Endoscopic approach through the minor papilla for the management of pancreatic diseases

Figure 1 Minor papilla cannulation and endoscopic minor papillotomy. A: Endoscopic features of the minor papilla (arrow); B: Minor papilla cannulation using wire-guided cannulation; C: Endoscopic minor papillotomy with a needle-knife; D: Endoscopic view after minor papillotomy with a needle-knife; E: Endoscopic minor papillotomy with a pull-type sphincterotome.

Figure 2 Endoscopic retrograde pancreatography in a patient with pancreas divisum. A: Pancreatogram via the major papilla showing a short ventral pancreatic duct tapering into small side branches; B: Pancreatogram via the minor papilla showing a dorsal pancreatic duct without a connection to the ventral pancreatic duct, indicating complete pancreas divisum.

Figure 3 Endoscopic retrograde pancreatography in a patient with a distortion of Wirsung’s duct. A-C: A patient with recurrent acute pancreatitis; A: Pancreatogram via the major papilla showing a distorted Wirsung’s duct (arrow); B: A guidewire could not be advanced along the main pancreatic duct (MPD) from the body to tail of the pancreas through the major papilla; C: Pancreatogram via the minor papilla. A guidewire could be advanced to Santorini’s duct and the distal MPD through the minor papilla (upper row). An endoscopic pancreatic stent was inserted through the minor papilla after minor papillotomy (lower row); D, E: A patient with a metastatic pancreatic tumor; D: Pancreatogram via the major papilla showing stenosis of the MPD in the body of the pancreas (arrowhead). However, a guidewire could not be advanced to the distal MPD due to distortion of Wirsung’s duct (arrow). The guidewire inserted through the major papilla entered duodenum via the minor papilla, and was confirmed by an endoscopic view; E: An endoscopic nasopancreatic drainage tube was inserted through the minor papilla after minor papilla cannulation using a rendezvous technique.