Removal of a lodged pancreatic duct stone using a retrieval snare

Abstract

A 63-year-old man with chronic calcific pancreatitis and a history of pancreatic duct (PD) stones was referred for recurrent chronic upper abdominal pain. He had previously undergone extracorporeal shockwave lithotripsy and ERCP with stone removal and stents that were removed a few years prior at outside facilities. CT and EUS showed pancreatic parenchymal chronic pancreatitis changes and recurrent PD stones (Fig. 1).ERCP was performed for PD stone removal. On pancreatography, the main PD was ectatic and dilated, especially in the head of the pancreas, giving a sac-like appearance, along with dilated side branches and a dominant duct of Santorini. There was a 10-mm oval filling defect consistent with a PD stone in the ectatic dilated portion of the main PD (Fig. 2). Balloon extraction was able to remove only small white stones; however, the 10-mm stone was persistently lodged in the sac-like portion on balloon sweep.A 1.5-cm retrieval basket was used; however, the basket would not fully open because it would enter a side branch in the head of the pancreas or the narrower upstream duct despite attempted opening in the proximal head of the pancreas. Peroral pancreatoscopy (POP) was then performed in attempt at laser lithotripsy (LL) of the lodged PD stone. LL proved difficult because only a portion of