restenosis of previously performed endoscopic pancreatobiliary sphincterotomy or surgical sphincteroplasty. Identification of the minor papilla orifice in patients with pancreas divisum can also be unsuccessful despite the use of intravenous secretin and methylene blue (MB) spray. We present here a series of cases in which cannulation of the pancreas was achieved after EUS guided injection of MB into the PD. Patients and Methods: We retrospectively reviewed files of 5 patients who underwent EUS guided MB pancreatography after unsuccessful ERP between January 2003 and December 2008. There were 4 females and 1 male. The age range was 32-71 years. Indications for ERP were: idiopathic recurrent pancreatitis in 2 patients, recurrent sphincter of Oddi dysfunction in 2 patients, and chronic pancreatitis with pancreas divisum in one patient. Three of 5 patients had prior surgical sphincteroplasty, and one had endoscopic sphincterotomy. All 4 of them developed restenosis of the pancreatic orifice. In the patient with pancreas divisum the minor papilla orifice could not be localized despite the prior secretin administration and MB spray. EUS of the pancreas with a linear array echoendoscope identified the PD. EUS-guided puncture of the PD was performed with a 22-gauge needle. Up to 15 mL of a mixture of 1% MB and full strength contrast media (1: 4 ratio) was injected into the PD. Contrast flow into the duodenum was confirmed fluoroscopically. The echoendoscope then was exchanged for a diagnostic side-viewing duodenoscope. MB was seen exiting the orifice of the minor papilla in the patient with pancreas divisum, and a subtle pancreatic orifice at the major papilla in the other 4 patients. The dorsal PD in the patient with pancreas divisum and the ventral PD in all other patients were then cannulated. A minor papilla sphincterotomy was performed in the patient with pancreas divisum. Ventral pancreatic sphincterotomy (nZ2) or ventral pancreatic orifice dilation (nZ2) with PD stenting were performed in the other patients. No complications were observed. Conclusions: EUS guided MB pancreatography appears to be a helpful technique for identification of PD orifice in patients with restenosis of the papilla of Vater or patients with pancreas divisum. This technique is simpler than transgastric guidewire passage. However, it will not be helpful if total orifice occlusion is present.
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