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for a balloon dilator trapped in the pancreatic duct A 71-year-old man was admitted to our department because of intermittent upper abdominal pain of 2 years’ duration. Computed tomography revealed a severely dilated pancreatic duct with multiple radiopaque stones, confirming a diagnosis of chronic pancreatitis (●" Fig.1a). We performed extracorporeal shock wave lithotripsy (ESWL) at the pancreatic head with a third-generation lithotripter (Compact Delta II; Dornier MedTech, Wessling, Germany) to break up the stones. A total of 5000 shocks were delivered during the therapeutic session at an intensity of 6 on a scale of 1 to 6 (16000kV) and a frequency of 120 shocks per minute. A combination of flurbiprofen and remifentanil was administered via intravenous infusion for analgesia. The pancreatic stones were pulverized after ESWL (●" Fig.1b) [1]. After 48 hours, endoscopic retrograde pancreatography (ERP) was performed to remove the residual fragments. ERP showed a severe stricture at the pancreas head and a dilated proximal pancreatic duct. Following sphincterotomy, a balloon dilator with a diameter of 8mm and length of 3cm (Quantum TTC; WilsonCook Medical, Winston-Salem, North Carolina, USA) was used to dilate the stricture. However, the stone fragments punctured and broke the balloon. When we tried to pull out the balloon dilator, we encountered a high degree of resistance and failed to remove it. ERP showed that the two markers on the balloon dilator were closer together than normal, indicating that the balloon was folded and trapped in the main pancreatic duct (MPD) (●" Fig.2, ●" Fig.3). The plunger handle of the balloon dilator was then cut off, and the duodenoscope was withdrawn. We tried to insert a guidewire beside the distorted balloon with the duodenoscope, but it inevitably slipped into a branch of the pancreatic duct without passing the trapped balloon. The duodenoscope was again withdrawn (●" Video 1). The balloon catheter was extracted through the nasal cavity and connected to a Tuohy–Borst connector as a nasopancreatic tube (●" Fig.4). To release the trapped balloon, another ESWL procedure was performed to break up the impacted stones into smaller pieces, targeting the stones around the two markers (●" Fig.5). At 48 hours after the second ESWL, a second ERP was performed. A GuideWire M (Radifocus; Terumo Corporation, Tokyo, Japan) and a 6-Fr plastic bougie dilator were inserted, but the latter could not pass through the stricFig.1 a Computed tomographic scan reveals a severely dilated pancreatic duct with multiple radiopaque stones, confirming a diagnosis of chronic pancreatitis in a 71-year-old man admitted because of intermittent upper abdominal pain of 2 years’ duration. b The pancreatic stones are pulverized after extracorporeal shock wave lithotripsy.

Extracorporeal shock wave lithotripsy as rescue for a balloon dilator trapped in the pancreatic duct