title: Endoscopic management of internally migrated pancreatic duct stents (with video).
abstract: OBJECTIVE
  Spontaneous intestinal migration of pancreatic stents is a known phenomenon. However, retrieval of a proximally migrated pancreatic stent (PMPS) poses a therapeutic challenge. The primary aim of this study was to evaluate technical success of endoscopic retrograde of cholangiopancreatography (ERCP) for extraction of PMPS, including number of sessions, need of surgery for failures and intervention-induced adverse events. The secondary outcome was to evaluate long-term effects of PMPS on the ductal morphology.
  
  
  METHODS
  Data of patients undergoing pancreatic stenting since January 2007 was reviewed. Fourteen patients were found to have PMPS. The level of stent migration was divided into two categories: level 1: retropapillary migration of the stent, the distal end seen till the genu (n = 6). Level II: PMPS with distal end seen beyond genu (n = 8). The stents were placed due to following reasons, prophylactic pancreatic stenting after common bile duct stone extraction (n = 6), pancreatic endotherapy for chronic pancreatitis (n = 7), and recurrent acute pancreatitis with incomplete pancreas divisum (n = 1). ERCP was done using Olympus TJF 160/180 duodenoscope. Stent extraction was initially attempted using rat tooth forceps, snare with or without wire, wire-guided basket, and in case of failures, pancreatoscope was used (Boston Scientific, USA).
  
  
  RESULTS
  PMPS could successfully be retrieved in 13 out of 14 patients (92.8 %). Stents were retrieved using stone extraction balloon in two (14.2 %), modified angiography balloon in one (7 %), rat tooth in three patients (21.4 %), over-the-wire snare in three patients (21.4 %), lasso technique in one (7 %), and under pancreatoscope guidance in three patients (21.4 %). Adverse events encountered were mild pancreatitis (n = 2, 14 %) and self-limited bleeding (n = 2, 14 %).
  
  
  CONCLUSIONS
  Endotherapy of PMPS could be complex and associated with adverse events. Level II-migrated stents may require specialized methods like pancreatoscopy for stent retrieval.
authors.affiliation: Baldota Institute of Digestive Sciences, 3rd Floor, Global Hospitals, 35, Dr. E. Borges Road, Opp Shirodkar High School, Parel East, Mumbai, 400 012, India. drsurya_b@yahoo.com.
authors.forename: Suryaprakash
authors.initials: S
authors.lastname: Bhandari
authors.affiliation: Baldota Institute of Digestive Sciences, 3rd Floor, Global Hospitals, 35, Dr. E. Borges Road, Opp Shirodkar High School, Parel East, Mumbai, 400 012, India.
authors.forename: Atul
authors.initials: A
authors.lastname: Sharma
authors.affiliation: Baldota Institute of Digestive Sciences, 3rd Floor, Global Hospitals, 35, Dr. E. Borges Road, Opp Shirodkar High School, Parel East, Mumbai, 400 012, India.
authors.forename: Rajesh
authors.initials: R
authors.lastname: Bathini
authors.affiliation: Baldota Institute of Digestive Sciences, 3rd Floor, Global Hospitals, 35, Dr. E. Borges Road, Opp Shirodkar High School, Parel East, Mumbai, 400 012, India.
authors.forename: Amit
authors.initials: A
authors.lastname: Maydeo
mesh_terms: D000328:Adult; D002760:Cholangiopancreatography, Endoscopic Retrograde / Q000379:methods*; D020878:Device Removal / Q000379:methods*; D016145:Endoscopy, Digestive System / Q000379:methods*; D005260:Female; D005548:Foreign-Body Migration / Q000209:etiology* / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D010183:Pancreatic Ducts / Q000000981:diagnostic imaging / Q000601:surgery*; D015607:Stents / Q000009:adverse effects*; D016896:Treatment Outcome
keywords: Pancreas; Pancreatoscopy; Rat tooth forceps; Stent migration