A new technique of minor papilla sphincterotomy in pancreas divisum

Sphincterotomy of the minor papilla (MiES) is indicated in some patients with pancreas divisum but is often limited by technical difficulty. Stent-guided needle-knife MiES is the accepted technique, but this requires initial stent placement which is not always possible due to the small caliber of the minor papilla. We have found that a wire-guided sphincterotome with its firm, 5.5 Fr rounded tip is useful in achieving cannulation of the minor papilla over a guidewire even when a 4.5 Fr. dilating catheter fails, and can be safely used to perform sphincterotomy of the minor papilla. The success and complications of wire-guided (WG) MiES were reviewed. METHODS: 23 consecutive patients (17 females, 6 males) with pancreas divisum and idiopathic pancreatitis underwent endoscopic therapy between 6/94 and 10/96. After pancreatography, we attempted to place a 0.035-inch guidewire into the dorsal duct. A dual-lumen standard sphincterotome was then advanced over the wire and a 4-6 mm MiES was performed with the guidewire in place. A 7 Fr stent was placed over the wire. All patients had 30 day follow-up. RESULTS: Guidewire cannulation of the dorsal was achieved in 15 of 23 (65%) patients. WG MiES was successful in 15 of 15 patients with guidewire placement. A 7 Fr stent was placed in 14 of 15 patients. The 8 patients in whom guidewire placement failed, underwent precut needle-knife MiES. Mean hospital stay after WG MiES was 1.1 days (range 0-2). Complications occurred in 2 patients (13.3%): 1 mild pancreatitis, 1 post-ERCP abdominal pain, hospital stay 2 days each. CONCLUSIONS : wire-guided minor papilla sphincterotomy is a safe and effective alternative to stent-guided MiES in patients in whom dorsal duct guidewire cannulation is achieved.