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

Table 1 Patient demographics and procedure indications

Number of patients	34
Mean age (range)	55 (13–79)
Male/female	19/15
Patients with pancreas divisum	16
ERCP sessions through the minor papilla	44
Total ERCPs during the study period	1418
Rate of minor papilla approach	3.10%
Causes of difficult access through the major papilla	44
Pancreas divisum (complete/incomplete)	20 (17/3)
Distortion of Wirsung’s duct	16
Stenosis or compression of Wirsung’s duct	6
Other	2
Diagnostic ERCP	26
Indications
Cystic neoplasm (IPMN/ MCN/ SCN)	7 (5/1/1)
AIP	5
Pancreas divisum	4
RAP	5
Pancreatic mass	3
Others	2
Pancreatic juice cytology (with ENPD/ with POPS)	11 (4/ 2)
Therapeutic ERCP	18
CP	8
RAP	5
Pancreatic pseudocyst	4
Pancreatic trauma	1
Minor papillotomy	17
Needle-knife	13
Pull-type papillotome	4

ERCP: Endoscopic retrograde cholangiopancreatography; IPMN: Intraductal papillary mucinous neoplasm; MCN: Mucinous cystic neoplasm; SCN: Serous cystic neoplasm; AIP: Autoimmune pancreatitis; CP: Chronic pancreatitis; RAP: Recurrent acute pancreatitis; ENPD: Endoscopic nasopancreatic drainage; POPS: Peroral pancreatoscopy.

Table 2 Success rate of minor papilla cannulation

	Success	Failure	Total	Success rate	P value
Before April 2009 (CC)	4	4	8	50%	0.04
After April 2009 (WGC)	31	5	36	86%	0.04
Total	35	9	44	80%

CC: Conventional contrast cannulation; WGC: Wire-guided cannulation.

Table 3 Patient characteristics and short-term outcomes of therapeutic interventions through the minor papilla

Patients	Age/sex	Session	Disease	Causes of difficult access through the major papilla	Intervention	Technical success/failure	Short-term outcome	Complication
1	13/F	1	Trauma	MPD injury		Failure	NA	None
2	62/M	2	Pseudocyst	Compression of WD	EMP + ENPD	Success	Appropriate drainage	None
		3	Pseudocyst	Compression of WD	Exchange of EPS	Success	Appropriate drainage	None
		4	Pseudocyst	Compression of WD	Removal of EPS	Success	Collapse of pseudocyst	None
3	69/M	5	CP	Distortion of WD	EMP + EPS	Success	Pain relief	None
4	36/M	6	CP	Distortion of WD	EMP + EPS	Success	Pain relief	None
5	69/M	7	CP	Divisum	EMP + EPS	Success	Pain relief	None
		8	CP	Divisum	Balloon dilation	Success	Pain relief	None
6	64/M	9	Pseudocyst	Compression of WD	EMP + ENPD	Success	Ineffective1	None
7	40/M	10	RAP	Stenosis of WD	EMP + EPS	Success	Appropriate drainage	PEP
		11	RAP	Stenosis of WD	Exchange of EPS	Success	No recurrence	None
8	36/M	12	RAP	Divisum	EMP + ENPD	Success	Appropriate drainage	None
		13	RAP	Divisum	Exchange of EPS	Success	No recurrence	None
9	62/M	14	CP	Divisum	EMP + EPS	Success	Pain relief	None
10	74/M	15	CP	Divisum	EMP + EPS	Success	Pain relief	None
11	42/M	16	CP	Distortion of WD		Failure	NA	None
12	68/F	17	CP	Distortion of WD	EMP + EPS	Success	Pain relief	None
13	68/M	18	RAP	Distortion of WD	EMP + EPS	Success	No recurrence	None

¹Required a surgical procedure. F: Female; M: Male; CP: Chronic pancreatitis; RAP: Recurrent acute pancreatitis; MPD: Main pancreatic duct; WD: Wirsung’s duct; EMP: Endoscopic minor papillotomy; EPS: Endoscopic pancreatic stent; ENPD: Endoscopic nasopancreatic drainage; PEP: Post-endoscopic retrograde cholangiopancreatography pancreatitis; NA: Not available.

Table 4 Review of recently published data on an endoscopic approach through the minor papilla

Ref.	No. of patients	Disease	Divisum	Cannulation method	Cannulation success	Intervention	Improvement	PEP
Borak et al[2]	113	RAP	100%	NA	NA	EMP + EPS	62%	10.60%
Maple et al[3]	64	RAP	100%	Endoscopists’ preference	85	EMP + EPS	NA	14%
Chacko et al[4]	57	RAP/CP	100%	Tapered catheter and guidewire	86	EMP + EPS	58%	10.70%
Attwell et al[5]	184	CP	100%	Tapered catheter	NA	EMP + EPS	72%	6.50%
Song et al[9]	11	CP	0%	Rendezvous technique or CC	91	EMP + ENPD, ESWL	91%	0%
Heyries et al[6]	24	RAP	100%	Tapered catheter and guidewire	NA	EMP 8, EMP + EPS 16	92%	12.50%
Maple et al[11]	25	RAP	88%	Physician-controlled WGC	96	EMP + EPS	NA	12%
Gerke et al[15]	53	RAP	100%	NA	NA	EMP	60.40%	11.20%
Ertan et al[16]	25	RAP	100%	Tapered catheter and guidewire	74	Dilation	76%	0%
Boerma et al[17]	16	CP	100%	NA	NA	EPS with/without EMP	69%	6.30%
This study	34	RAP/CP	45%	WGC or CC	80	EMP + EPS	83%	4.50%

PEP: Post-endoscopic retrograde cholangiopancreatography pancreatitis; RAP: Recurrent acute pancreatitis; CP: Chronic pancreatitis; WGC: Wire-guided cannulation; CC: Conventional contrast cannulation; EMP: Endoscopic minor papillotomy; EPS: Endoscopic pancreatic stent; ENPD: Endoscopic nasopancreatic drainage; ESWL: Extracorporeal shock wave lithotripsy; NA: Not available.