Pancreatic guidewire-assisted (dual wire) cannulation

This patient with risk factors for post-ERCP pancreatitis (ie, history of recurrent acute pancreatitis) underwent ERCP with biliary sphincterotomy. The patient had a flat papilla with small caliber bile and pancreatic ducts. After passage of an 0.018 inch guidewire deep into the pancreatic duct, the bile duct was cannulated with a wire-guided papillotome. Next, a second 0.018 inch wire was passed into the bile duct (A,B,D,E). Before removing the pancreatic guidewire, a 4 French, 11 cm unflanged, single pigtail pancreatic stent was placed. This was followed by biliary sphincterotomy (C,F).