An 80-year-old man with a history of pancreaticoduodenectomy for intraductal papillary
mucinous carcinoma 10 years earlier presented with recurrent pancreatitis caused by
stricture at the pancreaticojejunostomy. Magnetic resonance imaging and endoscopic
ultrasound (EUS) revealed a dilated main pancreatic duct (MPD) with pancreatolithiasis
([Fig. 1], [Fig. 2]). EUS-guided pancreatic duct drainage [1] was attempted.
Fig. 1 Pancreatolithiasis (arrowhead) and the dilated pancreatic duct (arrows) on magnetic
resonance cholangiopancreatography.
Fig. 2 Endoscopic ultrasound demonstrated a dilated duct (arrows) with pancreatolithiasis
(arrowhead).
The dilated MPD was punctured under EUS guidance, and a guidewire was successfully
advanced into the jejunum through the anastomotic stricture. Then, the fistula was
dilated with coaxial electrocautery and a 4-mm balloon. A 7-Fr double-pigtail stent
was then placed through the MPD across the jejunum and stomach. However, after stent
deployment in the stomach, the proximal pigtail fell into the peritoneal cavity from
the stomach as it curled up ([Fig. 3], [Video 1]).
Fig. 3 Endoscopic ultrasound-guided pancreatic duct stent placement. The proximal end of
the stent fell into the peritoneum (arrow).
Endoscopic ultrasound-guided placement of a double-pigtail pancreatic duct stent.
The MPD in the tail of the pancreas was punctured again under EUS guidance, and a
7-Fr straight plastic stent was successfully placed across the MPD and stomach ([Fig. 4], [Video 2]). However, to leave the misplaced stent end in the peritoneum would lead to leakage
of pancreatic juice, and therefore stent repositioning was attempted. The patient
already had an indwelling 12-Fr percutaneous transhepatic biliary drainage (PTBD)
tube in place for the stricture at the hepaticojejunosotmy. A percutaneous transhepatic
cholangioscope (PTCS) was inserted through this PTBD route into the jejunum. The distal
end of the misplaced stent was visualized on endoscopic view and was grasped with
a snare. The misplaced proximal end of the stent was successfully repositioned in
the MPD by pulling the PTCS through the PTBD route ([Fig. 5], [Video 3]).
Fig. 4 Second endoscopic ultrasound-guided pancreatic duct stent placement. The stent was
successfully deployed across the pancreatic duct and the stomach (arrows).
Second endoscopic ultrasound-guided placement of a straight, plastic, pancreatic
duct stent.
Fig. 5 The misplaced stent was repositioned using a percutaneous transhepatic cholangioscope.
The misplaced proximal end of the stent was pulled into the pancreatic duct (arrows).
Repositioning of the misplaced stent using a percutaneous transhepatic cholangioscope.
The clinical course after the procedure was uneventful without pancreatitis or leakage
of pancreatic juice, and 6 weeks later the misplaced stent was completely removed
through the PTBD route using the PTCS. The patient had no further episodes of acute
pancreatitis.
Endoscopy_UCTN_Code_CPL_1AL_2AD
