EOS guided removal of internally migrated and fractured pancreatic stent author Dr. Neelam Mehta, additional authors Dr. Narendrasi, Dr. Nokur Mehta. These are our disclosures. Internal stent migration of pancreatic stents sometimes fractured in various segments has negative clinical implications and require removal. Removal of an intact or fractured pancreatic stent can be challenging, even warranting surgery rarely. Various methods are described to remove the stent. Simplest is place another stent by the side of a migrated stent, remove it after few days or weeks and the previous stent comes out. Another method is to inflate a biliary stone extraction balloon by the side of a migrated stent, sweeps it and the stent comes out. However, many a times we have to grab the stent with a foreign body forceps and take it out. If we are lucky, cannulating a PD stent with a guide wire and removal is possible. Direct visualization of the stent and removal is possible nowadays with cholangiopancreatic scopi. Rarely surgery is indicated. However, no single method is ideal and each method has its challenges and failure. The stent can get impacted in the wall or side branch at the angulation while using particularly inflated balloon. A foreign body forceps is too stiff to introduce into pancreatic duct, even the maneuvering is very difficult. We know that cholangiopancreatic scopi cannot be done in a normal caliber or mildly dilated pancreatic duct and surgery has its own morbidity and is the least preferred model. U.S. guided pancreatic duct interventions either the rendezvous or EUSBD are established procedures. Overall technical success rate is around 80% with an adverse event rate of 20%. Success rate is much lower and complication rate is much higher compared to EUSBD. Success rate is particularly lower in patients with non-dilated or minimally dilated pancreatic duct and complication rates are higher if the pancreas is normal and not having chronic pancreatitis. Present a case wherein 29-year-old female patient underwent ERCP for suspected lower biliary obstruction. Prophylactic pancreatic stent was placed due to inadvertent pancreatic duct cannulation. However, in follow-up stent got fractured and there was a complete internal migration of the stent. Stent removal was tried outside but they could not take it out as pancreatic duct opening could not be identified. Patient was referred to us for further care. ERCP was planned but pancreatic duct opening could not be identified at our place. EUSBD guided pancreatic duct access was planned at this juncture. It was difficult in view of non-dilated duct. We were also worried about higher chances of complications like pancreatitis due to normal pancreatic parenchyma in a young patient. EUSBD guided pancreatic duct access was successful and 5-print pigtail stent was placed. Follow-up ERCP was carried out after 3 weeks. Several methods were used to remove the stent. Eventually, we were successful using a foreign body forceps. ERCP was planned. Fluoroscopy revealed a fractured internally migrated pancreatic stent. Unfortunately, pancreatic duct opening could not be seen even after multiple attempts. EUSBD was planned. Pancreatic duct could be visualized only because of the stent. A 22-gauge number needle was used and 0.018 wire was tried to negotiate through the duct into the duodenum which was not successful. Second puncture was done using 19-gauge needle and 0.021 wire. Wire was successfully negotiated into the duodenum which was caught by a foreign body forceps. However, wire could not be taken out from the mouth as it got entangled into the stomach. Pancreatic duct cannulation was done by the side of the wire. Cannula with a wire was passed. Pancreatogram revealed a non-dilated duct in head with mildly prominent duct in the body. 5-fringe pancreatic stent was placed into the duct. Pancreatogram revealed a non-dilated duct in head and body. Foreign body forceps caught the proximal most part of the stent and we tried to disimpact the stent. However, it was unsuccessful. Foreign body forceps was passed again and we tried to catch the middle part of the stent. Stent got folded on its own and got disimpacted and came out eventually. Pancreatic arm was again taken which revealed non-dilated duct in head, prominent duct in body, narrow duct in body with a leak. 5-fringe 12-centimeter single-pigtail pancreatic stent was placed. Niclophenic suppository was placed prior to procedure both the times and ring-electrode was infused. Patient was kept kneel-by-mouth for 12 hours. Fortunately, patient was asymptomatic without pancreatitis and was discharged after 2 days after both the sessions. There are very important learning points from this case. The reason of not identifying the pancreatic orifice happened because after the previous papillotomy biliary and pancreatic duct opening got wide apart and pancreatic opening got stenotic. Also, PDXS in a dilated duct in a normal pancreas is very difficult. Pancreatic duct we could see only because of pancreatic stent. 22-gauge needle is recommended when pancreatic duct is narrow. However, 0.018 wire is not easy to negotiated and it gets bend. We did two-stage procedure to avoid the complications. Several methods and attempts were required to remove the fractured stent. Even though stone extraction balloon is the safest, it was not useful in our case. Polangiopancreaticoscopy was also not possible as due to non-dilated duct. Even though retrieval using foreign body forceps was successful, gaining entry to and maneuvering inside the PD was difficult due to stenotic pancreatic duct opening and non-dilated pancreatic duct. We also thought that NSH suppository along with ring-elected infusion and careful maneuvering of accessories prevented pancreatitis and complications. To conclude, EOS guided PDXS followed by careful maneuvering of accessories is feasible and safe in non-dilated pancreatic duct with normal pancreas. Certain precautions should be taken to reduce complications.

pancreatic stent removal

EUS-guided access

post-papillotomy stenosis

foreign body forceps

pancreatitis prevention