Pancreatic duct stents reduce the incidence of pancreatitis following endoscopic retrograde cholangiopancreatography (ERCP), according to a study published in the October issue of Clinical Gastroenterology and Hepatology.
Pancreatitis is the most common and potentially serious complication following ERCP, occurring in up to 9% of patients that receive this procedure and as many as 40% of patients with risk factors for complications.
Post-ERCP pancreatitis (PEP) is believed to be caused by papillary edema and retention of pancreatic juice after the surgery. To prevent this, endoscopists sometimes insert a nasopancreatic drainage tube into the pancreatic duct, or used a flanged pancreatic stent.
Atsushi Sofuni et al. investigated whether this stenting procedure works. They determined the incidence of PEP among 213 patients who received a temporary-type, pancreatic duct stent (5F in diameter, 3 cm long, and straight with an unflanged inner end) during ERCP and 213 who did not.
Following surgery, only 7.9% of the patients that received the stents developed pancreatitis, compared with 15.2% of patients that did not receive stents. The authors proposed that the stent maintained the drainage route when the papilla was blocked by edema or spasm of sphincter of Oddi (or both) after ERCP.
However, development of PEP depended on several risk factors, including whether the pancreatography was performed first (because of factors such as papillary edema or chemical reactions in the upper side branch of the pancreatic duct), nonplacement of the pancreatic duct stent after ERCP, procedure times of 30 minutes or more, sampling of pancreatic tissue by any method, intraductal ultrasonography, and difficulty of cannulation (if it took more than 15 minutes). Patients with more than 3 risk factors had a significantly greater incidence of pancreatitis.
In a video abstract, Sofuni recommends placement of a temporary pancreatic ductal stent to reduce the incidence of post-ERCP pancreatitis, with careful consideration of risk factors.
In an accompanying editorial, Richard Kozarek says “data such as these might make us all rush out to buy stock in companies that make pancreatic stents”, but cautions that problems with this study keep it from being generalized to all patients who undergo, or providers who perform, ERCP. The endoscopists who participated in the study were very experienced and performed more than 300 ERCPs each year, (3- to 6-fold more than most community gastroenterologists), and there were other procedural issues that might have contributed to PEP in the study population.
Nonetheless, Kozarek states that endoscopists who perform ERCPs should probably become proficient in pancreatic stenting, and that it is inappropriate to finish an advanced year of ERCP training without mastering this skill.
More information on ERCP:
Read the article online. These articles have accompanying CME activities.
Sofuni A, Maguchi H, Mukai T, et al. Endoscopic pancreatic duct stents reduce the incidence of post–endoscopic retrograde cholangiopancreatography pancreatitis in high-risk patients. Clin Gastroenterol and Hepatol 2011;9: 851-858.
Read the accompanying editorial.
Kozarek RA. Prevention of post–endoscopic retrograde cholangiopancreatography pancreatitis by pancreatic duct stenting: should it be routine? Clin Gastroenterol and Hepatol 2011;9: 810-812.