Introduction

Ampullary endoscopic submucosal dissection (ESD) is a technically challenging procedure requiring utmost expertise. Post ESD, access of the common bile duct (CBD) and pancreatic duct (PD) is essential for drainage to prevent pancreatitis, and delayed bleeding and perforation. When the ducts are inaccessible the traditional way, endoscopic ultrasound (EUS) guided rendezvous (RV) can salvage the situation.

Aims & Methods

We present a case where post ampullary ESD, identification of CBD and PD openings was not possible and cannulation was achieved by EUS- RV technique. An 80 year male was referred to our center for management of a duodenal tumor detected incidentally on upper endoscopy. The descending duodenal tumor was a protruding mucosal lesion of around 30mm in size with a thick stalk, and lobular head with regular surface pattern. The ampulla could not be identified separately by forward or side- viewing endoscope (SVE). EUS showed no involvement of CBD or PD. Endoscopic resection was planned using total intravenous anesthesia due to elderly age and comorbidities (hypertension and obstructive lung disease). The tumor location made it unamenable to resection by SVE. Using the forward- viewing endoscope, complete ensnarement of the tumor could not be confirmed as the distal side could not be visualised. Hence, en bloc resection was done by ESD. Clip and line traction was used to overcome the challenges of location, size, and submucosal fibrosis. Post ESD, the visualised opening in the ulcer assumed to be the ampullary opening was confirmed to be a small muscle defect. No other opening could be visualised. The muscle defect was closed with a hemoclip and it was decided to conduct EUS- RV. Analysing a post ESD ulcer in the duodenum, and a non obstructed CBD near the portal vein, a transgastric puncture of extrahepatic hilar bile duct was decided and a guidewire was negotiated antegrade into the duodenum. It revealed an inconspicuous ampullary opening at the edge of the ulcer. A 5Fr nasopancreatic and a 6Fr nasobiliary drain were placed.

Results

Total procedure time (ESD + EUS- RV) was 50 minutes. Specimen measured 28mm X 20 mm. There were no immediate or early complications. Patient was discharged on day six after endonasal tube removal and tolerating a regular diet. Check endoscopy on day six revealed a healing ulcer with healthy granulation tissue. Pathology was tubular adenoma with high grade dysplasia and all margins negative.

Conclusion

Endoscopic retrograde stenting is reported to be fairly easy after ampullary resection due to distinct visibility of the opening. This case highlights an unfamiliar challenge of an obscured post ESD ampullary opening, probably due to being undermined below the edge of the ulcer. This shows a novel indication for EUS- RV. Hence, expert technical skill and equipment in therapeutic EUS along with ESD are imperative to perform ampullary resections.