S3334 T Bolting for Proximal Stent Migration

Introduction: Johlin plastic stents are tapered pancreatic duct (PD) stents with sideholes & without flanges are frequently used in endoscopic management of pancreatic duct (PD) strictures. However, stents without flanges are prone to proximal migration, especially during tandem stenting. We describe a novel technique employing hemostatic clips (Hemoclips) successfully to prevent proximal migration of PD stents. Case Description/Methods: Cases: A 58-year-old man with PD strictures and stones required a 10 Fr. 14 cm Johlin stent which had migrated proximally which was removed with a snare. He presented for a repeat endoscopic retrograde cholangiopancreatography (ERCP) and placement of 2 10 Fr. 12 cm Johlin stent. The stents threatened to migrate proximally. Seventy-year-old woman with PD strictures & fusiform dilatation and pancreatic parenchymal calcification had an ERCP and placement of a 10 Fr. 14 cm Johlin PD stent. A repeat ERCP was performed for the removal and placement of an new 10 Fr., 14 cm Johlin stent which threatened to migrate proximally during the procedure. A 50-year-old man with PD strictures & multiple prior plastic stents had a repeat ERCP. He required a 10 Fr., 16 cm Johlin stent. An 80-year-old man with PD stricture, stones & prior proximal stent migration presented for repeat ERCP. A 10 Fr., 14 cm Johlin stent was placed. Procedure: The ERCP procedures were performed under general anesthesia, all were administered with rectal indomethacin. The previously placed stents were removed intact with snare. The main PD were accessed with a 12 mm occlusion balloon or an 0.025 sphincterotome, and an 0.025” angled-tip guidewire. PD strictures or dilatation of the PD as mentioned were found. The PD strictures were dilated with balloon to 6 mm. followed by placement of a 10 Fr. Johlin stents. In our 1 st and 2nd pt the stents threatened to migrate proximally. Two Hemoclips were then placed at right angles to the externally visible tip of the stents on all patients to prevent proximal migration by forming a “barricade” effect. Fluoroscopy confirmed stable stent position before the scope withdrawal. Discussion: Flanged stents are typically preferred to prevent migration, however, stents without flanges (Johlin stents) offer advantages for its ease of placement but are prone to migration. The stent sideholes facilitate duct drainage. The described “barricade technique,” by Hemoclips to anchor the plastic PD stents provide a practical method to prevent proximal stent migration when using stents without flanges.