Dual device cannulation of an intradiverticular minor papilla

Cannulation of the minor papilla in pancreatic divisum frequently presents a challenge, even for experienced endoscopists. The difficulty is amplified when the minor papilla is inconspicuous within a duodenal diverticulum. A 46-year-old man with 2 cystic fibrosis transmembrane conductance regulator (CFTR) mutations had struggled with acute recurrent pancreatitis and constant pain for the previous several months. Imaging demonstrated divisum, dorsal duct irregularities, and loss of T1 signaling, the latter 2 suggesting chronic pancreatitis. Endoscopy revealed a fully recessed ampulla exposed only with downward deflection of the lower diverticular edge (Video 1, available online at www.giejournal.org). Synchronously, we used 2 independent devices through our 4.2-mm working channel: a 7F 2.33-mm blunt-tipped catheter for manipulation of the diverticulum and a 5F 1.67-mm tapered catheter for cannulation in concert with an 0.018-inch guidewire (Fig. 1). This allowed deep access to the dorsal duct. After an exchange to an insulated wire, traction papillotomy was performed, and 2 soft pancreatic stents were deployed. There were no adverse events, and the patient was discharged the same day. His clinical course over the following 6 months has been promising, with durable pain relief. We believe this represents the first published video of a seldom-used although powerful technique for hidden minor papilla.