Percutaneous transhepatic cholangioscopy-assisted repositioning of misplaced endoscopic ultrasound-guided pancreatic duct stent

An 80-year-old man with a history of pancreaticoduodenectomy for intraductal papillary mucinous carcinoma 10 years earlier presented with recurrent pancreatitis caused by stricture at the pancreaticojejunostomy. Magnetic resonance imaging and endoscopic ultrasound (EUS) revealed a dilated main pancreatic duct (MPD) with pancreatolithiasis ([Fig. 1], [Fig. 2]). EUS-guided pancreatic duct drainage [1] was attempted.

Fig. 1 Pancreatolithiasis (arrowhead) and the dilated pancreatic duct (arrows) on magnetic resonance cholangiopancreatography.

Fig. 2 Endoscopic ultrasound demonstrated a dilated duct (arrows) with pancreatolithiasis (arrowhead).

The dilated MPD was punctured under EUS guidance, and a guidewire was successfully advanced into the jejunum through the anastomotic stricture. Then, the fistula was dilated with coaxial electrocautery and a 4-mm balloon. A 7-Fr double-pigtail stent was then placed through the MPD across the jejunum and stomach. However, after stent deployment in the stomach, the proximal pigtail fell into the peritoneal cavity from the stomach as it curled up ([Fig. 3], [Video 1]).

Fig. 3 Endoscopic ultrasound-guided pancreatic duct stent placement. The proximal end of the stent fell into the peritoneum (arrow).

Endoscopic ultrasound-guided placement of a double-pigtail pancreatic duct stent.

The MPD in the tail of the pancreas was punctured again under EUS guidance, and a 7-Fr straight plastic stent was successfully placed across the MPD and stomach ([Fig. 4], [Video 2]). However, to leave the misplaced stent end in the peritoneum would lead to leakage of pancreatic juice, and therefore stent repositioning was attempted. The patient already had an indwelling 12-Fr percutaneous transhepatic biliary drainage (PTBD) tube in place for the stricture at the hepaticojejunosotmy. A percutaneous transhepatic cholangioscope (PTCS) was inserted through this PTBD route into the jejunum. The distal end of the misplaced stent was visualized on endoscopic view and was grasped with a snare. The misplaced proximal end of the stent was successfully repositioned in the MPD by pulling the PTCS through the PTBD route ([Fig. 5], [Video 3]).

Fig. 4 Second endoscopic ultrasound-guided pancreatic duct stent placement. The stent was successfully deployed across the pancreatic duct and the stomach (arrows).

Second endoscopic ultrasound-guided placement of a straight, plastic, pancreatic duct stent.

Fig. 5 The misplaced stent was repositioned using a percutaneous transhepatic cholangioscope. The misplaced proximal end of the stent was pulled into the pancreatic duct (arrows).

Repositioning of the misplaced stent using a percutaneous transhepatic cholangioscope.

The clinical course after the procedure was uneventful without pancreatitis or leakage of pancreatic juice, and 6 weeks later the misplaced stent was completely removed through the PTBD route using the PTCS. The patient had no further episodes of acute pancreatitis.

Endoscopy_UCTN_Code_CPL_1AL_2AD

• Reference

• 1 Itoi T, Kasuya K, Sofuni A et al. Endoscopic ultrasonography-guided pancreatic duct access: techniques and literature review of pancreatography, transmural drainage and rendezvous techniques. Dig Endosc 2013; 25: 241-252