Endoscopic Retrieval of Stent Fragments Retained in Main Pancreatic Duct

A 34-year-old male alcoholic patient was suffering from epigastric pain with nausea for last 1 month. He was referred to us when he developed new-onset breathlessness and chest discomfort. He was found to have left-sided massive pleural effusion on chest X-ray and computed tomographic scan of abdomen showed calcific pancreatitis with collection near the tail region of pancreas communicating toward left pleural cavity. He received intravenous antibiotics. Left intercostal tube drainage (ICD) was done and fluid showed amylase of 45,000 IU/mL suggestive of pancreatic pleural effusion. Endoscopic retrograde pancreatography (ERP) was done. Pancreatogram showed small collection in the tail region and contrast leak toward left pleural cavity and there were no stricture in the pancreatic duct (PD). Single pigtail plastic stent was placed (5 fr*12 cm) ([Fig. 1]). Patient improved, ICD was removed, and he got discharged. He was lost to follow-up for 1 year and again presented with dull aching epigastric discomfort. His pleural effusion resolved but fragments of PD stent were noted in situ. Repeat ERP was done after a rectal suppository of indomethacin 100 mg was administered 30 minutes before the procedure. Pancreatogram showed fragments of stent in the PD ([Fig. 2]). The downstream fragment was removed using stone extraction basket. The other fragments, which were more upstream in the PD, were completely retrieved using peroral pancreatoscope and SpySnare (Spyglass DS II; Boston Scientific, Marlborough, Massachusetts, United States). A PD stent (5 fr × 5 cm single pigtail stent) was placed at the end of the procedure after removal of the stent fragments. The procedure lasted 85 minutes ([Video 1]) ([Figs. 3] and [4]). Patient improved and got discharged. After 2 weeks the PD stent was removed and medical management was continued.

Fig. 1 Pancreatogram showing guidewire in main pancreatic duct and contrast leak at the tail region with extravasation towards left pleural cavity

Fig. 2 Broken stent fragments seen in main pancreatic duct

Video 1 Procedure of retrieval of the retained pancreatic stent fragments using extraction basket under fluoroscopy and pancreatoscopic guided snare.

Fig. 3 Guidewire placed in main pancreatic duct and over the wire basket placed to extract the downstream stent fragment

Fig. 4 Pancreatoscopic guided extraction of the upstream stent fragment using through the scope snare

Practical Implications for Endoscopists

• Regular patient follow-up is mandatory after ERP and stenting procedures. Advice for the removal of the stent should be an integral part of discharge advice to prevent complications due to forgotten stent.

• Fragmentation and retention of unattended stents in PD is a known complication but rare. Prompt removal is needed to prevent stent impaction and stent-induced pancreatitis.[1] Removal can be done under the guidance of fluoroscopy or pancreatoscopy.[2]

• Retrieval technique under fluoroscopic guidance could be by (1) indirect balloon traction method, or (2) direct grasp using basket, forceps, or snare, or (3) stent cannulation and capture using a basket, snare, or Soehendra stent retriever.[1]

• Peroral pancreatoscope allows retrieval of the stent fragments under direct visualization, which allows accurate maneuvering of accessories like dedicated through the scope forceps, snare, or basket.[3]

• Centers with limited resources can refer these patients to higher centers where advanced endoscopic facilities like ERP and SpyScope, etc. are available. However, surgical retrieval is still an option and can be considered after discussing with the patient.

• References

• 1 Lahoti S, Catalano MF, Geenen JE, Schmalz MJ. Endoscopic retrieval of proximally migrated biliary and pancreatic stents: experience of a large referral center. Gastrointest Endosc 1998; 47 (06) 486-491
• 2 Cai YL, Wang F, Li ZS, Hu LH. Endotherapy for the proximal migration of pancreatic stents: a systematic review. Pancreas 2024; 53 (08) e694-e699
• 3 Yao W, Huang Y, Chang H, Zhang Y, Li K. Endoscopic retrieval of a migrated pancreatic stent under direct pancreatoscopy by use of a “snare over in-stent wire guide” method. VideoGIE 2018; 3 (09) 272-274