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mostly used to demonstrate specialized epithelium in Barrett’s esophagus [1], for locating the minor papilla during endo− scopic retrograde cholangiopancreatog− raphy (ERCP) [2], or injected into the submucosa before endoscopic mucosal resection and polypectomy [3]. Endoso− nography (EUS)−guided injection of MB into the pancreatic duct (PD) has been de− scribed to identify the minor papilla after unsuccessful ERCP [4]. Endoscopic ampullectomy is a therapeu− tic approach for resecting the ampullary area in case of superficial tumors. This is a challenging procedure because of techni− cal difficulties and the risk of postproce− dural complications. A randomized con− trolled trial found that PD stenting after endoscopic snare excision of the ampulla in patients with papillary tumors [5] was more effective than not stenting in pre− venting postprocedure pancreatitis. Nevertheless PD cannulation during en− doscopic retrograde pancreatography can be challenging; moreover, edema and ar− tifacts due to electrocautery during am− pullectomy can make it even harder to identify the pancreatic orifice. EUS is con− sidered the best method for staging am− pullary lesions and selecting those suita− ble for endoscopic resection. We injected MB intraductally under EUS guidance in three patients with adenoma of the ampulla (l" Figure 1) to help in de− tecting the pancreatic orifice and in plac− ing a stent after ampullectomy. Two pa− tients had PD dilation. A 25−gauge needle, primed with MB (methylthionine 100 mg/10 mL, dilution 1 :20 000), was used to puncture the PD under EUS gui− dance (l" Figure 2). Then MB was slowly injected into the duct, and its flow was visible from the papillary orifice after a few seconds (l" Figure 3; video). After ampullectomy, performed during the same session, the MB flow was evident from the pancreatic orifice and was a guide for placing a stent in the PD (l" Fig− ure 4). No complications were observed. All pancreatic stents were successful EUS−guided methylene blue injection into the pancreatic duct as a guide for pancreatic stenting after ampullectomy

EUS-guided methylene blue injection into the pancreatic duct as a guide for pancreatic stenting after ampullectomy