PMC6317836_01
Endoscopic ultrasound-guided transgastric pancreatogram showing PD leak from the genu.
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F1
PD was punctured, and contrast was injected using a 19-G EUS fine-needle aspiration (FNA) needle (ECHO HD 19A, Cook Medical, Bloomington, IN). Pancreatography showed leakage of contrast from the PD at the genu (Figure 1).
Guidewire advanced across the minor papilla into the duodenum.
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F2
As it was advanced, the wire exited through the minor papilla, suggestive of pancreas divisum (Figure 2).
Modification of the ERCP cannula into a wedge.
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F3
The tip of the cannula was refashioned to form a v-shaped wedge so that it could "rail-road" over the guidewire exiting the minor papilla (Figure 3).
Transpapillary placement of the guidewire to bridge the PD leak.
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F4
Another 0.025-in guidewire (VisiGlide, Olympus Medical Systems) was advanced through the cannula into the pancreatic duct and then negotiated across the leak (Figure 4).
A 7-F PD stent deployed across the PD leak.
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F5
The second guidewire was maneuvered into the tail of the pancreas, and a plastic stent (7-Fr, 12-cm Amsterdam stent) was successfully deployed (Figure 5).