The removal of a proximally migrated pancreatic stent is technically challenging [1]
[2]
[3]. A novel device delivery system (EndoSheather; Piolax) was recently developed, which
comprises a slim-tipped guide catheter and pusher tube that facilitate the insertion
of devices up to 1.9 mm in diameter [4]
[5].
An 80-year-old man was admitted to our hospital for treatment of choledocholithiasis.
We removed the bile duct stone by performing endoscopic sphincterotomy; however, black
stools were observed 2 days after the procedure. Emergency endoscopy revealed an exposed
blood vessel in the papilla of Vater. We planned to perform hemostasis by injecting
hypertonic saline and epinephrine after stenting both the bile and pancreatic ducts;
however, the pancreatic stent (Geenen, 5 Fr, 3 cm; Cook Medical Japan) migrated during
the procedure. We were unable to remove the migrated pancreatic stent despite attempts
with several different devices, including a dilation balloon, stone removal balloon,
and basket catheter, with the stent finally ending up in the tail of the pancreatic
duct (PD) ([Fig. 1 a]). We therefore replaced the additional pancreatic stent, and the procedure was terminated
once hemostasis had been achieved.
Fig. 1 Fluoroscopic images showing: a the pancreatic stent (arrow) that had migrated into the tail of the pancreatic duct;
b a novel device delivery system (EndoSheather; arrowhead) that was inserted close
to the stent (arrow), with the inner catheter then removed; c the intraductal cholangioscopy forceps with a 1-mm diameter (SpyBite) being used
to grasp the migrated stent; d the biopsy forceps being pulled up within the outer sheath.
Cessation of the bleeding was confirmed 2 days later, when we also attempted to remove
the migrated pancreatic stent. First, a guidewire (EndoSelector; Boston Scientific)
was placed on the proximal side of the PD. Second, the novel device delivery system
(EndoSheather) was inserted close to the migrated pancreatic stent, and the inner
catheter was removed ([Fig. 1 b]). A biopsy forceps with a 1.8-mm diameter (Radial Jaw; Boston Scientific) was then
inserted through the sheath; however, it was not possible to open the jaws because
of the narrow PD. We therefore used a smaller biopsy forceps with a 1-mm diameter
(SpyBite; Boston Scientific) to grasp the migrated pancreatic stent ([Fig. 1 c]). Finally, we pulled the biopsy forceps up into the outer sheath of the device ([Fig. 1 d]) and were able to successfully remove the migrated stent ([Fig. 2]). Endoscopic nasopancreatic drainage was subsequently performed to prevent pancreatitis
due to clots ([Video 1]), and the patient was discharged without further complications.
Fig. 2 Endoscopic view showing the migrated stent being successfully grasped with the biopsy
forceps and removed.
Video 1 Successful removal of a proximally migrated pancreatic stent using a novel device
system.
Endoscopy_UCTN_Code_TTT_1AR_2AZ
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