Rendezvous-assisted endoscopic retrograde pancreatography using a dual-wire balloon technique for stenotic pancreaticojejunostomy in post-Whipple anatomy.

Background and Aims: Pancreatic duct (PD) stones and a stenotic pancreaticojejunal anastomosis (PJA) can make ERCP highly challenging, especially in post-Whipple anatomy. EUS-assisted rendezvous (RV) may serve as a salvage approach, but severe stenoses can prevent guidewire passage. We describe a novel dual-wire balloon technique to achieve PD drainage in this setting. Methods: A 67-year-old man with Zollinger-Ellison syndrome and previous Whipple surgery presented with recurrent pancreatitis. Imaging revealed PD stones impacted at the PJA. Multiple enteroscopy-assisted ERCPs and an initial EUS-assisted RV failed. On repeat EUS-assisted RV, a 22-gauge needle was used to puncture the PD, and a 0.018-inch guidewire was advanced antegrade into the jejunum. Standard devices could not achieve dual-wire access. A therapeutic gastroscope was introduced, and a 5.5F balloon catheter was used to dilate the anastomosis. Removing the wire stiffener allowed a second 0.021-inch wire to be placed alongside the first. Results: This approach enabled retrograde cannulation, deep wire access beyond the rendezvous wire through a stenotic PJA precluding larger dual-wire devices, and stent placement. The patient was discharged without adverse events, with stone extraction planned at follow-up. Conclusions: This case demonstrates the utility of a dual-wire balloon technique for EUS-guided PD drainage in severe PJA stenosis.