Indications for Minor Papilla Cannulation and Sphincterotomy

Box 20.1 lists the indications for minor papilla cannulation and sphincterotomy. The most frequent are recurrent pancreatic-type pain with a nondilated pancreatic ductal system, acute recurrent pancreatitis with or without dorsal duct dilation, and obstructive pancreatic-type pain or recurrent pancreatitis in patients with chronic changes of the pancreatic ductal system. In some patients without pancreas divisum, access to the pancreatic duct through the minor papilla and MiES can be useful.¹³

Sedation, Supplemental Drugs, and ERCP Accessories

Supplemental Drugs

Antispasmodic agents enhance visualization of the minor papilla and should be readily available for administration. However, these agents should not be administered until the endoscope is passed to the descending duodenum, as gastric distension may occur and make passage through the pylorus difficult. Once the endoscope has been placed in a stable position in front of the minor papilla, intravenous injection of a smooth muscle inhibitor such as glucagon is administered in 0.25- to 0.50-mg increments.

Although newer-generation, high-definition video endoscopes make it easier to identify the minor papilla and its orifice, in approximately one third of cases the orifice is not initially visible. In these cases dyes such as methylene blue or indigo carmine, and/or secretin, can be used to identify the papilla and its orifice. Secretin is expensive, so we usually use a dye spraying before secretin administration, although in many centers secretin is widely used initially to identify the papillary orifice, followed by dye spray when identification is unsuccessful. Methylene blue (vital dye) diluted with saline solution (1 : 10) or, preferably, indigo carmine 0.4% undiluted can be sprayed over the area suspected to contain the minor papilla in order to identify the papillary orifice or the papilla itself, respectively (Fig. 20.1). Once dye solution has been sprayed, the orifice may appear as a whitish spot emerging on a bluish mucosa, or is evidenced by clear juice washing away from the background blue dye.^12,14 In patients with known incomplete pancreas divisum, methylene blue can be diluted 1 : 10 with contrast medium and injected into the pancreatic ductal system through the major papilla; part of the dyed pancreatic juice flows out through the dorsal duct and minor papilla. With this method it is best to avoid opacifying the entire pancreatic ductal system so as to limit intraductal pressure during contrast-dye injection and thus reduce the risk of post-ERCP pancreatitis (PEP).

Fig. 20.1 A, The minor papilla is located at the 12 o’clock position above the major papilla. The orifice of the minor papilla is not clearly visible. B, The orifice of the minor papilla (arrow) is visible after spraying with 0.4% undiluted indigo carmine.

Secretin is a 27 amino acid polypeptide that strongly stimulates secretion of water and bicarbonate from pancreatic ductal cells; the enhanced secretion of pancreatic juice may render the minor papilla orifice visible. Intravenous secretin stimulates pancreatic juice flow between 1 and 3 minutes after injection with transient ductal dilation lasting about 15 minutes. However, when the pancreatic ducts are dilated or obstructed, as in severe chronic pancreatitis or dorsal duct stricture, the pancreatic juice flow after secretin may be insufficient to identify the minor papilla orifice. Two synthetic porcine and one synthetic nonporcine secretins are available for widespread clinical application in the U.S. and Europe, respectively. All secretin formulations significantly improve minor papilla cannulation rates and shorten cannulation time.^15,16

Intraduodenal hydrochloric acid (HCl) infusion reportedly improves the minor papilla cannulation rate in patients with pancreas divisum during difficult cannulation.¹⁷ Intraduodenal HCl physiologically induces secretin release¹⁸ and is less costly than secretin. However, the preliminary data need to be confirmed in more patients.

ERCP Accessories

In general, cannulation and papillotomy of the minor papilla require much the same accessories as for the major papilla: a sphincterotome or an ERCP catheter and a soft-tip guidewire (Fig. 20.2). If the papillary orifice is very small, a needle-tip catheter (ERCP-1-CRAMER, Cook Endoscopy, Winston-Salem, N.C.) can be useful. Sometimes a stenotic orifice requires dilation, which can be done with a tapered 3 to 5 Fr dilator (Contour catheter, Boston Scientific, Natick, Mass.).

Fig. 20.2 Various tapered tip catheters (a–c), pull-type sphincterotomes (d and e), and a needle-knife sphincterotome (f) used in minor papilla endotherapy.

The following equipment should be kept in the endoscopy room when attempting minor papilla cannulation and papillotomy:

 Catheters: tapered tip 3 to 5 Fr catheters, some with metal tips

 Guidewires: partially or totally hydrophilic guidewire 0.018 to 0.035 in with straight and angled tips

 Sphincterotomes: pull-type short-tip sphincterotome (4 to 5 Fr diameter) with a 20- to 25-mm cutting wire

 Dilators: tapered 4 to 7 Fr dilators

 Needle knife: 4-mm cutting wire with or without a channel for passing a guidewire or for contrast injection

 Pancreatic stents: (a) “prophylactic”: 3 to 5 Fr stents, 2 to 8 cm long, flanged or unflanged with or without a duodenal pigtail; (b) “therapeutic”: 7 to 10 Fr, 3 to 7 cm long, flanged

 Cautery unit: we use an ERBE generator model ICC 200 (ERBE Elektromedizin, Tubingen, Germany) usually set with effect 3, 120 W and “ENDOCUT” mode

Minor Papilla Cannulation (Video 20.1)

The patient is generally prone, as for standard ERCP; endoscopists who perform ERCP in the supine position for pancreatic endotherapy prefer the same position for minor papilla cannulation. A standard duodenoscope is used. In some cases a small caliber, more flexible diagnostic duodenoscope is selected, because it is believed to be easier to keep the endoscope in a long position along the greater curvature of the stomach to achieve an en face position of the minor papilla. However, our experience does not confirm this and newer therapeutic duodenoscopes are smaller and more flexible than older models. To date, ERCP in pancreas divisum should be done only for therapeutic purposes, so a standard large-channel duodenoscope is preferable because it allows large bore stents to be placed, if needed.

The first step of the procedure is to locate the minor papilla. It is usually in the right upper quadrant of the visual field, when facing the major papilla, 2 to 3 cm cephalic and anterior to the major papilla, but it may be as close as 1 cm from the major papilla, at the rim of its longitudinal fold (Fig. 20.3). The minor papilla can be recognized by carefully withdrawing the endoscope from the position of the major papilla. The long endoscope position makes for easier identification because of the better endoscopic and fluoroscopic views. The minor papilla can be very small and difficult to locate or quite prominent and, rarely, located within a diverticulum. When recognition is problematic, dyeing techniques or secretin injection can be helpful (Fig. 20.4). Gentle probing of the duodenal folds may be necessary to identify the minor papilla mound and to make it more prominent, although care must be taken to avoid excessive manipulation-related edema that may make it more difficult to identify the papilla.

Fig. 20.3 Endoscopic view of the minor papilla; it is located at the 2 o’clock position (arrow), 1 cm from the major papilla, which is visible at the top of the image.

Fig. 20.4 The papillary orifice was not visualized after spraying with 0.4% undiluted indigo carmine but was visualized only 5 minutes after secretin intravenous injection.

The endoscopic appearance of the minor papilla can predict pancreas divisum and underlying pancreatographic findings.^19,20 Bulging of the minor papilla mound and patency of its orifice may differ in patients with normal and abnormal ductography. About 70% of patients with pancreatic dorsal duct abnormalities have substantial bulging and a visible orifice, while most cases with a normal pancreatogram have no bulging and/or no visible orifice.²¹

Once the minor papilla has been recognized, cannulation is generally best achieved with the endoscope in the long position. The endoscope may fall back into the stomach and must be readvanced to maintain the long position.

The papilla can be cannulated using a needle-tip catheter specifically designed for this purpose (ERCP-1-CRAMER), using standard or tapered tip 5 Fr catheters or a 3 Fr catheter, or directly using a 20- to 25-mm cutting wire pull-type sphincterotome. The ERCP-1-CRAMER catheter does not accept a guidewire but dilates the opening of the orifice and facilitates further catheter and guidewire-assisted deep cannulation. The 5 Fr catheters can be preloaded with a 0.021- or 0.035-in guidewire; 3 Fr catheters can be used only with a 0.018-in guidewire, which is sometimes too floppy and not easy to manipulate. Catheters without a tapered tip are less helpful.

The guidewire is used to enter the minor papilla orifice directly and should preferably be passed to the midbody of the dorsal duct before touching the papilla with a catheter or sphincterotome. This helps avoid trauma-related edema, which makes subsequent cannulation more difficult. When the orifice is very small or stenotic the wire will pass into the duct, though the catheter will not. In such cases the wire is left in place and a highly tapered push catheter is passed alongside it, or a precut can be done alongside or over the wire following the path of the wire. In most of these cases dilation by the push catheter is sufficient. In addition, if one cautiously places the endoscope in the short position it increases the mechanical advantage to allow a catheter to be passed.

When minor papilla sphincterotomy is planned, it is preferable to begin cannulation using a pull-type sphincterotome preloaded with a guidewire, which is then used to enter the papillary orifice (Fig. 20.5). The sphincterotome also has an advantage when the en face orientation to the minor papilla cannot be achieved for initial cannulation: The sphincterotome can “bow” into the correct axis, facilitating cannulation. Once deep cannulation is achieved with the guidewire, if a long position has been maintained it is advisable to withdraw the endoscope into the short position along the lesser curvature of the stomach; this puts it into a more stable position in front of the papilla (Fig. 20.6).

Fig. 20.5 A, A 0.035-in hydrophilic guidewire is gently advanced through the tip of a 5 Fr sphincterotome and directed within the minor papilla orifice. B, The minor papilla is cannulated by the sphincterotome preloaded with the guidewire.

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