Endoscopic minor papilla intervention (EMPI) is an option for diagnosing or treating symptomatic pancreatic diseases in cases with failed pancreatic duct deep cannulation via the major papilla, pancreas divisum with obstruction of the minor papilla, or an abnormal patulous orifice of the minor papilla during endoscopic retrograde cholangiopancreatography (ERCP). However, the relatively low patency and small opening of the minor papillae pose technical challenges.

To evaluate the technical success, clinical success, stone clearance, and safety profile of EMPI for diagnosis and treatment of symptomatic pancreatic diseases.

Patients diagnosed with symptomatic pancreatic diseases and EMPI between February 1996 and February 2023 were included. The primary outcomes were the initial technical success, defined as successful deep cannulation via the minor papilla (DCMP; access of the guidewire to the upstream pancreatic duct via the minor papilla) alone, overall technical success, defined as successful DCMP alone and successful DCMP with additional needle-knife precut minor papillotomy (NKPMP), and immediate clinical success, defined as > 50% improvement in abdominal pain after therapeutic EMPI. Secondary outcomes included long-term clinical success at 1, 3, and 7 years, pancreatic stone clearance, and procedure-related early and late adverse events (AEs).

Overall, 43 patients, 32 with obstructive chronic pancreatitis, 8 with pancreatic divisum, and 3 with intraductal papillary mucinous neoplasm were included. The initial and overall technical success rates were 74.4% (32/43) and 88.4% (38/43), respectively. The immediate clinical success rate was 79.1% (34/43), and the long-term clinical success rates at 1, 3, and 7 years were 74.7%, 55.3%, and 41.5%, respectively, among the 22 patients with a follow-up period of 57.5 (7-266) months. Complete and partial success of pancreatic stone clearance was achieved in 53.9% (7/13) and 15.4% (2/13), respectively. Early AEs included post-ERCP pancreatitis (PEP, n = 5) and self-limiting bleeding (n = 1); surgery therapy was required for 1 case with severe PEP and conservative management for the other 4 with mild PEP. Late AEs included minor papilla stricture (n = 1) after endoscopic minor papillotomy and pancreatic duct stricture (n = 1) after double pancreatic stent placement; no specific treatment was implemented for these events.

EMPI is feasible, effective, and safe for symptomatic pancreatic diseases, in terms of the technical and clinical success, stone clearance, and incidence and severity of AEs. NKPMP appears to enhance technical success. However, potential risks of developing PEP and late AEs should be kept in mind.

• Endoscopic minor papilla intervention
• Symptomatic pancreatic diseases
• Obstructive chronic pancreatitis
• Pancreas division
• Abdominal pain improvement

• calculi
• chronic pancreatitis
• endoscopy
• extracorporeal shockwave lithotripsy
• stricture

• Humans
• Pancreatitis, Chronic/complications
• Pancreatitis, Chronic/surgery
• Pancreatitis, Chronic/therapy
• Lithotripsy/methods
• Cholangiopancreatography, Endoscopic Retrograde/methods
• Endosonography/methods
• Forecasting
• Pancreatic Pseudocyst/etiology
• Pancreatic Pseudocyst/surgery

• Chronic pancreatitis
• Endoscopy
• Management
• Nutritional support
• Surgery
• Therapy

• Humans
• Pancreatitis, Chronic/therapy
• Pancreatectomy/methods
• Nutritional Support/methods
• Islets of Langerhans Transplantation

• Acute pancreatitis
• Chronic pancreatitis
• Disconnected pancreatic duct syndrome
• Endotherapy
• Pancreaticogastrostomy

• Intervention EUS
• Pancreas
• Stones

• Endoscopic ultrasound
• Endoscopic ultrasound-guided biopsy
• Endoscopic ultrasound-guided drainage
• Pancreatic cancer
• Pancreatitis

• Biliary drainage
• Choledochoduodenostomy
• Endoscopic ultrasound
• Hepaticogastrostomy
• Lumen apposing metal stents
• Necrotic fluid collections
• Pancreatic cyst ablation
• Pancreatic ductal drainage

• acute necrotizing pancreatitis
• disconnected pancreatic duct syndrome
• endoscopic drainage

• Acute Disease
• Drainage/methods
• Humans
• Pancreatic Ducts/surgery
• Pancreatic Fistula/diagnosis
• Pancreatitis, Acute Necrotizing/complications
• Pancreatitis, Acute Necrotizing/diagnosis
• Retrospective Studies
• Syndrome
• Treatment Outcome

• EHL, electronic hydraulic lithotripsy
• EUS-PG, endoscopic ultrasound-guided pancreaticogastrostomy
• FCSEMS, fully-covered self-expandable metal stent
• MPD, main pancreatic duct
• SEMS, self-expandable metal stent

EUS has opened a new frontier in endoscopic techniques for accessing pancreatic ducts in patients with failed ERCP. The major indications of EUS-guided pancreatic duct intervention (EUS-PDI) are main pancreatic duct (MPD) strictures due to chronic pancreatitis or strictures of pancreaticojejunal or pancreaticogastric anastomosis after Whipple resection, which lead to recurrent acute pancreatitis. EUS-guided pancreaticogastro or duodenostomy offers an alternative to surgery when transpapillary drainage fails or is not possible. We provide an expert commentary and a brief overview on this relatively novel technique utilizing EUS-PDI creation in patients with impaired drainage of the MPD who have failed other conventional endoscopic techniques for MPD drainage and either are poor surgical candidates or are reluctant to undergo surgery.

• acute pancreatitis
• endosonography
• interventional endosonography

• Chronic pancreatitis
• Early chronic pancreatitis
• Endoscopic ultrasound

• Abdominal Pain/etiology
• Abdominal Pain/therapy
• Contrast Media
• Debridement/methods
• Drainage
• Elasticity Imaging Techniques
• Endosonography/methods
• Humans
• Nerve Block/methods
• Pancreatic Diseases/complications
• Pancreatic Diseases/diagnosis
• Pancreatic Diseases/diagnostic imaging
• Pancreatic Diseases/therapy
• Pancreatic Ducts/diagnostic imaging
• Pancreatic Ducts/surgery
• Pancreatitis, Chronic/classification
• Pancreatitis, Chronic/complications
• Pancreatitis, Chronic/diagnostic imaging
• Pancreatitis, Chronic/therapy
• Stents
• Ultrasonography, Interventional/methods

Endoscopic ultrasound (EUS)-guided pancreatic access is an emergent method that can be divided into the two main techniques of EUS-guided rendezvous and pancreatic transmural stenting (PTS). While many reports have described EUS-guided procedures, the indications, technical tips, clinical effects, and safety of EUS-guided pancreatic duct drainage (EUS-PD) remain controversial. This review describes the current status of and problems associated with EUS-PD, particularly PTS. We reviewed clinical data derived from a total of 334 patients. Rates of technical and clinical success ranged from 63% to 100% and 76% to 100%, respectively. In contrast, the rate of procedure-related adverse events was high at 26.7% (89/334). The most frequent adverse events comprised abdominal pain (n=38), acute pancreatitis (n=15), bleeding (n=9), and issues associated with pancreatic juice leakage such as perigastric fluid, pancreatic fluid collection, or pancreatic juice leaks (n=8). In conclusion, indications for EUS-PTS are limited, as is the evidence of its viability, due to the scarcity of expert operators. Despite improvements made to various devices, EUS-PTS remains technically challenging. Therefore, a long-term, large-scale, multicenter study is required to establish this technique as a viable alternative drainage method.

• Endoscopic retrograde cholangiopancreatography
• Endoscopic ultrasound
• Endoscopic ultrasound-guided pancreatic duct drainage
• Pancreas
• Pancreatic duct stricture

• Biliary drainage
• Roux-en-Y gastric bypass anatomy
• peripancreatic collection
• targeted angiotherapy

• PD, pancreatic duct
• PGS, pancreaticogastrostomy

• Endoscopic ultrasound
• pancreatic duct obstruction
• rendezvous
• transmural drainage