Use of a fully covered metal stent to treat obstruction of the minor papilla in pancreas divisum.

tion of the minor papilla in pancreas divisum A 70-year-old woman was admitted with an episode of epigastric pain radiating into her back, accompanied by intermittent nausea and vomiting. Acute pancreatitis was diagnosed and transabdominal ultrasound revealed a dilated pancreatic duct of 6mm due a ductal stone. The first attempt of endoscopic retrograde pancreatography (ERP) failed to cannulate the pancreatic duct. Following a magnetic resonance cholangiopancreatography, the patient was diagnosed with a complete pancreas divisum. Hence, the pancreatic duct was accessed via the minor papilla, and ERP showed a dilated duct with an impacted stone near the orifice (●" Fig.1). Unfortunately, the stone could not be removed despite dilation of the distal duct. Surgical interventions or shock wave lithotripsy were discussed, but the patient preferred an endoscopic approach. Subsequently, a fully covered self-expanding metal stent (SEMS, WallFlex 8×60mm; Boston Scientific Corp., Marlborough, Massachusetts, USA) was placed for 5 months in the minor papilla (●" Fig.2). After implantation of the SEMS, the patient had no complaints and reported fewer episodes of epigastric pain. During pancreaticoscopy with electrohydraulic lithotripsy, after retrieval of the SEMS only fragments of the stone could be removed. Because of the good response following implantation of the covered SEMS, we again decided to place an SEMS (●" Fig.3, ●" Video1). So far, 14 months after the initial stent implantation, the patient has gained weight and, apart from occasional episodes of pain, she reports no complaints. Our results are in line with a case series reported by Liao et al., which showed similar success in three patients [1]; however, in these cases the SEMS passed spontaneously after 6months, and data on longer follow-up after migration aremissing. In conclusion, this case describes the possibility of draining obstruction due to pancreatic ductal stone in the minor papilla in complete pancreas divisum using a fully covered SEMS, with good clinical response.