Pancreatic duct stents are useful in reducing the risk of post-ERCP pancreatitis. Risks of placing pancreatic duct stents include internal migration, difficult or failed placement, and ductal damage. Improper placement of pancreatic duct stents can predispose to migration. Removal of internally migrated pancreatic duct stents can be technically challenging.
A 24 year-old female with history of a laparoscopic band procedure had an ERCP performed for choledocholithiasis at an outside hospital. Prophylactic pancreatic duct stent placement was performed due to difficult cannulation. The patient was later found to have internal migration of the pancreatic duct stent. She underwent multiple ERCPs which were all unsuccessful in removing the pancreatic duct stent. The patient presented to our institution for attempted removal of the stent.
The pancreatic duct was cannulated with a sphincterotome. It is evident that a pancreatic sphincterotomy had previously been performed. The pancreatic duct stent and a laparoscopic band port can be seen on fluoroscopy. Contrast has been injected into the pancreatic duct, confirming the location of the stent in the tail of the pancreas. A standard size biopsy forcep is used to cannulate the pancreatic duct. The forcep is advanced through the head of the pancreas and towards the genu of the duct. Care is taken to manipulate the endoscope in such a fashion to keep the forceps straight in line with the duct to avoid trauma while passing through the sharply angled genu. The forceps are gently advanced and we can see that the tip of the forceps has reached the stent. The fluoroscopy image has been magnified to obtain greater detail. The tip of the stent has been grasped and gentle traction is being applied. The stent has been dislodged from its position in the tail of the pancreas. It is gently pulled through the duct with care being taken to avoid losing grip of the stent. With some manipulation of the endoscope, the stent is successfully extracted from the pancreatic orifice. A snare is used to grasp the stent and it is removed through the endoscope. Once removed, the stent was carefully examined. It was noted that the flange had been cut off of one end and left on the other, to promote spontaneous migration out of the duct. However, on closer inspection, the bite marks from the biopsy forceps were located on the same side that the flange was removed from, indicating that the end with the flange was placed into the duct. In other words, the stent was put in backwards, which is likely why the stent migrated.
In summary, pancreatic duct stents can be useful to reduce the risk of post-ERCP pancreatitis. However, there is a risk of internal migration. Removal of internally migrated stents can be technically challenging and proper placement is necessary to avoid migration. Removal should be performed only by those who have expertise in this area to avoid further complications.
Ara B. Sahakian, MD, Yale University
Harry Aslanian, M.D., Yale University
James Ostroff, MD, University of California, San Francisco
Priya A. Jamidar, MD, Yale University