Pancreatic Duct Small-Caliber Plastic Stenting Using a Molting Technique Under Endoscopic Retrograde Cholangiopancreatography Guidance

Abstract

Pancreatic duct stenting is a feasible technique for the treatment of symptomatic pancreatic duct obstruction. However, pancreatic obstruction because of impaction of large pancreatic duct stones makes the insertion of various devices, including plastic stents, challenging. Recently, a novel stent delivery system with a dilation function (EndoSheather; Piolax Medical Devices, Kanagawa, Japan) has become available in Japan. The diameter of the outer sheath of this device is 7.2Fr, and that of the inner sheath is 5.9Fr. In addition, the tip of this device is extremely tapered (3.9Fr), conforming to a 0.035-inch guidewire. These characteristics allow for easier penetration of the stricture site, and after removal of the inner sheath, various devices less than 5.9Fr in size can be inserted. A recently available small-caliber plastic stent (5Fr, Through & Pass Type IT; Gadelius Medical, Tokyo, Japan) can also be inserted within this outer sheath. We herein describe technical tips for a novel pancreatic duct stent technique using the EndoSheather, which is called the "Molting technique" (a). A 49-year-old man was admitted to our hospital to be treated for frequent pancreatitis because of impaction of a large pancreatic duct stone, for which endoscopic retrograde cholangiopancreatography was attempted. Although a 0.025-inch guidewire was successfully advanced into the main pancreatic duct across the pancreatic stone, several devices, including a Soehendra stent retriever, could not be inserted. Therefore, EndoSheather insertion was attempted. Although this device was successfully inserted, the tip of the device barely passed through the site of obstruction. Subsequently, the inner sheath of the EndoSheather was removed, and a small-caliber plastic stent was inserted into the outer sheath. Finally, we removed the outer sheath and retained the plastic stent (b). He discharged without any adverse events and also underwent contentious stent exchange. The presented technique might be useful for pancreatic duct stenting in challenging cases. Watch the Video, Supplementary Digital Content 1, http://links.lww.com/AJG/C469.