Percutaneous transhepatic cholangioscopy-assisted repositioning of misplaced endoscopic ultrasound-guided pancreatic duct stent.

Abstract

An 80-year-old man with a history of pancreaticoduodenectomy for intraductal papillary mucinous carcinoma 10 years earlier presented with recurrent pancreatitis caused by stricture at the pancreaticojejunostomy. Magnetic resonance imaging and endoscopic ultrasound (EUS) revealed a dilated main pancreatic duct (MPD) with pancreatolithiasis (● Fig.1, ● Fig.2). EUS-guided pancreatic duct drainage [1] was attempted. ThedilatedMPDwaspuncturedunder EUS guidance, and a guidewire was successfully advanced into the jejunum through the anastomotic stricture. Then, the fistula was dilated with coaxial electrocautery and a 4-mm balloon. A 7-Fr double-pigtail stent was then placed through the MPD across the jejunumand stomach. However, after stent deployment in the stomach, the proximal pigtail fell into the peritoneal cavity from the stomach as it curled up (● Fig.3,● Video 1). The MPD in the tail of the pancreas was punctured again under EUS guidance, and a 7-Fr straight plastic stent was successfully placed across the MPD and stomach (● Fig.4, ● Video 2). However, to leave themisplaced stent end in the peritoneum would lead to leakage of pancreatic juice, and therefore stent repositioning was attempted. The patient already had an indwelling 12-Fr percutaneous transhepatic biliary drainage (PTBD) tube in place for the stricture at the hepaticojejunosotmy. A percutaneous transhepatic cholangioscope (PTCS) was inserted through this PTBD route into the jejunum. The distal end of the misplaced stent was visualized on endoscopic view and was graspedwith a snare. Themisplaced proximal end of the stent was successfully repositioned in the MPD by pulling the PTCS through the PTBD route (● Fig.5,● Video 3). The clinical course after the procedure was uneventful without pancreatitis or leakage of pancreatic juice, and 6 weeks later the misplaced stent was completely removed through the PTBD route using the PTCS.The patient had no further episodes of acute pancreatitis.