Downstream balloon dilation technique for endoscopic removal of an impacted pancreatic duct stone after pancreatoduodenectomy

Endoscopic retrograde pancreatography is an established modality for the treatment of pancreatic duct stones [1] [2]. Although it is technically challenging in patients with prior pancreatoduodenectomy [3] [4], balloon-assisted endoscopic retrograde pancreatography and/or endoscopic ultrasound-guided pancreatic drainage has been increasingly utilized to manage pancreatic diseases in patients with surgically altered anatomy [5]. Here we report a simple and feasible technique for the endoscopic removal of an impacted pancreatic duct stone after pancreatoduodenectomy using a short-type single-balloon enteroscope.

A 61-year-old man, who underwent pylorus-preserving pancreatoduodenectomy with modified Childʼs reconstruction three years earlier for pancreatic neuroendocrine tumor, was referred to our department for the treatment of acute pancreatitis. Contrast-enhanced computed tomography showed three radiopaque stones in the main duct; one of the three stones was impacted in the main pancreatic duct, resulting in obstructive pancreatitis ([Fig. 1]). Therefore, an endoscopic intervention was performed using a short-type single-balloon enteroscope (SIF-H290S; Olympus Medical Systems, Tokyo, Japan) with a transparent hood. A tapered double-lumen catheter with a tip diameter of 3.6 Fr (Uneven Double Lumen Cannula Standard Type; Piolax Medical Devices, Kanagawa, Japan) was advanced through the pancreaticojejunal anastomosis, and a 0.025-inch guidewire (VisiGlide 2; Olympus Medical Systems) was placed into the pancreatic duct; however, the catheter could not pass through the impacted stone at all. After placing an additional guidewire, the section downstream of the stone was dilated with a 6-mm balloon catheter (REN; Kaneka Medix, Osaka, Japan) ([Fig. 2 a]), and as the balloon deflated, the impacted stone moved downstream toward the balloon ([Fig. 2 b], [Video 1]).

Fig. 1 Contrast-enhanced computed tomography showed three radiopaque stones in the main duct; one of the three stones was impacted in the main pancreatic duct, resulting in obstructive pancreatitis.

Fig. 2 Fluoroscopic images. a An impacted pancreatic duct stone (arrow) during the downstream balloon dilation. b As the balloon deflated, the pancreatic duct stone (arrow) moved downstream toward the balloon. c The pancreatic stone was captured with a wire-guided basket catheter.

Video 1 Downstream balloon dilation technique for endoscopic removal of an impacted pancreatic duct stone after pancreatoduodenectomy.

Finally, the pancreatic stones were successfully retrieved by using a wire-guided basket catheter (TetraCatch V; Olympus Medical Systems) ([Fig. 2 c], [Fig. 3]).

Fig. 3 Endoscopic view of pancreatic duct stones retrieved from the main pancreatic duct.

The downstream balloon dilation technique is simple and is worth a try when confronting impacted pancreatic duct stones.

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Publication History

Article published online:
15 October 2021

• References

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