancreatic fluid collection. Any of these collections can get infected, which does present with a critical condition and needs to be managed very aggressively. Over many years, we have changed from surgical management to endoscopic intervention. In this section, we will show examples of these collections and endoscopic management and importance of endoscopic ultrasound in managing these collections. In patients where there is an obvious bulge in the stomach or the duodenum, it is our personal preference to use EUS in all such cases. EUS also gives additional information regarding the solid component in the collection and helps in avoiding blood vessels which could be traversing the path of the needle. Recent randomized trials from Varadarajulu and colleagues have shown a high technical success rate of EUS-guided training over no use of EUS. Some of the key elements when performing a cyst gastrostomy or cyst enterostomy to be kept in mind are if a therapeutic echo endoscope is used, the entire procedure can be performed with one scope. We always use a 19-gauge needle to access the cavity as it gives us the option of using different guide wires. Further, when a puncture is made with a 19-gauge needle, it is easy to pass a dilating balloon such as a cystotome or needle knife. We give pre-drainage antibiotics. We perform all these procedures under general anesthesia for airway protection, especially when draining large pseudocysts as there can be a gush of cyst fluid into the stomach. Now we will discuss some of these cases. In a patient where the pseudocyst is communicating with the main pancreatic duct, a transpapillary stent can be placed into the cyst This patient has a pseudocyst in the head of the pancreas as seen on CAT scan and MRCP. At ERCP, communication with the pancreatic duct is noted. A guide wire is first passed to the tail of the pancreas and a second guide wire is coiled into the cyst. Transpapillary stents are placed to the tail and one in the cyst. Follow-up CAT scan shows complete resolution of the cyst cavity. Repeat ERCP, no filling of the cyst cavity is noted. In a similar such case, a pseudocyst communicating with the main pancreatic duct is identified. As can be seen in this sequence, the cyst communicates with the main pancreatic duct. A transpapillary stent is placed into the cyst cavity. At follow-up ERCP, there is complete resolution of the cyst and the guide wire is advanced into the tail of the pancreas and a stent is placed. In this next case, a pseudocyst is drained from the stomach in a traditional way without the use of endoscopic ultrasound. When a pseudocyst has completely liquefied and has an obvious bulge seen endoscopically, the cyst can probably be drained without the EUS, although nowadays we routinely use EUS for drainage as we mentioned earlier. CAT scan can also assist in identifying the ideal site for puncture for drainage. Using a needle knife, a puncture is made into the cyst, and a sudden gush of fluid is noted. After dilating the tract with a balloon, multiple double pigtail stents are placed. Follow-up imaging shows complete resolution of the pseudocyst. The following patient presented with ongoing abdominal pain following an episode of severe acute pancreatitis. On imaging, a well-defined pseudocyst with a discrete wall is noted. Endoscopically, no bulge is noted in the stent of the duodenum. Sonographically, the cyst is seen from the second portion of the duodenum. Color doppler is used to rule out any intervening vascular structures. A 19-gauge needle is used to access the cyst, and a O1-8 wire is coiled into the cyst. The echoendoscope is then carefully changed to a duodenoscope. The cyst gastrostomy tract is dilated using a stent retriever as a screw dilator. The tract is then dilated using an 8-millimeter dilating balloon. Two 10-french-by-1-centimeter double pigtail stents are placed. Patient recovered completely with resolution of the pseudocyst as seen on these CAT scans. It is not unusual to find complete disruption of the pancreatic duct, usually in the body of the pancreas, where a segment of pancreas is completely necrotic, as seen on these MRCP. In such cases, we'll place a transpapillary stent in the pancreatic duct and also drain the necrotic area through the stomach. If the pancreatic duct in the head and the distal body tail cannot be connected, attempt is made at subsequent ERCP to connect the duct once the necrosis is completely drained. This is a patient with history of alcohol use who presented with severe abdominal pain for more than one month. Imaging showed a complex and irregular fluid collection in and around the pancreas with necrosis of the mid-body. At ERCP, a very tortuous pancreatic duct is noted. A O1-8 wire is passed after forming a knuckle. Injection of contrast shows complete disruption of the pancreatic duct in the mid-body. A 7-french stent is placed across the papilla extending to the disruption. A biliary sphincteromy is performed, and a bile duct stent is placed for drainage. The fluid collection is then visualized by a CT scan of the pancreas. From the stomach using EUS, the cavity is punctured using a 19-gauge needle, and a O1-8 wire is advanced under EUS guidance and fluoroscopy guidance. The echoendoscope is removed, and a regular duodenoscope is advanced over the guide wire. The cyst gastrostomy tract is then dilated using a 8-millimeter dilating balloon. A loop-tip wire is advanced over the first wire. Two 10-french by 1-centimeter double-peaked tail stents are placed into the cavity. A follow-up CAT scan after one week shows significant decrease in the collection. At subsequent ERCP, pancreatic duct is accessed using a 021-inch guide wire, and a 021-inch guide wire is advanced over the second wire. And a guide wire is successfully advanced to the tail of the pancreas across the disruption. Previously placed stent is removed. A 7-french and a 5-french stent are placed to the tail of the pancreas. At subsequent intervention, depending on imaging, we will remove the stents from the collection and evaluate the pancreatic duct for any residual leak. Endoscopic debridement of organized pancreatic necrosis. When treating organized pancreatic necrosis, the patient is advised to use a non-invasive pancreatic necrosis. When treating organized pancreatic necrosis or infected collections. It has to be kept in mind that just putting stents in collection will not be enough. We usually dilate the cystosomy using a balloon up to 12 millimeter. Subsequently, a regular upper endoscope is passed into the cavity and endoscopic debridement completed. The cavity is also lavaged aggressively using saline. The following case shows such an example where the patient presented with infected necrosis. Here on CAT scan, imaging shows a large peripancreatic collection. Initially, a traditional ERCP is performed and transpapillary stents are placed in the bile duct and the pancreatic duct. A transgastric cyst gastrostomy is performed. A guide wire is coiled into the cyst cavity. The cyst gastrostomy is then dilated using a balloon. Two 10 French double pigtail stents are placed. Follow-up CAT scan shows marked reduction in the collection as seen on these CAT scans. At subsequent procedure, the cyst gastrostomy tract is further dilated to 10 millimeter. A regular upper endoscope is passed through the cyst gastrostomy into the cavity and the cavity is aggressively lavaged. In patients with infected collections, we also place a nasocystic drain and this can be used to irrigate the cavity from outside. Depending on the clinical course of the patient, the procedure is repeated in few weeks interval till complete resolution of the collection. In cases with large amount of necrosis, we are more aggressive, especially in patients who are poor surgical candidates. The following patient has extensive cardiac disease and presents with severe necrosis. The patient presented with severe necrotizing gallstone pancreatitis with sepsis from infection of the necrosis. Any surgical intervention was deemed high risk. A CAT scan showed necrosis with air suggestive of infection as seen here. At initial ERCP, biliary sphincterotomy is performed, a transpapillary stent is placed and a EUS guided cyst gastrostomy is performed. A nasocystic drain is also placed for lavage of the cavity from outside. The patient improved clinically with complete resolution of sepsis. At subsequent ERCP, the cyst gastrostomy tract is dilated using a balloon and a regular endoscope is passed into the cavity. Using basket and forceps, the necrotic material is removed as seen in these images. After aggressive debridement, the transpapillary stent can be visualized in the cavity and also the opening of the disconnected duct in the tail of the pancreas, which is also confirmed by injecting contrast from the cyst cavity as seen on these images. This patient recovered well and at subsequent procedures, transpapillary stents and stents in the cyst gastrostomy are removed. In certain cases, there is a large apposition of the organized pancreatic necrosis with the stomach wall and there is absolutely no liquefaction. The cavity is full of solid material. In such cases, a laparoscopic cyst gastrostomy is also a preferred technique. The advantage is that a large cyst gastrostomy can be created and patient does not need repeated procedures. In this case, the organized necrosis is accessed from the posterior wall of the body of the stomach. The dead material is then removed after a large surgical cyst gastrostomy is created. The following scans show progression of a patient from initial presentation to current state. Again, patient presented with severe acute gallstone pancreatitis. Imaging showed extensive necrosis with peripancreatic fluid collection as seen on these CAT scan and EUS images. Patient improved rapidly with conservative management. On repeated imaging, 11 months are from the initial episode. She has large area of organized necrosis, but she is clinically asymptomatic as seen on these MRI scans. This patient we are following clinically with no endoscopic intervention. It should be kept in mind that sometimes intervention should be done only if patient is having clinical symptoms and not to treat imaging findings. Pancreatic endotherapy in special situations. Fistulas and leaks, pancreatic duct disruptions. Pancreatic fistulas are a frequent complication of severe pancreatitis. Fistulas can also occur after pancreatic surgery such as a whipple or tail resection. Whereas treatment of bile leaks post cholecystectomy has become commonplace for doctors performing ERCP, endoscopic treatment of pancreatic duct leaks can be very challenging. Unlike stenting of bile leaks in which simply stenting across the papilla is enough to divert flow through the stent, there is data to suggest pancreatic duct leaks respond better to stenting across the leak rather than simply across the papilla. Therefore, it is important to opacify the pancreatic duct and pass a wire across the leak so that a stent can be placed that actually bridges the leak. This is much more easily accomplished with partial leaks in the pancreatic duct as compared to complete duct blowouts in which the contrast spills freely from the leak into pancreatic fluid collections, especially when the tail is not easily opacified. When a complete duct disruption is identified, this can be much more difficult to treat endoscopically. A pancreatic stent can be placed from the papilla across the disruption and into the pancreatic fluid collection with the hopes that after the fluid collection resolves, a repeat attempt at ERCP may be successful at identifying the tail of the duct and stenting across the leak. Strong consideration should be made in this setting to drain the pancreatic fluid collection either via transgastric or transduodenal endoscopic drainage, percutaneous drainage, or surgical drainage. In the setting of a complete duct disruption in the mid-duct, simply stenting below the point of disruption may reduce the leak from the head of the gland in a retrograde fashion out of the site of the leak, although this is less likely to lead to long-term clinical success. As always, choosing the proper stent is important. A larger, stiffer stent that is designed to hold itself in place rather than pass spontaneously is preferred. In this case, you can see a moderate-sized pancreatic fluid collection in the middle of the abdomen on the patient's CT scan. You can see that there is a nice abutment of the gastrointestinal lumen at the duodenal bulb. A needle knife is used to puncture the pancreatic pseudocyst endoscopically. A wire is coiled into the pseudocyst cavity. The needle knife is then removed and several loops of wire are passed into the cavity. A dilation balloon is then used to dilate the cyst gastrostomy tract, and copious fluid is then seen draining from the cyst gastrostomy. A 10-french, two-centimeter double pigtail stent is then passed across the pseudocyst drainage site. A second stent is then placed alongside the first stent in order to keep the drainage tract open. The patient did well after the initial pseudocyst drainage, but imaging one month later showed a residual pseudocyst cavity. A secretin-stimulated MRCP shows a disconnected duct syndrome with a persistent fluid cavity. ERCP performed at that time shows a wire that is passed into the cyst cavity at the end of the pancreatic duct. A stent is then passed through the stump of the duct into the cyst cavity. Notice the pancreatic secretions draining from the stent. The cyst cavity is then entered alongside of the 10-french stent, and the cavity is flushed. Necrotic-looking debris is seen coming from the cyst cavity. A nasocystic drain is then placed for ongoing flushing and lavage of the cyst cavity for a couple of days with normal saline. The patient is brought back again one month after this time. And at this point, the stent is flushed and the patient is able to walk again. The patient is able to walk again, and the patient is able to walk again. The patient is able to walk again one month after this time. And at this point, the cyst cavity has completely resolved. The pancreatogram from the papilla shows fluid extravasation directly into the cyst cavity. The cyst cavity is then injected and the cavity fills, but also a bit of the tail can be opacified. This suggests that the patient has a persistent fluid pocket with a disconnected duct and is somehow draining contrast from the tail into the cyst cavity. This may predict a recurrence of the cyst or ongoing fistula in the future. Attempts at reconnecting the head and tail of the pancreatic duct endoscopically were not successful in this patient. In this case, a patient had a pancreatic stent placed for post-DRCP pancreatitis prevention. The stent was found to have migrated inwardly and needed to be retrieved. A small pancreatic stone basket is used to grasp the stent. And the stent is pulled from the papilla. A standard rat-tooth forceps is then used to retrieve the stent. Given the concern for potential trauma and pancreatitis from the procedure, another stent with a large external pigtail is placed. This patient had previously undergone a PUSTO procedure and subsequently developed recurrent pain. She was found to have a stricture at the pancreatic jejunal anastomosis. A guidewire is passed into the jejunal limb and balloon dilation is performed. While admittedly the efficacy of this procedure is likely limited, it was deemed fairly safe given the patient's degree of chronic pancreatitis and bidirectional drainage due to her PUSTO anatomy. Several barriers stand in the way to performing pancreatic therapy in post-whipple patients. Oftentimes a pediatric colonoscope rather than a standard duodenoscope is required due to the extra length of the colonoscope. Even when the pancreatic anastomosis can be reached, cannulation is quite challenging, particularly in the setting of a strictured anastomosis. In our experience, endoscopic ultrasound or percutaneous rendezvous, as discussed elsewhere in this video, are nearly always required to obtain access into the duct. We recently reported a series of 10 patients in whom pancreatic endotherapy was attempted after whipple surgery. Successful access and treatment of the pancreas using conventional methods was successful in only one of the 10 patients in our series. This patient had a whipple pancreatic duodenectomy for head-dominant pancreatitis. She subsequently developed relapsing pancreatitis and was found on imaging to have a stenosed pancreatic jejunostomy. After a difficult cannulation, multiple procedures with placement of pancreatic stents were made, but resolution of the stricture could not be achieved. A decision was made to place a covered 8mm by 4cm stent, which was modified by trimming the inner flanges. This was placed across the anastomosis in an attempt to better dilate the stricture. This is certainly an experimental use of metal stents and was used in this case only after several failed attempts at dilating the anastomosis with conventional methods. Pancreatic ultrasound ERCP rendezvous for pancreatic duct access. In cases when pancreatic duct cannot be accessed via standard approach, EOS guided pancreatic duct access can be considered. We perform all these procedures under general anesthesia. From the gastric wall, the pancreatic duct is punctured and guide wire is passed anti-grade. This is a patient with stenosis of the pancreatic jejunostomy and some intraductal stones after ripple surgery. Pancreatic duct was not accessed endoscopically. Here, the pancreatic duct is punctured from the gastric wall. A guide wire is passed anti-grade. The echo endoscope is then carefully removed. Using a colonoscope, the pancreatic jejunostomy is identified and the pancreatic duct is cannulated alongside the EOS guided wire. The pancreatic jejunostomy is dilated using a 6mm biliary dilating balloon. The pancreatic duct is swept using a stone extraction balloon to clear off the stone material. Two pancreatic duct stents, 4 French and 5 French are placed and the EOS guide wire is removed. In another patient with severe chronic calcified pancreatitis and pseudodivism, the dorsal duct was not accessed due to severe stenosis. The pancreatic duct is dilated upstream from the stricture. Using a 19-gauge needle, the pancreatic duct is punctured under endosonographic guidance. A 0-1 inch guide wire is passed anti-grade into the duodenum. The dorsal pancreatic duct is cannulated alongside the EOS guide wire and the guide wire is passed to the tail. The minor papilla is then dilated using a 4mm dilating balloon. A pancreatic duct stent is placed. The pancreatic duct is cannulated upstream from the stricture. The pancreatic duct is cannulated again. The EOS guide wire is then removed. A second 5 French pancreatic duct stent is placed to provide drainage. As seen in these examples, the EOS guide wire is cannulated using a 4mm dilating balloon. Thank you for watching.

endotherapy

pancreatic diseases

endoscopic techniques

imaging modalities

tools and devices

clinical cases

recurrent pancreatitis

chronic pancreatitis

pancreatic sphincterotomy

pancreas divisum

complications

total pancreatectomy