Endoscopic retrograde pancreatography is an established modality for the treatment
of pancreatic duct stones [1]
[2]. Although it is technically challenging in patients with prior pancreatoduodenectomy
[3]
[4], balloon-assisted endoscopic retrograde pancreatography and/or endoscopic ultrasound-guided
pancreatic drainage has been increasingly utilized to manage pancreatic diseases in
patients with surgically altered anatomy [5]. Here we report a simple and feasible technique for the endoscopic removal of an
impacted pancreatic duct stone after pancreatoduodenectomy using a short-type single-balloon
enteroscope.
A 61-year-old man, who underwent pylorus-preserving pancreatoduodenectomy with modified
Childʼs reconstruction three years earlier for pancreatic neuroendocrine tumor, was
referred to our department for the treatment of acute pancreatitis. Contrast-enhanced
computed tomography showed three radiopaque stones in the main duct; one of the three
stones was impacted in the main pancreatic duct, resulting in obstructive pancreatitis
([Fig. 1]). Therefore, an endoscopic intervention was performed using a short-type single-balloon
enteroscope (SIF-H290S; Olympus Medical Systems, Tokyo, Japan) with a transparent
hood. A tapered double-lumen catheter with a tip diameter of 3.6 Fr (Uneven Double
Lumen Cannula Standard Type; Piolax Medical Devices, Kanagawa, Japan) was advanced
through the pancreaticojejunal anastomosis, and a 0.025-inch guidewire (VisiGlide
2; Olympus Medical Systems) was placed into the pancreatic duct; however, the catheter
could not pass through the impacted stone at all. After placing an additional guidewire,
the section downstream of the stone was dilated with a 6-mm balloon catheter (REN;
Kaneka Medix, Osaka, Japan) ([Fig. 2 a]), and as the balloon deflated, the impacted stone moved downstream toward the balloon
([Fig. 2 b], [Video 1]).
Fig. 1 Contrast-enhanced computed tomography showed three radiopaque stones in the main
duct; one of the three stones was impacted in the main pancreatic duct, resulting
in obstructive pancreatitis.
Fig. 2 Fluoroscopic images. a An impacted pancreatic duct stone (arrow) during the downstream balloon dilation.
b As the balloon deflated, the pancreatic duct stone (arrow) moved downstream toward
the balloon. c The pancreatic stone was captured with a wire-guided basket catheter.
Video 1 Downstream balloon dilation technique for endoscopic removal of an impacted pancreatic
duct stone after pancreatoduodenectomy.
Finally, the pancreatic stones were successfully retrieved by using a wire-guided
basket catheter (TetraCatch V; Olympus Medical Systems) ([Fig. 2 c], [Fig. 3]).
Fig. 3 Endoscopic view of pancreatic duct stones retrieved from the main pancreatic duct.
The downstream balloon dilation technique is simple and is worth a try when confronting
impacted pancreatic duct stones.
Endoscopy_UCTN_Code_TTT_1AR_2AH
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