Category: Monday Poster Session

P1378 - Endoscopic Ultrasound (EUS)-Guided Methylene Blue Injection: An Innovative Endoscopic Approach to a Post-Ampullectomy Papillary Stenosis and Recurrent Pancreatitis

Monday, Oct 16
10:30 AM – 4:00 PM



Award: 2017 Presidential Poster Award

Category: Interventional Endoscopy       Sub-Category: Clinical Vignettes/Case Reports

Andrew M. Aneese, MD, MS, Vinayata Manuballa, DO, Gehad Ghaith, MD, Michael E. Cannon, MD, Mitchell S. Cappell, MD, PhD, FACG
Beaumont Health, Royal Oak, MI
Ampullary adenomas (AA) are common in patients with familial adenomatous polyposis (FAP). Endoscopic resection is recommended for large AA, but has been associated with high rates of iatrogenic pancreatitis. Prophylactic pancreatic duct (PD) stenting is recommended in patients undergoing ampullectomy. A case is presented describing an innovative technique of PD stenting, in a patient with FAP post ampullectomy, using endoscopic ultrasound (EUS) guided methylene blue injection, to assist in PD identification, cannulation, and successful stent deployment after failed standard endoscopic retrograde cholangiopancreatography (ERCP).

A 46-year-old man with a history of FAP presented for surveillance EGD. A 35 x 20 mm ampullary adenomatous polyp with low grade epithelial dysplasia was discovered. Cannulation of the common bile duct (CBD) and PD was attempted, however, the adenoma obscured the orifice. After piecemeal removal of the polyp, the CBD was cannulated, but cannulation of the PD was unsuccessful with a Glo-Tip catheter. Six months later, after being hospitalized for 2 episodes of acute pancreatitis, the patient underwent evaluation with EUS and ERCP using the GF-UCT140-AL5 Endosonoscope. The PD was dilated in the body of the pancreas to 3 mm with a tortuous and ectatic appearance, however the PD orifice was obliterated post ampullectomy [Figure 1]. Under EUS guidance, 1 mLof methylene blue was injected into the PD to trace the PD back to the duodenal lumen. Next the duodenoscope was introduced, the bile duct was deeply cannulated with the short-nosed traction sphincterotome, and a soft guidewire was left in the common bile duct. Using a needle knife, a 5 mm pre cut was made in the area of the PD, now made more visible by the methylene blue. A 4 mm ventral pancreatic sphincterotomy was made, and a 5 french by 3 cm temporary plastic pancreatic stent was placed 2.5 cm into the ventral PD [Figure 2]. Four weeks later the stent was removed. Twelve months after ampullectomy, the patient continues to do well with no adverse events reported.

Cannulation and successful stent placement in the PD can be difficult in the setting of an AA resection. As illustrated by the current patient course, the risk of postprocedural pancreatitis is high after AA resection. The addition of EUS guided methylene blue injection into the PD to standard ERCP may improve rates of successful PD stent placement, in these difficult cases.

Supported by Industry Grant: No


Well healed site of the ampullectomy 2 months post initial resection. The pancreatic duct orifice is not visible and could not be identified or cannulated with standard ERCP technique.
Blue hue is appreciated at the PD orifice made by methylene blue injection into the distal pancreatic duct under EUS guidance. Methylene blue illuminated the PD orifice and allowed identification, cannulation, sphincterotomy, and successful pancreatic duct stent placement.

Citation: . ENDOSCOPIC ULTRASOUND (EUS)-GUIDED METHYLENE BLUE INJECTION: AN INNOVATIVE ENDOSCOPIC APPROACH TO A POST-AMPULLECTOMY PAPILLARY STENOSIS AND RECURRENT PANCREATITIS. Program No. P1378. World Congress of Gastroenterology at ACG2017 Meeting Abstracts. Orlando, FL: American College of Gastroenterology.

Andrew M. Aneese

Resident
Beaumont Health-Royal Oak
Royal Oak, Michigan