Post written by Jorge D. Machicado, MD, MPH, from the Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA.

In this video, we describe a case of a guidewire that fractured in the pancreatic duct during ERCP and different tools used for its successful removal. This occurred during attempts at placing a plastic stent across a severe pancreatic duct stricture in the head of the pancreas, resulting in 15 cm of a fractured wire retained upstream of the stricture.

Numerous maneuvers performed to remove the wire included stricture dilation with a 10F Soehendra stent retriever (Cook Medical, Bloomington, Ind, USA) and 6-mm balloon dilation, followed by use of balloon sweeps, a snare, a pediatric forceps, a rat tooth forceps, and a cytology brush with a SpyBite forceps (Boston Scientific Endoscopy, Natick, Mass, USA) through one of the catheter lumens. These pancreatography-guided maneuvers were unsuccessful.

Pancreatoscopy was attempted, but the catheter could not traverse the severe stricture. A month later, ERCP was repeated. A temporal fully covered self-expandable metal stent (fcSEMS) was placed across the pancreatic duct stricture, allowing successful passage of the pancreatoscopy catheter and visualization of the fractured wire. The sheared end of the wire appeared embedded in the duct wall or the pancreatic parenchyma.

The fractured wire was first moved forward with a SpyBite forceps until the impacted sheared portion was exposed. This enabled successful grasp of the fractured wire under pancreatography guidance with a rat tooth forceps and removal out of the duct.

Guidewire fracture in the pancreatic duct is an uncommon event, with only 8 cases previously reported. Of these, 3 cases had successful endoscopic removal with conventional ERCP methods, 1 required surgery for successful removal, 3 were left in place without further adverse events, and 1 was left in place with migration into the retroperitoneum and a major vessel, requiring interventional radiology removal. Fractured wires are difficult to retrieve from the pancreatic duct, especially in the setting of chronic pancreatitis and pancreatic duct stricture/stones.

This case illustrates the different tools that can be used to remove retained fractured guidewires or other migrated foreign objects from the pancreatic duct. To the best of our knowledge, our case is the first to use a fcSEMS and pancreatoscopy to assist in retrieving a migrated fractured guidewire from the pancreatic duct. Temporal placement of a fcSEMS allowed passage of the pancreatoscopy catheter across a severe pancreatic duct stricture, a helpful maneuver to facilitate pancreatoscopy in the setting of chronic pancreatitis.

Fractured wire grasped with SpyBite forceps (Boston Scientific Endoscopy, Natick, Mass, USA).

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