title: Minor papilla endotherapy in patients with ventral duct obstruction: identification and management.
abstract: OBJECTIVE
  Pancreatic duct (PD) cannulation via the major papilla may be compromised by downstream obstruction of the ventral PD from a stone or stricture. In patients with a patent accessory PD, cannulation of the minor papilla permits stenting or stone removal upstream of the ventral PD obstruction. Data on this technique are limited.
  
  
  METHODS
  University of Colorado Hospital and Maine Medical Center endoscopy databases were queried for ERCPs with minor papilla cannulation. Technical success was defined as deep cannulation of the minor papilla. Minor papilla endotherapy included sphincterotomy, stricture dilation, stenting, or stone treatment. Clinical improvement was designated as >50% reduction in pain or narcotic analgesia. Follow-up was obtained by chart review and telephone contact.
  
  
  RESULTS
  Over a 22-year period, 464 patients had minor papilla cannulation. Congenital and incomplete pancreas divisum were excluded, and 64 patients met study criteria. Technical success was achieved in 58 of 64 patients (91%). In patients with stones, 25 of 34 (74%) had clearance using endoscopic techniques. Median follow-up was 15.5 months. Twelve of 28 patients (43%) on chronic narcotic regimens reported a reduction in narcotic use by >50%, and 32 of 44 patients (73%) reached for discussion noted improved abdominal pain by >50%. Thirteen patients required surgery for symptom control.
  
  
  CONCLUSIONS
  In this multicenter experience, 15% of patients undergoing minor papilla cannulation had acquired a ventral PD obstruction. Access via the minor papilla to the upstream main PD for endotherapy and clinical improvement was achieved in most patients. Increased and early recognition of these intensive therapeutic options may enhance treatment options for this complex group of patients.
authors.affiliation: Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, University of Colorado Hospital, Aurora, Colorado, USA.
authors.forename: Nicholas G
authors.initials: NG
authors.lastname: Brown
authors.affiliation: Portland Gastroenterology Associates, Maine Medical Center Portland, Maine, USA.
authors.forename: Douglas A
authors.initials: DA
authors.lastname: Howell
authors.affiliation: Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, University of Colorado Hospital, Aurora, Colorado, USA.
authors.forename: Brian C
authors.initials: BC
authors.lastname: Brauer
authors.affiliation: Portland Gastroenterology Associates, Maine Medical Center Portland, Maine, USA.
authors.forename: John
authors.initials: J
authors.lastname: Walker
authors.affiliation: Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, University of Colorado Hospital, Aurora, Colorado, USA.
authors.forename: Sachin
authors.initials: S
authors.lastname: Wani
authors.affiliation: Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, University of Colorado Hospital, Aurora, Colorado, USA.
authors.forename: Raj J
authors.initials: RJ
authors.lastname: Shah
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002404:Catheterization; D002648:Child; D002760:Cholangiopancreatography, Endoscopic Retrograde; D003251:Constriction, Pathologic / Q000601:surgery; D004106:Dilatation; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010182:Pancreatic Diseases / Q000601:surgery; D010183:Pancreatic Ducts / Q000601:surgery*; D050500:Pancreatitis, Chronic / Q000601:surgery*; D012189:Retrospective Studies; D015607:Stents; D055815:Young Adult