Endoscopy 2016; 48(S 01): E129-E130
DOI: 10.1055/s-0042-105210
Cases and Techniques Library (CTL)
© Georg Thieme Verlag KG Stuttgart · New York

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

Yousuke Nakai
Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
,
Hiroyuki Isayama
Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
,
Gyotane Umefune
Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
,
Suguru Mizuno
Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
,
Hirofumi Kogure
Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
,
Natsuyo Yamamoto
Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
,
Kazuhiko Koike
Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
› Author Affiliations
Further Information

Corresponding author

Hiroyuki Isayama, MD, PhD
Department of Gastroenterology
Graduate School of Medicine
The University of Tokyo
7-3-1 Hongo Bunkyo-ku
Tokyo 113-8655
Japan   
Fax: +81-3-38140021   

Publication History

Publication Date:
01 April 2016 (online)

 

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.

Zoom Image
Fig. 1 Pancreatolithiasis (arrowhead) and the dilated pancreatic duct (arrows) on magnetic resonance cholangiopancreatography.
Zoom Image
Fig. 2 Endoscopic ultrasound demonstrated a dilated duct (arrows) with pancreatolithiasis (arrowhead).

The dilated MPD was punctured under 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 jejunum and 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]).

Zoom Image
Fig. 3 Endoscopic ultrasound-guided pancreatic duct stent placement. The proximal end of the stent fell into the peritoneum (arrow).


Quality:
Endoscopic ultrasound-guided placement of a double-pigtail pancreatic duct stent.

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 the misplaced 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 grasped with a snare. The misplaced proximal end of the stent was successfully repositioned in the MPD by pulling the PTCS through the PTBD route ([Fig. 5], [Video 3]).

Zoom Image
Fig. 4 Second endoscopic ultrasound-guided pancreatic duct stent placement. The stent was successfully deployed across the pancreatic duct and the stomach (arrows).


Quality:
Second endoscopic ultrasound-guided placement of a straight, plastic, pancreatic duct stent.

Zoom Image
Fig. 5 The misplaced stent was repositioned using a percutaneous transhepatic cholangioscope. The misplaced proximal end of the stent was pulled into the pancreatic duct (arrows).


Quality:
Repositioning of the misplaced stent using a percutaneous transhepatic cholangioscope.

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.

Endoscopy_UCTN_Code_CPL_1AL_2AD


#

Competing interests: None

  • Reference

  • 1 Itoi T, Kasuya K, Sofuni A et al. Endoscopic ultrasonography-guided pancreatic duct access: techniques and literature review of pancreatography, transmural drainage and rendezvous techniques. Dig Endosc 2013; 25: 241-252

Corresponding author

Hiroyuki Isayama, MD, PhD
Department of Gastroenterology
Graduate School of Medicine
The University of Tokyo
7-3-1 Hongo Bunkyo-ku
Tokyo 113-8655
Japan   
Fax: +81-3-38140021   

  • Reference

  • 1 Itoi T, Kasuya K, Sofuni A et al. Endoscopic ultrasonography-guided pancreatic duct access: techniques and literature review of pancreatography, transmural drainage and rendezvous techniques. Dig Endosc 2013; 25: 241-252

Zoom Image
Fig. 1 Pancreatolithiasis (arrowhead) and the dilated pancreatic duct (arrows) on magnetic resonance cholangiopancreatography.
Zoom Image
Fig. 2 Endoscopic ultrasound demonstrated a dilated duct (arrows) with pancreatolithiasis (arrowhead).
Zoom Image
Fig. 3 Endoscopic ultrasound-guided pancreatic duct stent placement. The proximal end of the stent fell into the peritoneum (arrow).
Zoom Image
Fig. 4 Second endoscopic ultrasound-guided pancreatic duct stent placement. The stent was successfully deployed across the pancreatic duct and the stomach (arrows).
Zoom Image
Fig. 5 The misplaced stent was repositioned using a percutaneous transhepatic cholangioscope. The misplaced proximal end of the stent was pulled into the pancreatic duct (arrows).