Endoscopic ultrasound-guided pancreatic gastrostomy to facilitate retrieval of approximately migrated pancreatic duct stent in a post-ripple patient. Proximal migration of pancreatic duct stents can occur in 5% of cases. Failure of stent retrieval is associated with pancreatitis, bleeding, duct disruption, stent fracture, and occlusion. Therefore, prompt retrieval of the stent is necessary, though it is challenging due to the narrow diameter and complex path of the pancreatic duct. In this case, we present a staged approach for the retrieval of approximately migrated pancreatic duct stent in a post-ripple patient with a pancreatic ojiginal anastomotic stricture. We present a case of a 70-year-old male with history of pancreatic acinar cell carcinoma who had undergone ripple surgery and had several presentations with recurrent episodes of acute pancreatitis. CT scan with IV contrast revealed dilation of the main pancreatic duct to 6 mm upstream of the pancreatic ojiginal anastomosis. Enteroscopy-assisted ERCP was attempted, but we were unable to locate the pancreatic ojiginal anastomosis. Ultrasound demonstrated dilation of the main pancreatic duct to 4.7 mm, proximal to the PG anastomosis, tapering to 2 mm in the distal pancreatic body. A hyper-echoic round structure was identified within the duct, consistent with the migrated pancreatic stent. EUS-guided pancreatic gastrostomy was performed with placement of a 7-french 15-cm straight plastic pancreatic stent crossing the PG and PG ojiginal anastomosis. The plastic pancreatic stent was then upsized to an 8 mm by 16 mm fully covered self-expanding metal stent through the PG gastrostomy tract to further dilate the tract for stent retrieval. Here we present a pictorial representation of the patient's anatomy and the migrated pancreatic stent in relation to the PG stent. This video demonstrates our approach to removal of the migrated pancreatic duct stent after staged dilation of the PG site. The fully covered self-expanding metal stent was removed from the pancreatic gastrostomy site. Sphincterotome pre-ordered with a guide wire was used to cannulate the pancreatic gastrostomy site and guide wire was advanced into the pancreatic duct past the pancreatic jejunal anastomosis. A cholangioscope was then advanced over the guide wire. The pancreatic jejunal anastomotic structure was noted. As a cholangioscope was removed, we noted the migrated pancreatic stent. The stent was grasped with cholangioscopic forceps and removed completely from the pancreatic duct. The stent was confirmed to be completely intact. The pancreatic gastrostomy site was cannulated again and guide wire left in place across the PJ anastomosis. The PJ anastomotic structure was then dilated with a balloon dilator. A plastic pancreatic stent was then advanced over the guide wire and placed crossing both the pancreatic adjustional and pancreatic gastric anastomosis sites. This video demonstrates our approach to removal of the migrated pancreatic duct stent after stage dilation of the pancreatic gastrostomy site. In follow-up, the patient remains asymptomatic without recurrent episodes of abdominal pain or pancreatitis and is scheduled to follow-up for an ERCP for stent upsizing to treat the pancreatic adjustment on asthmatic stricture. In summary, step-wise dilation and stenting via EUS-guided pancreatic gastrostomy is an effective approach for facilitating pancreatoscopy and retrieval of approximately migrated pancreatic duct stent, especially in patients with altered anatomy.

pancreatic duct stent

endoscopic ultrasound

pancreatic gastrostomy

Whipple surgery

cholangioscope