A main pancreatic duct stricture on the papillary side of a pancreatic duct stone may impede device passage and stone extraction. 1 We temporarily placed a fully covered self-expandable metal stent (FCSEMS) to dilate the stricture and facilitate balloon extraction without lithotripsy. 2
A 33-year-old woman with a 10-year history of recurrent abdominal pain and multiple admissions for acute pancreatitis was referred to our institution. Magnetic resonance cholangiopancreatography showed pancreatic atrophy, main pancreatic duct dilation, and an intraductal filling defect suggestive of a stone. Endoscopic ultrasonography showed a 2.3×3.5-mm hyperechoic intraductal focus without acoustic shadowing.
Pancreatography showed a tortuous main pancreatic duct approximately 6 mm in diameter, a 5×6-mm filling defect, and a stricture on the papillary side of the stone ( Fig. 1 ). Given the duct tortuosity and tight stricture, direct stone extraction was considered unlikely to succeed. As extracorporeal shock wave lithotripsy and other lithotripsy modalities were unavailable, temporary FCSEMS placement was selected to facilitate subsequent stone extraction, taking procedural safety and cost into consideration. After sequential bougie dilation (7-Fr, 8.5-Fr, and 9-Fr), a 10×60-mm FCSEMS was deployed across the stricture ( Video 1 ). A 7-Fr×7-cm biliary plastic stent was placed prophylactically ( Fig. 2 ). Whitish stone debris was observed after FCSEMS deployment.
Fig. 1.
ERP demonstrating a main pancreatic duct stone with an associated stricture on the papillary side.
Fig. 2.
A 10×60-mm FCSEMS across the pancreatic duct stricture and a prophylactically placed 7-Fr×7-cm biliary plastic stent.
Video 1 Temporary placement of a fully covered self-expanding metal stent to facilitate pancreatic duct stone extraction during a subsequent procedure.
At repeat ERCP 41 days later, both stents were removed ( Fig. 3 ). An extraction balloon readily traversed the previously narrowed segment, and repeated balloon sweeps retrieved whitish stone fragments without lithotripsy ( Fig. 4 ). No immediate procedure-related adverse events occurred.
Fig. 3.
Removal of both stents using foreign-body forceps.
Fig. 4.
Balloon extraction of whitish, flocculent pancreatic duct stone fragments.
During 3 years of follow-up, the patient had no recurrent abdominal pain, pancreatitis, or related hospitalizations. For papillary-side strictures precluding routine stone retrieval, short-term intraductal FCSEMS placement may facilitate lithotripsy-free extraction and improve pancreatic duct drainage. 3
Endoscopy_UCTN_Code_TTT_1AR_2AH
Footnotes
Conflict of Interest The authors declare that they have no conflict of interest.
Contributorsʼ Statement Nan Zeng: conceptualization, data curation, software, supervision, visualization, writing – original draft, and writing – review and editing. Beibei Li: conceptualization, project administration, resources, writing – original draft, and writing – review and editing. Jingbo Yang: conceptualization, formal analysis, methodology, project administration, resources, and supervision.
Declaration of GenAI Use
During the preparation of this manuscript, the authors used ChatGPT, developed by OpenAI, solely for English-language editing to improve grammar, clarity, and readability. All artificial intelligence–assisted contents were reviewed and revised by the authors, who take full responsibility for the final manuscript.
References
- 1.van der Wiel S E, Stassen P M, Poley J-W et al. Pancreatoscopy-guided electrohydraulic lithotripsy for the treatment of obstructive pancreatic duct stones: a prospective consecutive case series. Gastrointest Endosc. 2022;95:905–INF. doi: 10.1016/j.gie.2021.11.047. [DOI] [PubMed] [Google Scholar]
- 2.Strand D S, Law R J, Yang D et al. AGA clinical practice update on the endoscopic approach to recurrent acute and chronic pancreatitis: expert review. Gastroenterology. 2022;163:1107–1114. doi: 10.1053/j.gastro.2022.07.079. [DOI] [PubMed] [Google Scholar]
- 3.Tringali A, di Prampero SF V, Landi R et al. Fully covered self-expandable metal stents to dilate persistent pancreatic strictures in chronic pancreatitis: long-term follow-up from a prospective study. Gastrointest Endosc. 2018;88:939–946. doi: 10.1016/j.gie.2018.08.019. [DOI] [PubMed] [Google Scholar]