A successful endoscopic pancreatic stone extraction in a patient with pancreatic divisum with cholangiojejunostomy reconstruction

A 21-year-old woman who previously underwent choledochojejunostomy during childhood was admitted with a 1-week history of worsening upper abdominal pain. She was diagnosed with acute pancreatitis, and magnetic resonance cholangiopancreatography (MRCP) revealed a pancreatic divisum with multiple stones in both dilated ventral and dorsal pancreatic ducts ([Fig. 1]).

Fig. 1 a Magnetic resonance cholangiopancreatography (MRCP) demonstrated a dilated ventral pancreatic duct filled with multiple stones (red arrow) and the stenosed choledochojejunal anastomosis (black arrow). b The dorsal pancreatic duct was dilated with filling defects at the neck region (red arrow).

An endoscopic retrograde cholangiopancreatography (ERCP) was performed. Initial endoscopic assessment found a stenosed proximal duodenum ([Fig. 2]) and it was not passed until a smaller JF-240 duodenoscope (Olympus, Tokyo, Japan) with an 11-mm outer diameter was changed. The major papilla was cannulated and a cholangiogram showed a few anomalies. First, there was a dilated fusion with multiple calculi between the ventral pancreatic and common bile duct. The distal main pancreatic duct was not seen ([Fig. 3]). Secondly, it also revealed a stenosed side-to-side choledochojejunal anastomosis. We proceeded to remove the stones through the major papilla with an extractor balloon ([Fig. 4]), and a 7 Fr nasobiliary catheter was inserted. The amylase of the bile obtained during ERCP was 49 999 U/L (normal < 150 U/L), while the postoperative amylase of bile from the nasobiliary drainage tube was 3156 U/L.

Fig. 2 Fluoroscopic image showed the stenosed duodenal lumen at the junction of duodenal bulb and second part of duodenum (red arrow); also note the air cholangiogram that represented the common bile duct (white arrow).

Fig. 3 Cannulation of the major papilla demonstrated anomalous of fusion of the ventral pancreatic duct and common bile duct. There was a cystic dilation at the fused segment with multiple filling defects (red arrow). The guidewire failed to pass to the distal pancreas duct despite several attempts.

Fig. 4 Complete stone removal from the ventral pancreatic duct.

We then cannulated the minor papilla and revealed a 6-mm dilated dorsal pancreatic duct, which was also filled with stones ([Fig. 5]). These calculi were cleared and a 7 Fr 7-cm single-pigtail plastic stent was inserted ([Video 1]). The patient recovered uneventfully after the procedure.

Fig. 5 Cannulation of the minor papilla showed the dilated pancreatic duct with filling defects at the neck region (red arrow).

Video 1 Detailed procedures of ERCP for successful pancreatic stone extraction in a patient with pancreatic divisum with cholangiojejunostomy reconstruction.

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The cystic dilations of the main and accessory pancreatic duct along with multiple stone formation are rare. The presence of pancreas divisum, anomalous pancreaticobiliary junction (APBJ), and choledochojejunostomy reconstruction may have contributed to the stones’ formation in pancreaticobiliary ducts in this patient [1] [2]. Further surgery for this patient may reduce long-term risk of bile duct cancer, as APBJ is known to increase the risk of cholangiocarcinoma by promoting reflux of pancreatic juice into the biliary system; decreased amylase in the bile may delay this process.

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Competing interests

The authors declare that they have no conflict of interest.

• References

• 1 Ende AR, Irani S, Kozarek RA. Symptomatic pancreatic duct stones in the disconnected bile duct: A case series. Pancreatology 2017; 17: 51-54
• 2 Diao M, Li L, Zhang JZ. et al. A shorter loop in Roux-Y hepatojejunostomy reconstruction for choledochal cysts is equally effective: Preliminary results of a prospective randomized study. J Pediatr Surg 2010; 45: 845-847

Publication History

Article published online:
25 November 2022