PMC10167413_01
Magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography of the patient: (a, b) Magnetic resonance cholangiopancreatography and pancreaticography showed an accessory pancreatic duct draining into a minor papilla and looping of the proximal part of the main pancreatic duct. (c) A pancreatic stent was placed into the dorsal pancreatic duct through the minor papilla.
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A followed magnetic resonance cholangiopancreatography revealed an accessory pancreatic duct (of Santorini) draining into a minor papilla and looping of the proximal part of the main pancreatic duct (of Wirsung; Figure 1a). Pancreaticography reconfirmed the anatomic variation of the pancreatic duct and the patient was diagnosed as ansa pancreatica (Figure 1b). An 11 cm 5 Fr pancreatic stent was placed into the dorsal pancreatic duct through the minor papilla (Figure 1c and Video S1).
A major duodenal papilla lesion was identified: (a, b) A major duodenal papilla lesion was identified during endoscopic retrograde cholangiopancreatography. (c) Endoscopic ultrasonography showed intact submucosa to a depth of 7 mm.
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ERCP, and histopathological examination of a forceps biopsy suggested a probable tubular adenoma (Figure 2a,b). Endoscopic ultrasonography showed intact submucosa with a depth of 7 mm and no intraductal extension (Figure 2c). Hemostasis was performed carefully by using endoclips (Figure 3d and Video S2).
Hybrid endoscopic mucosal dissection of the duodenal major papilla adenoma: (a) A submucosal cushion was created by injection into the anterior, posterior, and oral sides of the lesion. (b) A halfway circumferential incision was made with a dual knife. (c) An en bloc resection with a snare. (d) A 5 cm 8 Fr biliary stent was inserted and hemostasis was performed by using endoclips.
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A month later, hybrid endoscopic mucosal dissection (ESD) was performed: a submucosal cushion was created by injection of a mixture of saline solution, methylene blue, and adrenaline into the anterior, posterior, and oral sides of the lesion, a halfway circumferential incision was made with a dual knife, and the lesion had an en bloc resection with a snare (Figure 3a-c). Hemostasis was performed carefully by using endoclips (Figure 3d and Video S2).