Self-expandable covered metallic stent as a conduit for pancreatic stone extraction

A 50-year-old man was referred for evaluation of alcohol-related chronic relapsing pancreatitis. Initial endoscopic retrograde cholangiopancreatography (ERCP) revealed a dilated pancreatic duct with a stone proximal to a distal stricture. The stricture was dilated to 6 mm using a balloon, and an 8.5-Fr plastic stent was placed to ensure drainage. ERCP 2 months later showed no improvement in the stricture and a 10-Fr stent was placed.

Repeat pancreatography 2 months later ([Video 1]) revealed a persistent distal stricture with a floating ovoid-shaped stone (6 × 10 mm) in the proximally dilated duct ([Fig. 1 a]). The stricture was dilated to 6 mm ([Fig. 1 b]), and an 8 mm × 4 cm fully covered Gore Viabil (Conmed Corp., Utica, New York, USA) self-expandable metallic stent (SEMS) was placed across the stricture. A rat-tooth forceps was passed through the SEMS and the stone was grasped ([Fig. 2]) under fluoroscopic guidance. The stone and stent were then simultaneously extracted from the duct and removed from the patient ([Fig. 3], [Video 1]). There were no post-procedural complications.

Video 1 Removal of a pancreatic duct stone with the aid of a self-expandable metallic stent.

Fig. 1 Pancreatography. a Distal stricture with associated stone. b Dilation of the pancreatic duct stricture.

Fig. 2 Use of the rat-tooth forceps. a Endoscopic image showing advancement of rat-tooth forceps through the self-expandable metallic stent. b Fluoroscopic image showing rat-tooth forceps grasping the pancreatic duct stone.

Fig. 3 Fluoroscopic image showing simultaneous removal of the pancreatic duct stone and metallic stent.

Ductal hypertension, as a result of obstruction from pancreatic duct stones and strictures in chronic pancreatitis, is believed to be the major cause of pain and recurrent pancreatitis [1]. Treatment options for pancreatolithiasis vary depending on stone location and size [2] [3]. The 2015 European Society of Gastrointestinal Endoscopy recommends the use of ERCP as first-line therapy in patients with a small number of stones with a diameter of < 5 mm in the body and proximal pancreas. For larger stones, extracorporeal shock wave lithotripsy prior to ERCP is recommended [4]. We present a unique method of pancreatic stone removal using a fully covered SEMS as a conduit for passage of a rat-tooth forceps across a distal stricture to facilitate pancreatic stone extraction.

Endoscopy_UCTN_Code_TTT_1AR_2AH

Competing interests

None

• References

• 1 Choi E, Lehman G. Update on endoscopic management of main pancreatic duct stones in chronic calcific pancreatitis. Korean J Intern Med 2012; 27: 20-29
• 2 Beyna T, Neuhaus H, Gerges C. Endoscopic treatment of pancreatic duct stones under direct vision: revolution or resignation?. Systematic review. Dig Endosc 2018; 30: 29-37
• 3 Chandrasekhara V, Chathadi KV. ASGE Standards of Practice Committee. et al. The role of endoscopy in benign pancreatic disease. Gastrointest Endosc 2015; 82: 203-214
• 4 Dumonceau J, Delhaye M, Tringali A. et al. Endoscopic treatment of chronic pancreatitis: European Society of Gastrointestinal Endoscopy Clinical Guideline. Endoscopy 2012; 44: 784-800