Many techniques have been described for the removal of proximally migrated pancreatic
duct (PD) stents, with a reported success rate of 80 % [1]. Success depends on the location of the stent and caliber of PD. In general, it
is more difficult if the PD is narrow or not dilated and the stent in located in the
pancreatic tail.
A 64-year-old woman underwent a routine endoscopic retrograde cholangiopancreatography
(ERCP) for choledocholithiasis and received a straight 5-Fr plastic PD stent placement
owing to difficult biliary cannulation. Unfortunately, the PD stent migrated to the
pancreatic genu and attempts at removal using a Dormia basket and rat tooth forceps
pushed the stent deeper beyond the genu.
Owing to the COVID-19 situation, a conventional wire-guided Soehendra stent retriever
was not available in our country and would have needed a few months for delivery.
Balloon and grasping devices were again unsuccessfully used in an attempt to remove
the PD stent. A third ERCP was performed 2 days later. The plan to snare the distal
end of the PD stent using a “lasso-over-the-guidewire” technique [2] was unsuccessful because the distal stent edge abutted the PD wall, preventing the
snare wire from looping around the migrated PD stent.
With the use of Hi-Torque Command 0.018-inch guidewire (Abbott Laboratories, Chicago,
Illinois, USA), a VisiGlide 2 0.025-inch straight-tip guidewire (Olympus Medical,
Tokyo, Japan), and a 4-mm microsnare and microcatheter, we report this novel “closed-loop”
method of removing a migrated PD stent in the tail of the pancreas, where conventional
techniques failed and the wire-guided stent retriever was not available ([Fig. 1], [Video 1]). This method securely removes the impacted stent with minimal trauma to the pancreatic
duct.
Fig. 1 The novel “closed-loop” method is demonstrated in six steps. a The 0.018-in guidewire (purple) was passed into the pancreatic duct (PD) through
the migrated PD stent (green). b The microcatheter (grey) was then railroaded through an 0.018-in guidewire into the
PD stent. c The 0.018-in guidewire was then exchanged for a microsnare (brown). d A 0.025-inch guidewire (red) was then passed externally alongside the PD stent and
maneuvered through the microsnare loop at the proximal end of the PD stent. e The microsnare was used to snare the non-hydrophilic portion of the guidewire to
minimize slipping and the microcatheter was pulled back to the proximal end of the
PD stent to form a closed loop. f With this closed loop system, the PD stent was removed successfully.
Video 1 Novel “closed-loop” method to retrieve proximally migrated pancreatic duct stent.
Endoscopy_UCTN_Code_TTT_1AR_2AZ
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