S3347 Proximal Migration of Pancreatic Stent in Pancreatic Divisum: Challenges in Retrieval and Review of Literature

Abstract

INTRODUCTION: Pancreatic divisum is the commonest congenital malformation of pancreas. When patients get symptomatic with recurrent attacks of pancreatitis, they undergo ERCP with sphincterotomy and stent placement. Proximal migration of pancreatic stent in Pancreatic divisum is rare and is challenging to manage. We describe an interesting case of proximal migration of pancreatic stent in Pancreatic divisum and perform review of literature. CASE DESCRIPTION/METHODS: A 55-year-old female with past medical history of Pancreas Divisum, Recurrent Pancreatitis presented with sharp epigastric pain radiating to her back associated with nausea and vomiting. On physical exam, she appeared stable with moderate epigastric tenderness. Imaging revealed stones in the main pancreatic duct (PD) with Pancreas Divisum. ERCP was performed, which revealed stenosed minor papilla, which was selectively cannulated and sphincterotomy was performed, ductal stone was removed, and an 8.5 Fr x 9 cm straight plastic stent was placed (Figure 1). During repeat ERCP 3 weeks later, stent was found to have migrated deep into the main PD (Figure 2). The PD was explored endoscopically using SpyGlass Direct Visualization System (Boston Scientific, Natick, Massachusetts, USA). Proximally migrated PD stent was seen which was successfully retrieved using a SpyGlass Retrieval Snare and multiple PD stents were removed. A 5 Fr x 9 cm pigtail PD stent was placed to ensure adequate pancreatic drainage after intraductal intervention. DISCUSSION: Pancreatic stents can migrate both distally as well as proximally into the PD. Migrated stent can cause recurrent pancreatitis, infection, perforation as swell as stenosis of the duct. Incidence of stent migration has been reported at about 1.5% in medical literature.(1) Retrieval of migrated stent is challenging, especially in pancreatic divisum due to anatomical location of main pancreatic duct and the acute angle at which endoscope must be maneuvered. Use of SpyGlass Direct Visualization System enables direct and fluoroscopic visualization of the pancreatic duct. If endoscopic retrieval is not possible, surgical retrieval may be necessary. Risk factors for proximal migration of stent include cholangiocarcinoma, malignant strictures, longer stent use.(1,2).Figure 1.: Cannulation of minor papilla and stone in PD (as pointed by arrow), stent placement.Figure 2.: Migrated PD stent.