Nursing management for patients with minor papilla stent placement after failed endoscopic retrograde cholangiopancreatography cannulation: Two case reports

Abstract

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is the standard intervention for pancreatic ductal drainage. Selective cannulation of the main pancreatic duct via the major papilla fails in 5%-10% of cases due to anatomic variants, particularly suspected pancreas divisum, and cannulation often occurs via the minor papilla.

CASE SUMMARY

This case report describes two patients (a 37-year-old female and a 71-year-old female) who presented with pancreatic ductal dilation and underwent ERCP for diagnostic and therapeutic purposes. In both cases, selective cannulation of the main pancreatic duct via the major papilla failed after repeated attempts; however successful minor papilla cannulation and pancreatic stent placement were achieved without intraprocedural or postprocedural complications, including post-ERCP pancreatitis, bleeding, or perforation at the 1-month follow-up. This report emphasizes the critical role of comprehensive nursing interventions throughout the perioperative period.

CONCLUSION

Preoperatively, nurses contributed to risk identification by thoroughly reviewing imaging and anatomical variations. Intraoperatively, they ensure seamless instrument preparation, timely device exchange, and steady guidewire stabilization, which are pivotal for procedural success. Postoperatively, a standardized “fasting-enzyme inhibition-fluid resuscitation” protocol was strictly implemented to enable early detection and prompt management of potential complications. These nursing strategies optimize outcomes in this high-risk population, offering a forward-looking nursing perspective for minor papillary cannulation, and proposing a nursing framework for such complex procedures.

Key Words: Endoscopic retrograde cholangiopancreatography; Minor papilla; Pancreatic stent; Nursing care; Pancreas divisum; Case report

Core Tip: This case report describes the nursing care of two patients undergoing minor papilla pancreatic stent placement after failed major papilla cannulation during endoscopic retrograde cholangiopancreatography (ERCP). We propose a three-component nursing framework encompassing preprocedural imaging review to identify anatomical variants and prepare specialized instruments, intraprocedural “major-first, minor-second” sequential strategy with coordinated guidewire manipulation, and a postprocedural “fasting-enzyme inhibition-fluid resuscitation” protocol for post-ERCP pancreatitis prevention. These nursing strategies may be helpful for optimizing outcomes in this high-risk population and provide practical guidance for endoscopy nursing teams.

INTRODUCTION

Endoscopic retrograde cholangiopancreatography (ERCP) has become a prominent therapeutic technique for managing pancreatobiliary disorders[1-3]. However, selective cannulation of the main pancreatic duct (MPD) via the major papilla remains technically challenging in 5%-10% of cases, even in high-volume centers[4,5]. Anatomic variants, most notably suspected pancreatic divisum (PD), significantly contribute to cannulation failure[6,7].

When selective MPD cannulation via the major papilla fails, the minor papilla offers an alternative access route for diagnostic pancreatography and therapeutic interventions, including minor papilla sphincterotomy and pancreatic stent placement[8-10]. Minor papilla cannulation is associated with a higher risk of post-ERCP pancreatitis (PEP) due to the smaller orifice diameter, greater anatomical complexity, and frequent need for multiple cannulation attempts[11,12]. PEP remains the most common and serious adverse event following ERCP, occurring in approximately 3.5%-10% of all procedures[12-14]. Proactive nursing cooperation contributes critically to the higher success rate of ERCP minor papilla cannulation and a lower risk of postoperative complications, including PEP.

While endoscopic techniques for minor papilla cannulation are well described, the nursing perspective remains underexplored. Correct education for patients undergoing ERCP is helpful in improving both perioperative compliance and recovery of patients[15]. Nurses are integral members of the ERCP team, contributing to preoperative risk assessment, intraoperative instrument coordination, and postoperative complication monitoring[16]. We present two cases of successful minor papillary pancreatic stent placement after failed MPD cannulation, focusing on the nursing care that enabled these outcomes.

CASE PRESENTATION

Chief complaints

Case 1: A 37-year-old female was admitted to our hospital due to a pancreatic mass detected during a routine physical examination one week previously.

Case 2: A 71-year-old female was admitted to our hospital with recurrent epigastric pain persisting for over four years.

History of present illness

Case 1: The patient was asymptomatic one week before admission when a routine health checkup revealed a pancreatic mass, and denied symptoms such as upper abdominal pain, radiating pain, nausea, vomiting, chest tightness, shortness of breath, or abdominal distension, with no significant weight loss. A contrast-enhanced computed tomography (CT) scan performed at an external hospital on December 4, 2025, revealed a cystic lesion accompanied by calcification in the pancreatic head, suggesting a potential neoplastic lesion (with serous cystadenoma and solid pseudopapillary tumor listed as differential diagnoses); it also noted gallbladder polyps and a calcified focus in liver segment S6. A subsequent magnetic resonance imaging (MRI) scan on December 6, 2025, confirmed the cystic mass with calcification in the pancreatic head. For definitive diagnosis and management, she was admitted to our department under the preliminary diagnosis of a “pancreatic space-occupying lesion”. Since onset, her mental status, appetite, sleep, and bowel/urinary habits had remained normal.

Case 2: The patient experienced paroxysmal, dull epigastric pain after bending forward more than four years ago, which could resolve spontaneously without nausea, vomiting, chest tightness, shortness of breath, or abdominal distension. She had been followed up at an external hospital with abdominal MRI every six months, which revealed a pancreatic occupying lesion [branch-duct intraductal papillary mucinous neoplasm (IPMN)]. MRI performed in July 2025 showed that the lesion had increased in size compared with previous imaging. The patient was admitted to our hospital for further evaluation. Her mental status, appetite, sleep, bowel and bladder habits, and body weight showed no significant changes.

History of past illness

Case 1: The patient denied any history of hypertension, cerebral infarction, chronic emphysema, rheumatic heart disease, coronary heart disease, myocardial infarction, atrial fibrillation, hepatitis, tuberculosis, or other infectious diseases, with no blood transfusion, trauma, surgery, toxin exposure, or known drug allergies.

Case 2: The patient had a history of cardiac arrhythmia for 10 years and was treated with bisoprolol (Concor), which had been discontinued for several years. She denied hypertension, cerebral infarction, chronic emphysema, rheumatic heart disease, coronary heart disease, myocardial infarction, atrial fibrillation, hepatitis, tuberculosis, or other infectious diseases. She had a surgical history of thyroidectomy 30 years and 10 years ago (currently on levothyroxine replacement) and hysterectomy with bilateral adnexectomy for uterine fibroids 20 years ago. She had no history of blood transfusion, trauma, toxin exposure, or known drug allergies.

Personal and family history

Case 1: The patient was a non-smoker and non-drinker with no history of occupational exposure to dust, toxins, or radioactive substances. Her vaccination history was up to date. Her menstrual cycles were regular, with a medium volume and no dysmenorrhea (menarche at age 13, lasting 10 days every 28 days, and her last menstrual period was on December 5, 2025). She was married, living in a harmonious family, and had given birth to healthy children. Family history was negative for diabetes, coronary heart disease, stroke, tumors, or hypertension.

Case 2: The patient was born and raised in her local region with no residential history in endemic or infectious disease areas. She had no history of occupational exposure to dust, toxins, or radioactive substances. She maintained a regular daily schedule and had no history of smoking or alcohol consumption. She was married with two healthy children. Her family history was negative for diabetes, coronary heart disease, stroke, malignant tumors, or hypertension.

Physical examination

Case 1: Vital signs were as follows: Temperature 36.6 °C, pulse 96 beats/minute, respiratory rate 20 breaths/minute, blood pressure 121/84 mmHg, weight 55 kg, and height 156 cm. The patient was conscious, well-developed, and well-nourished, with normal skin and mucosa, no jaundice, no spider angiomas, and no superficial lymphadenopathy. Cardiopulmonary examination was normal. Abdominal examination revealed a soft, nontender abdomen without rebound tenderness, no palpable masses, no hepatosplenomegaly, and negative Murphy’s sign. Bowel sounds were normal at 4/minute. Neurological examination was unremarkable.

Case 2: Vital signs were as follows: Temperature 36.3 °C, pulse 81 beats/minute, respiratory rate 20 breaths/minute, blood pressure 138/95 mmHg, weight 56 kg, and height 150 cm. The patient was conscious, well-developed, and well-nourished. Physical examination was largely normal, with a soft, nontender abdomen, no palpable masses, and no organomegaly. Bowel sounds were normal at 4/minute. Neurological examination was unremarkable.

Laboratory examinations

Case 1: Baseline laboratory tests on admission were within normal limits. Postoperative laboratory results showed the following: Lipase 137.4 U/L (elevated), amylase 104 U/L, alanine aminotransferase 141 U/L (elevated), aspartate aminotransferase 75 U/L (elevated), total bilirubin 11.9 μmol/L, direct bilirubin 1.9 μmol/L, creatinine 37.81 μmol/L (decreased), D-dimer 860 ng/mL (elevated), prothrombin time 15.20 s (elevated), international normalized ratio 1.18 (elevated), procalcitonin 0.530 ng/mL (elevated), and interleukin-6 14.1 pg/mL (elevated). White blood cell count dropped to 1.71 × 10⁹/L on January 2, 2026, and 1.56 × 10⁹/L on January 9, 2026, which improved to 15.10 × 10⁹/L on January 12, 2026, after antiviral and antibiotic treatment. Pathological examination of the pancreatic specimen revealed pancreatic serous cystadenoma, microcystic type, with calcification; the maximum tumor diameter was approximately 3.0 cm; one peripancreatic lymph node showed reactive changes without tumor involvement.

Case 2: Baseline laboratory tests on admission were unremarkable. Postoperative laboratory results showed the following: Direct bilirubin 4.5 μmol/L (elevated), D-dimer 3040 ng/mL (elevated), procalcitonin 0.387 ng/mL (elevated), and high-sensitivity C-reactive protein 37.8 mg/L (elevated). Pathological examination of the pancreatic specimen revealed pancreatic serous cystadenoma. The pathology report noted that serous cystadenoma and serous cystadenoma are difficult to distinguish histologically, and differentiation mainly depends on clinical biological behavior; regular follow-up was recommended.

Imaging examinations

Case 1: Preoperative MRI on December 6, 2025, showed a cystic lesion with calcification in the pancreatic head, suggestive of a neoplastic lesion (possible IPMN or cystadenoma). Contrast-enhanced CT of the whole abdomen showed a cystic-solid lesion at the pancreatic head-neck junction, highly suggestive of serous cystadenoma. Contrast-enhanced CT on December 24, 2025 (compared with December 12, 2025) showed: (1) Postoperative changes of the pancreas with peripancreatic exudation and fluid accumulation, requiring follow-up; (2) High-density shadow in the gallbladder, suggesting biliary sludge; (3) A sacral canal cyst extending into the left pelvis through the anterior sacral foramen; and (4) Small bilateral pleural effusions with adjacent lung tissue atelectasis.

Case 2: MRI performed at an external hospital in July 2025 showed a predominantly cystic tumor in the pancreatic head and neck, considered to be branch-duct IPMN or serous cystadenoma. Preoperative CT and MRI at our hospital on December 4, 2025 and December 6, 2025, showed a cystic lesion with calcification in the pancreatic head, suggestive of a neoplastic lesion (possible IPMN or cystadenoma), with gallbladder polyps. Postoperative CT on December 24, 2025, showed: (1) Postoperative changes of the pancreatic head with peripancreatic exudation and main pancreatic duct and common bile duct stents in place; (2) Multiple liver cysts; (3) Small bilateral pleural effusions; and (4) Bilateral renal cysts.

FINAL DIAGNOSIS

Case 1: Pancreatic benign tumor (pancreatic serous cystadenoma); gallbladder biliary sludge.

Case 2: Pancreatic benign tumor (pancreatic serous cystadenoma); post-thyroidectomy (bilateral thyroidectomy); post-hysterectomy.

Although PD was suspected preoperatively in both cases based on the difficulty of main pancreatic duct cannulation via the major papilla and the need for minor papilla access, it was not formally confirmed by pancreatography. The final diagnosis was established by surgical pathology in both cases. Therefore, PD should be regarded as a possible anatomic variant rather than a confirmed diagnosis.

TREATMENT

Following ERCP, both patients subsequently underwent pancreatic lesion resection as definitive treatment. The perioperative nursing care described in this report focuses exclusively on the ERCP phase; postoperative nursing management after pancreatic resection is beyond the scope of this case report.

Case 1

The patient underwent ERCP to define the ductal anatomy and exclude communication between the lesion and the MPD before the planned resection on December 15, 2025, under sedation. The major papilla appeared hemispherical with a villous opening and prominent oral elevation; the minor papilla was identified approximately 2 cm from the major papilla. Selective biliary cannulation via the major papilla was achieved; however, repeated attempts at MPD cannulation via the major papilla failed. A 7 Fr × 7 cm straight biliary stent was deployed via the major papilla to secure biliary drainage and to serve as an anatomical landmark during the subsequent minor papilla cannulation. Subsequently, the minor papilla was cannulated using a sphincterotome, and a guidewire was successfully advanced into the pancreatic tail. A 7 Fr × 10 cm single-pigtail pancreatic stent was deployed as a prophylactic measure against PEP following difficult cannulation. No intraprocedural adverse events were observed (Figure 1).

Figure 1 Minor papilla cannulation and fluoroscopic confirmation in Case 1. A: Endoscopic view of precut sphincterotomy at the minor papilla; the preplaced biliary stent serves as a landmark, with coordinated instrument assistance; B: Intraprocedural fluoroscopic confirmation of guidewire advancement to the pancreatic tail with adjusting patient position to optimize fluoroscopic field; C: Fluoroscopic view of the double-guidewire technique with changing to cannulate via the minor papilla under the reference marker of indwelling biliary guidewire; D: Fluoroscopic confirmation after the stent placement, verifying correct stent positioning and unobstructed biliary drainage.

Preprocedural nursing preparation: Comprehensive preoperative nursing assessment is critical for identifying risk factors that may predict difficult MPD cannulation and the potential need for minor papillary intervention[12]. The nursing team reviewed preprocedural imaging (MRCP and CT) to identify anatomic variants, such as PD. Although the classic ERCP triad of PD (a short ventral duct from major papilla cannulation, non-visualization of the dorsal duct from the major papilla, and a dominant dorsal duct visualized from minor papilla cannulation) could not be fully assessed because major papilla MPD cannulation was unsuccessful, the clinical scenario—characterized by repeated failure of MPD cannulation via the major papilla with subsequent successful minor papilla cannulation—raised the possibility of PD or an anatomical variant thereof, although alternative explanations, including purely technical factors, cannot be excluded[6,10]. Such identifications allow the nursing team to prepare specialized accessories for minor papilla cannulation (e.g., fine-caliber sphincterotomes, hydrophilic guidewires, and appropriately sized pancreatic stents) before the procedure commenced[17]. Preprocedural coagulation parameters were verified, and antiplatelet and anticoagulant medications were withheld to reduce the risk of bleeding. Psychological support and informed consent help alleviate patient anxiety and ensure that informed consent is truly informed[18].

Intraprocedural nursing coordination: Based on our experience with these two cases, four key nursing actions were identified. Step 1: Stabilization of the endoscope position. Once the position of the minor papilla is confirmed, the primary assistant (Nurse A) stabilizes the endoscope shaft, as even minor shifts in endoscope position can result in loss of target visualization. Step 2: Seamless instrument exchange. When MDP access via the major papilla fails and changes to minor cannulation, the nursing team withdraws the sphincterotome and rapidly hands a fresh fine-caliber preloaded with a hydrophilic guidewire to the endoscopist, maintaining sterility and minimizing delays. Step 3: Coordinated guidewire manipulation. When the guidewire is advanced through the minor papilla into the pancreatic duct, the assistant simultaneously advances the guidewire from the port as the endoscopist withdraws the sphincterotome, preventing guidewire dislodgement or inadvertent advancement into the branch ducts. Step 4: Stent deployment verification. The nursing team verbally confirmed the stent type, diameter, and length with the endoscopist before deployment. Following release, fluoroscopy confirmed correct positioning

After ERCP, the patient underwent robotic-assisted pancreatic lesion resection on December 15, 2025. On postoperative day 1, she developed intra-abdominal bleeding requiring emergency arterial embolization on December 16, 2025. This complication was unrelated to the ERCP procedure. She also developed transient leukopenia secondary to viral infection, which resolved after antiviral and antibiotic treatment. No ERCP-related complications were observed.

Case 2

The patient underwent ERCP to assess communication between the lesion and the MPD and to exclude main-duct involvement before the planned resection on December 16, 2025. The major papilla was hemispherical with a villous opening and prominent oral elevation; the minor papilla was identified approximately 2 cm from the major papilla, with normal morphology. Biliary cannulation via the major papilla was successful; however, repeated attempts at MPD cannulation via the major papilla failed. A 7 Fr × 11 cm straight biliary stent was deployed to secure biliary drainage and to serve as an anatomical landmark during the subsequent minor papilla cannulation. Subsequently, minor papillary cannulation was performed, and a 7 Fr × 7 cm single-pigtail pancreatic stent was deployed as a prophylactic measure against PEP following difficult cannulation. No intraprocedural adverse events were observed (Figure 2).

Figure 2 Sequential deployment of pancreatic stent under combined endoscopic and fluoroscopic surveillance in Case 2. A: Endoscopic view of completed minor papilla cannulation with the catheter positioned inside the orifice for pancreatic stent delivery; B: Initial fluoroscopic localization: Guidewire anchored deep within the pancreatic tail to provide stable rail for stent advancement; C: Fluoroscopic monitoring during stent propulsion: The single-pigtail pancreatic stent is advanced along the guidewire with coordinated nursing instrument preparation; D: Final fluoroscopic confirmation after full stent release; dual endoscopic-fluoroscopic inspection confirms appropriate stent location and satisfactory pancreatic drainage.

Preprocedural nursing preparation and intraprocedural coordination: The same nursing protocol was applied as in Case 1, including preprocedural imaging review, verification of coagulation parameters, preparation of minor-papilla-specific accessories, stabilization of the endoscope, seamless instrument exchange, coordinated guidewire manipulation, and verbal verification before stent deployment.

After ERCP, the patient underwent laparoscopic pancreatic lesion resection on December 16, 2025. The procedure was successful, and she recovered well. She was discharged on December 26, 2025. No ERCP-related complications were observed.

Table 1 summarizes the key clinical and procedural characteristics of the two cases.

Table 1 Clinical and procedural characteristics of two patients undergoing minor papilla pancreatic stent placement.

Characteristic	Case 1	Case 2
Age (years)	37	71
Sex	Female	Female
Major papilla MPD cannulation	Failed (repeated attempts)	Failed (repeated attempts)
Biliary cannulation via major papilla	Successful	Successful
Minor papilla morphology	Hemispherical, normal	Hemispherical, normal
Minor papilla cannulation	Successful (first attempt)	Successful (first attempt)
Guidewire advancement	To pancreatic tail	To pancreatic tail
Pancreatic duct findings	Neck narrowing, body/tail dilation	Body/tail dilation
Pancreatic stent size	7 Fr × 10 cm	7 Fr × 7 cm
Biliary stent size	7 Fr × 7 cm	7 Fr × 11 cm
Intraprocedural complications	None	None
Postprocedural complications (PEP, bleeding, perforation)	None at 30 days	None at 30 days

MPD: Main pancreatic duct; PEP: Post-endoscopic retrograde cholangiopancreatography pancreatitis.

OUTCOME AND FOLLOW-UP

Case 1

The patient recovered well after surgery. She was discharged on January 13, 2026, with a drainage tube in place. At discharge, she was in good general condition, conscious, and in good spirits, with no fever, chills, nausea, vomiting, hematochezia, melena, dizziness, fatigue, chest tightness, dyspnea, or urinary symptoms. Physical examination showed stable vital signs, normal cardiopulmonary auscultation, a soft abdomen with wound tenderness but no rebound tenderness, and no bleeding or exudation from the wound. The pancreatic and biliary stents were left in place at discharge, and the patient was scheduled for follow-up at the outpatient clinic two weeks after discharge.

Laboratory and imaging follow-up in Case 1 was performed during the postoperative hospital stay. On January 12, 2026 (postoperative day 28), serum lipase was mildly elevated at 137.4 U/L, whereas serum amylase was normal at 104 U/L; total and direct bilirubin were normal, and the white blood cell count had recovered to 15.10 × 10⁹/L after antiviral and antibiotic treatment. Follow-up contrast-enhanced CT showed no abnormal findings. These results were considered consistent with the expected postoperative course rather than with ERCP-related complications.

Case 2

The patient recovered well after surgery and was discharged on December 26, 2025. At discharge, she was in good general condition, conscious, and in good spirits, with no fever, chills, nausea, vomiting, hematochezia, melena, dizziness, fatigue, chest tightness, dyspnea, or urinary symptoms. Physical examination showed stable vital signs, normal cardiopulmonary auscultation, a soft abdomen with wound tenderness but no rebound tenderness, and no bleeding or exudation from the wound. The pancreatic and biliary stents were left in place at discharge, and the patient was scheduled for follow-up at the outpatient clinic two weeks after discharge.

In Case 2, the 30-day follow-up consisted of an outpatient clinic visit. The patient was asymptomatic, with no abdominal pain, fever, nausea, vomiting, hematochezia, or melena, and physical examination was unremarkable. Serum amylase, lipase, liver function tests, and inflammatory markers were within normal limits. Follow-up abdominal CT showed no peripancreatic fluid collection, pancreatic or biliary duct obstruction, stent migration, intra-abdominal or retroperitoneal bleeding, or intestinal perforation.

Post-ERCP nursing management and complication surveillance: The ‘fasting-enzyme inhibition-fluid resuscitation’ protocol was adapted from the Japanese Clinical Guideline on post-ERCP pancreatitis 2023[12]. Specifically, perioperative aggressive hydration with lactated Ringer’s solution is recommended as a key preventive measure, with evidence suggesting that early intravenous fluid resuscitation (initiated pre-procedurally or immediately post-procedurally) reduces PEP incidence[12,14]. Serum amylase and lipase were measured at 2 hours and 6 hours post-procedure. According to the Japanese guidelines, levels below 1.5 × upper limit of normal (ULN) for amylase or 4 × ULN for lipase at 4 hours post-ERCP support safe discharge[12]. Based on this protocol, both patients received the following standardized care: Monitoring in the recovery unit for 2-4 hours, with serum amylase and lipase measured at 2 hours and 6 hours post-procedure. The ‘fasting-enzyme inhibition-fluid resuscitation’ protocol included nil-per-os for 6-12 hours, somatostatin administration, and lactated Ringer’s solution at 1-2 L initial bolus followed by 200-250 mL/hour continuous infusion[19]. Surveillance for ERCP-related bleeding and perforation was maintained.

DISCUSSION

This case report provides several nursing insights for minor papilla pancreatic stent placement.

Nursing recognition of difficult MPD cannulation and suspected anatomic variants. Although PD has not been formally documented preprocedurally in these cases, incomplete PD or a variant thereof remains a possibility that cannot be confirmed or excluded in the clinical scenario[6,7]. From a nursing perspective, recognition of this suspected anatomic variant enables the preemptive preparation of minor-papilla-specific instruments and anticipation of rapid transition between approaches. Thus, systematic reviews of MRCP or CT images should be included in preprocedural nursing assessments. It should be noted that MRCP has limited sensitivity (48.4%-63%) for detecting PD[6,7]; therefore, a negative MRCP finding does not exclude the diagnosis. In cases where clinical suspicion remains high, endoscopic ultrasound may offer superior diagnostic accuracy[6]. From a nursing perspective, this underscores the importance of preparing for minor papilla cannulation even when preprocedural imaging does not definitively identify PD.

The “major-first, minor-second” sequential strategy: Based on our experience in these two cases, this approach offered the following advantages: Successful biliary stenting stabilizes the guidewire, provides an anatomical landmark, reduces the number of cannulation attempts of the minor papilla, minimizes mechanical trauma to the smaller orifice, and ensures biliary drainage even if minor papillary cannulation fails. From a nursing coordination standpoint, this required: (1) A pre-organized sterile field with both biliary and pancreatic instruments positioned for immediate access; (2) Clear verbal communication; (3) Role clarity; and (4) Familiarity with the distinct instrument requirements for each approach.

“Walking the wire”: The coordinated “advance-withdraw” motion of the guidewire is perhaps the most technically demanding aspect of nursing care. When the assistant fails to advance the guidewire as the endoscopist withdraws, the guidewire may dislodge, or aggressive advancement may send the wire into unintended branches. The simulation-based practice of this maneuver before complex procedures is recommended.

Aggressive protocol for PEP prevention: The nursing protocol extends beyond facilitating stent placement, including the preprocedural identification of PEP risk factors, intraprocedural minimization of pancreatic duct contrast injections, immediate postprocedural measurement of serum amylase/lipase at 2 hours and 6 hours, aggressive intravenous fluid resuscitation with lactated Ringer’s solution, administration of somatostatin analogs, and close clinical monitoring. These proactive approaches are consistent with guideline recommendations for PEP prophylaxis[12], although their efficacy cannot be established from the present two cases.

Study limitations: This case report represents a small sample size (n = 2), both patients were female and from the same institution with limited long-term follow-up. Although PD was suspected, a formal confirmatory pancreatography was not performed. Alternative explanations for failed MPD cannulation unrelated to anatomy cannot be excluded; accordingly, the nursing framework proposed here applies to failed MPD cannulation of any cause rather than exclusively to PD. As ERCP and pancreatic resection were performed on the same day, early postprocedural events cannot be unequivocally attributed to either procedure alone. In Case 1, the postoperative bleeding and transient hyperlipasemia were considered surgical in origin based on the timing (postoperative day 1), angiographic findings, and resolution pattern; nevertheless, a contribution from ERCP cannot be formally excluded. Nonetheless, these detailed nursing insights offer practical guidance in similar complex scenarios.

CONCLUSION

Minor papillary pancreatic stent placement has been described in the literature as a feasible rescue strategy when selective MPD cannulation via the major papilla fails during ERCP[8]. Nursing care plays a pivotal role throughout the perioperative period. We propose a nursing framework for minor papilla pancreatic stent placement that includes: (1) Systematic preprocedural assessment for suspected PD and other predictors of difficult MPD cannulation; (2) Intraprocedural “major-first, minor-second” sequential strategy with coordinated guidewire “walking”; and (3) Postprocedural aggressive protocol for PEP prevention. These nursing contributions may help optimize outcomes in this high-risk patient population and should be recognized as integral components of advanced endoscopic practice. This case report provides a detailed nursing documentation of minor papilla pancreatic stent placement in two patients, which may offer practical guidance for endoscopy nursing teams to manage complex ERCP scenarios.