Dr. Mohit Girotra, MD, FACP, and Dr. Benjamin Tharian, MD, MRCP, FRACP, from the Stanford University School of Medicine, Stanford, California and the University of Arkansas for Medical Sciences, Little Rock, Arkansas present this video case.

A 73-year-old woman with failed prior ERCP for choledocholithiasis underwent successful endoscopic retrograde cholangiopancreatography (ERCP) with extraction of a large stone and subsequent pancreatic duct (PD) stent placement for post-ERCP pancreatitis (PEP) prophylaxis. The stent spontaneously migrated deep into the PD and could not be retrieved using standard ERCP tools, including grasping forceps, snares, and extraction balloon. An innovative technique was then devised, where a 4cm x 4mm biliary dilation balloon was carefully placed alongside the stent to drag the stent down from the deeper portions of PD. Subsequently, a digital cholangioscope was used to visualize the stent and successfully retrieve it through the use of the cholangioscope forceps.

Removal of proximally migrated pancreatic stents is technically challenging because of the small PD diameter, the bent course, the presence of strictures, and the lack of suitable devices for stent removal. The new digital cholangioscope has improved visualization of the bile and pancreatic ducts and, hence, has become an important tool in armamentarium for advanced endoscopists for an extended range of therapeutics.

Figure 1. A, Dragging stent down from deep PD using 4 mm 4 cm balloon under fluoroscopy. B, Retrieval of stent using direct cholangioscopy forceps.

Although cholangioscope-assisted stent removal has been described, ours is a unique case of the removal of a deeply migrated pancreatic duct stent using a biliary dilation balloon and the new digital cholangioscope. This novel technique was innovated when all standard measures of deeply migrated stent removal had failed. We expect our technique will help other endoscopists by adding to the existing tools and techniques for management of this complex endoscopic challenge.

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