Pancreatic stent eroding into the stomach
27 November 2013 (online)
A 32-year-old alcoholic man diagnosed as having acute necrotizing pancreatitis and being managed conservatively developed high-grade fever not responsive to intravenous antibiotics. A percutaneous catheter inserted into the large, infected acute necrotic collection drained frank pus. The patient gradually improved and contrast-enhanced computed tomography (CECT) 3 weeks later revealed a marked reduction in the size of the collection. The transgastric route of the percutaneous catheter was visible on the CECT scan. The catheter continued to drain 300 – 500 mL of clear pancreatic juice and 4 weeks later the patient underwent endoscopic retrograde pancreatography (ERP). This revealed a complete pancreas divisum with partial disruption of the dorsal duct. A bridging 5-Fr stent was placed through the minor papilla and the patient showed marked improvement, with the external drainage of pancreatic juice subsiding after 2 weeks. The percutaneous catheter was thereafter removed. After another 4 weeks, the patient underwent another ERP for removal of the stent and to document healing of the ductal disruption. During the passage of the duodenoscope into the stomach a stentlike foreign body was seen in the stomach, protruding through the posterior wall ([Fig. 1]). The transpapillary stent placed a few weeks earlier was seen at the papilla but the flanges had migrated inwards ([Fig. 2]). Fluoroscopic examination revealed that the transpapillary stent had migrated into the stomach through the pancreatic duct disruption, following the route created by the transgastric percutaneous catheter ([Fig. 3]). The stent was removed via the minor papilla ([Fig. 4]) and a pancreatogram revealed persistence of ductal disruption. A bridging 5-Fr transpapillary stent was placed. ERP was repeated 4 weeks later and revealed healing of both the ductal disruption and the fistulous opening in the stomach.
Transpapillary stents and nasopancreatic drains have been successfully used for healing of pancreatic ductal disruptions. Stent treatment may be associated with significant complications such as infection, stent block, duct perforation, migration, and stent-induced ductal changes .
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