Removal of a deeply migrated pancreatic stent in a normal-size pancreatic duct using a modified snare with a cut plastic sheath.

A 79-year-oldman underwent endoscopic retrograde cholangiopancreatography (ERCP) for removal of stones in the common bile duct. The stones were removed successfully and a pancreatic stent was placed in the pancreatic duct to prevent post-ERCP pancreatitis. The next day the patient suddenly complained of abdominal pain; his serum amylase was 125U/L. At a second ERCP, we found that the stent had migrated slightly toward the inner side of pancreatic duct (●" Fig.1). In order to remedy the situation, a guide wire was inserted alongside the stent, and then we attempted to pass an extraction balloon over the stent. This pushed the stent further upstream. Subsequent attempts with biopsy forceps, a basket, and a snare caused the stent to migrate to the tail of the pancreatic duct. We tried once again with the small snare, but were unsuccessful. The wire tip of the snare only reached up to the middle of the stent, due to the resistance between the plastic sheath and stent (●" Fig.2). Finally, we cut off about 2 cm of the plastic sheath over the distal tip (●" Fig.3) and when the snare with the shortened plastic sheath was advanced to the proximal end of the stent, it was able to hook the proximal tip of the stent (●" Fig.4). The snare was withdrawn carefully until the stent could be seen at the ampulla (●" Fig.5), and was subsequently removed. The patient’s abdominal symptoms resolved soon after this procedure. Althoughmany papers have reported useful endoscopic devices for retrieving proximally migrated pancreatic stents [1–4], these techniques have limited applicability in a normal or narrow pancreatic duct [5]. Our method of using a modified snare with a cut plastic sheath was successful in removing a proximally migrated pancreatic stent inserted deeply in an undilated pancreatic duct.