A 70-year-old woman was admitted with an episode of epigastric pain radiating into
her back, accompanied by intermittent nausea and vomiting. Acute pancreatitis was
diagnosed and transabdominal ultrasound revealed a dilated pancreatic duct of 6 mm
due a ductal stone.
The first attempt of endoscopic retrograde pancreatography (ERP) failed to cannulate
the pancreatic duct. Following a magnetic resonance cholangiopancreatography, the
patient was diagnosed with a complete pancreas divisum. Hence, the pancreatic duct
was accessed via the minor papilla, and ERP showed a dilated duct with an impacted
stone near the orifice ([Fig. 1]). Unfortunately, the stone could not be removed despite dilation of the distal duct.
Surgical interventions or shock wave lithotripsy were discussed, but the patient preferred
an endoscopic approach. Subsequently, a fully covered self-expanding metal stent (SEMS,
WallFlex 8 × 60 mm; Boston Scientific Corp., Marlborough, Massachusetts, USA) was
placed for 5 months in the minor papilla ([Fig. 2]). After implantation of the SEMS, the patient had no complaints and reported fewer
episodes of epigastric pain.
Fig. 1 Endoscopic retrograde pancreatography using cannulation of the minor papilla. The
dilated pancreatic duct (arrow heads) with impacted stone (arrow) can be seen.
Fig. 2 Plain radiographic image of the pancreatic region, showing the pancreatic duct stone
and fully covered self-expanding metal stent 5 months after insertion through the
minor papilla.
During pancreaticoscopy with electrohydraulic lithotripsy, after retrieval of the
SEMS only fragments of the stone could be removed. Because of the good response following
implantation of the covered SEMS, we again decided to place an SEMS ([Fig. 3], [Video 1]). So far, 14 months after the initial stent implantation, the patient has gained
weight and, apart from occasional episodes of pain, she reports no complaints.
Fig. 3 The fully covered self-expanding metal stent through the minor papilla.
Introduction and release of the fully covered self-expanding metal stent through
the minor papilla, and visualization of the stent lumen after release.
Our results are in line with a case series reported by Liao et al., which showed similar
success in three patients [1]; however, in these cases the SEMS passed spontaneously after 6 months, and data
on longer follow-up after migration are missing.
In conclusion, this case describes the possibility of draining obstruction due to
pancreatic ductal stone in the minor papilla in complete pancreas divisum using a
fully covered SEMS, with good clinical response.
Endoscopy_UCTN_Code_TTT_1AR_2AZ
