Endoscopic retrieval of a proximally migrated pancreatic stent: variation of the lasso technique

Inhaltsübersicht

Many devices have proved to be useful to retrieve proximally migrated pancreatic stents [1] [2]. The lasso technique involves inserting a guide wire through the lumen of the migrated stent followed by insertion of a partially opened polypectomy snare over the wire to grasp the stent [3].

We present the case of a 72-year-old woman with recurrent acute biliary pancreatitis, who underwent endoscopic retrograde cholangiopancreatography (ERCP) for biliary sphincterotomy due to high surgical risk. During the ERCP procedure, a flared pancreatic stent (diameter 5 Fr; length 5 cm) was placed. However, in spite of the stent, the patient developed pancreatitis. A computed tomography (CT) scan showed proximal migration of the pancreatic stent ([Fig. 1]), and another ERCP procedure was carried out to retrieve it.

Fig. 1 CT scan showing the migrated pancreatic stent in the pancreatic duct (arrow). There are signs of acute postendoscopic retrograde cholangiopancreatography (ERCP) pancreatitis.

The pancreatic duct was deeply cannulated with a guide wire introduced alongside the stent. We then threaded the external end of the wire through a partially opened polypectomy snare ([Fig. 2]) and gently closed the snare and introduced it over the wire in the pancreatic duct until it reached the distal end of the stent ([Fig. 3]).

Fig. 2 The polypectomy snare threaded over the wire for insertion into the pancreatic duct.

Fig. 3 Fluoroscopic image of the migrated stent (both ends marked with white arrows), the guide wire alongside it, and the polypectomy snare inserted over the wire at the level of the genu (arrowhead).

At this point, we gently opened the snare ([Fig. 4]) and manipulated it until we had lassoed the stent.

Fig. 4 The opened snare inside the pancreatic duct (arrowhead) being manipulated to grasp the stent (white arrow) and the wire simultaneously.

We then extracted the entire stent pulling the snare and the wire simultaneously ([Fig. 5]).

Fig. 5 Simultaneous extraction of the stent and the wire from the pancreatic duct. Once the stent had been fully retrieved, the guide wire, whose proximal end was still in the pancreatic duct, was inserted again without the need to recannulate.

The patient had an uneventful recovery following the procedure.

The present variation of the previously described lasso technique [3] consists of inserting the guide wire alongside the stent rather than through the stent lumen. Like the original technique, this maneuver allowed us to gently insert a polypectomy snare into the pancreatic duct up to the level of the genu, and then open it within the pancreatic duct to lasso the stent and wire and extract them simultaneously. Since the guide wire was deeply placed in the pancreatic duct, further access to the pancreatic duct was maintained without the need for recannulation.

Endoscopy_UCTN_Code_TTT_1AR_2AZ

References

• 1 Price L H, Brandabur J J, Kozarek R A. et al . Good stents gone bad: endoscopic treatment of proximally migrated pancreatic duct stents.  Gastrointest Endosc. 2009;  70 174-179
• 2 Lahoti S, Catalano M F, Geenen J E, Schmalz M J. Endoscopic retrieval of proximally migrated biliary and pancreatic stents: experience of a large referral center.  Gastrointest Endosc. 1998;  47 486-491
• 3 Sherman S, Hawes R H, Uzer M F. et al . Endoscopic stent exchange using a guide wire and mini-snare.  Gastrointest Endosc. 1993;  39 794-799