Lions and Tigers and Pancreatic Foreign Bodies, Oh My! Endoscopic Pancreatic Duct Exploration and Foreign Body Retrieval, a case series. These are our disclosures. Pancreatic duct structures often benefit from endoscopic duct decompression with the use of stents or various dilation and tools. Endoscopic exploration and pancreatic ductal anatomic variations and equipment-related complications are infrequent and pose a challenge to endoscopists. We present a case series of two successful intrapancreatic ductal foreign body retrievals with unique strategies. The first case we call, the one that almost got away, a case of pancreatic duct exploration and retrieval of a fractured pancreatic duct stent. We have a 57-year-old male with recurrent pancreatitis due to hypertrichlysiridemia, hydrochlorothiazide, and alcohol with pancreatic pseudocysts who was evaluated with ERCP, which initially demonstrated a pancreatic duct leak at the tail of the pancreas into a 4-centimeter fluid collection. An appropriate intervention using a straight stent was placed into the ventral pancreatic duct to traverse the leak. A month later, during outpatient ERCP, the pancreatic duct stent was traversing the papilla, grasped the snare and withdrawn. However, the downstream tip had fractured, leaving the upstream 3-centimeter of the stent in the duct. Here, we see the balloon occlusion cholangiogram demonstrating the fractured upstream stent. A safety loop traversed through the distally migrated stent. A few different modalities were thought of intra-procedure, including utilizing a unique modality, such as placement of a stent introducer catheter as a conduit for retrieval devices, as it would act as a stable channel to access the tail of the pancreatic duct. After attempts with a snare, rat tooth forceps, dilating balloon, the downstream duct appeared open enough for successful withdrawal. Attempts at using the dilating balloon itself as a withdrawal device, uniquely by inflating the balloon while it was through the fractured stent tip, was not successful. Finally, the stent retriever had successfully used to withdraw the fractured piece of the stent. As seen here, the stent retriever is turned carefully and seated well into the distally migrated fractured stent piece. And here, in endoscopic view, we see that it is withdrawn carefully. Here it comes, out traversing the ampulla. The wire was carefully advanced and a new stent was replaced. The broken piece of the stent that was in the duodenum was carefully retrieved with a snare. And here we see the fractured stent tip withdrawn and removed with the snare through the scope. In follow-up, the patient had great success and had subsequent ERCPs demonstrating resolution of the leak. At one year follow-up, imaging demonstrated no residual peripancreatic fluid collection, and he has been asymptomatic and not required further pancreatic endoscopic intervention for six years. The second case we call, when the ansa loop throws you for a loop. Intrapancreatic duct exploration and retrieval of the fractured stent retriever tip. This is a case of a 47-year-old male with hemorrhagic pancreatitis and fluid collections in the head and tail who underwent ERCP revealing ansa pancreatica and ductal stenosis in the genu. He underwent stent placement and interval upsizing of the stent with prompt clinical response. Interval CT demonstrated resolution of the pancreatitis, decompression of the duct, and resolution of prior fluid collections. He presents for ERCP and a wire was advanced through the ansa loop as seen here with the blue arrow to the tip of the pancreatic duct and previous stent was removed successfully. Now was the challenge. Multiple devices were used and attempted to pass but were unsuccessful due to the tight stricture as seen by the blue arrow here at the genu of the ansa loop. Ultimately, the stent retriever could partially traverse the stricture. At which time, the tip fractured and disconnected into the ansa loop. After balloon dilation, that did aid in opening up the downstream duct. Here we see the fractured tip that was disconnected into the bend of the ansa loop. After balloon dilation, retrieval with aid of cholangioscopy utilizing the basket was successful. We demonstrate here the excellent fluoroscopic images and cholangioscopic views. This is the cholangioscopic view of the metal tip being carefully withdrawn with the snare into the scope. Here's the fractured tip. No new stents were required as prompt contrast drainage was visualized. In follow-up, the patient had great success and improved clinically. MRI showed resolution of the pancreatic head and stable pancreatic tail cyst. In conclusion, removal of pancreatic intraductal foreign bodies is challenging and various tools may be used in retrieval. Tools may be advanced into the pancreatic or biliary duct via stent introducer catheter as a stable conduit for foreign body retrieval. Stents was not required during these ERCPs as dilation of the downstream duct did aid in successful retrieval. Ductal variations such as ansa pancreatica did require more intensive and strategic planning for duct exploration. Thank you.

intrapancreatic ductal foreign body retrieval

fractured pancreatic duct stent

stent introducer catheter

retrieval devices

ansa loop