Migration of a pancreatic duct stent further into the duct (proximal
migration) after implantation is a relatively rare complication
[1]. Various pieces of equipment such as a small balloon,
snare, forceps, and grasping tripod have been used successfully to extract such
stents [2]
[3]
[4]. However, their removal has proved technically
challenging because of the narrow and tortuous shape of the pancreatic duct
[2]
[4]. This report describes a new
method for extraction of a proximally migrated pancreatic duct stent with the
help of a pre-positioned guide wire.
A 16-year-old boy with recurrent acute pancreatitis caused by
pancreas divisum ([Fig. 1]) was treated by
implantation of a plastic stent into the pancreatic duct. Endoscopic retrograde
cholangiopancreatography (ERCP) 1 month later showed that the pancreatic
duct stent had migrated further along the pancreatic duct into the body of the
pancreas ([Figs. 2] and [3 a]). After dilation of the minor pancreatic duct
with an 8.5-Fr dilator, extraction of the stent was attempted using a snare and
a basket, but both failed because they could not be fully opened in the
pancreatic duct. A 1-cm balloon and a rat-tooth forceps were then tried, both
of which were able to pull the stent out by a little bit. However, they were
finally hampered by the sharp angle formed by the stent and the minor
pancreatic duct in the pancreatic head because of the narrow and tortuous shape
of the pancreatic duct ([Fig. 3 b, c]).
Fig. 1 Magnetic resonance
cholangiopancreatography (MRCP) showing that within the pancreatic head the
minor pancreatic duct (white arrow) was dilated and the major pancreatic duct
(double white arrows) was invisible.
Fig. 2 Endoscopic retrograde
cholangiopancreatography (ERCP) 1 month after implantation showing that
the stent (black arrows) had migrated further along the duct into the body of
the pancreas.
Fig. 3 Entire process for
extraction of the proximally migrated stent from the pancreatic duct. CBD,
common bile duct; MPD, minor pancreatic duct.a The stent
that had migrated further along the pancreatic duct into the body of the
pancreas. b An attempt to pull out the stent with a
small balloon that had been inserted and inflated was hampered by the sharp
angle formed by the stent and the minor pancreatic duct. c An attempt to pull out the stent with a rat-tooth forceps
was also hampered by the same angle. d A pre-positioned
guide wire was used to keep the pancreatic duct relatively straight and the
stent was successfully extracted using forceps.
A second ERCP was tried 3 days later. First, a 0.035-Fr guide
wire was placed in the pancreatic duct, which helped to keep the minor
pancreatic duct in a relatively straight shape and in this way blunted the
angle. A forceps was then inserted along the guide wire in the same working
channel and finally grasped and successfully extracted the whole stent ([Fig. 3 d]). The patient was discharged
2 days later without complications.
In this case, a proximally migrated stent was successfully extracted
with the help of a pre-positioned guide wire. This method may be a good
alternative option for other similar cases.
Endoscopy_UCTN_Code_TTT_1AR_2AZ
