Distal pancreatectomy: another indication for prophylactic pancreatic stenting?

Abstract

Distal pancreatectomy (DP), the removal of the left portion of the pancreas, is less frequently performed than pancreatic head resection. It is mostly done to resect rare pancreatic tumors and, less frequently, to treat complicated chronic pancreatitis. After DP, the whole bile duct and the cephalic portion of the main pancreatic duct remain unaffected so that the pancreatic remnant is usually simply closed (by hand sewing or by using a stapler) with a percutaneous drain left close to the transected pancreas. A pancreaticojejunostomy is performed in a minority of cases. Both DP and pancreatic head resection currently carry an acceptable mortality rate in high-volume centers, but morbidity remains extremely high. Pancreatic fistula is the most frequent serious complication after DP, with an incidence of 32% in a recent meta-analysis that totaled 479 patients.1Knaebel H.P. Diener M.K. Wente M.N. et al.Systematic review and meta-analysis of technique for closure of the pancreatic remnant after distal pancreatectomy.Br J Surg. 2005; 92: 539-546Crossref PubMed Scopus (296) Google Scholar Although postoperative pancreatic fistulae (POPFs) may resolve spontaneously, they are associated with hospital readmissions in a majority of cases (mean of 1.7 readmissions per patient in a recent study) because they often cause other complications, including sterile intra-abdominal collections, abscesses, and wound disruptions.2Rodríguez J.R. Germes S.S. Pandharipande P.V. et al.Implications and cost of pancreatic leak following distal pancreatic resection.Arch Surg. 2006; 141 (discussion 6): 361-365Crossref PubMed Scopus (109) Google Scholar Management of POPFs requires multiple medical interventions such as repeated CT scans, percutaneous drainage, and visits for months after surgery, the total average cost of which was equal to that of an uncomplicated DP in a recent study.2Rodríguez J.R. Germes S.S. Pandharipande P.V. et al.Implications and cost of pancreatic leak following distal pancreatic resection.Arch Surg. 2006; 141 (discussion 6): 361-365Crossref PubMed Scopus (109) Google Scholar Therefore, strategies to prevent POPFs are needed and can even be costly and cost-effective at the same time.Various strategies have been attempted to prevent POPFs, including different surgical techniques (pancreatic transsection with a stapler, fibrin glue sealing of the pancreatic stump, Roux-en-Y pancreaticojejunostomy) and drugs (mainly octreotide). In 1993, Saeed et al3Saeed Z.A. Ramirez F.C. Hepps K.S. Endoscopic stent placement for internal and external pancreatic fistulas.Gastroenterology. 1993; 105: 1213-1217PubMed Google Scholar reported the successful treatment of internal and external pancreatic fistulae by endoscopic pancreatic stenting in a case series that included 1 POPF after the DP. The idea was to abolish the pressure gradient between the pancreatic duct and the duodenum to divert the outflow of pancreatic juice from the pancreas section plane to the duodenum. This would in turn quicken the sealing at the site of pancreatic leakage, as happens with biliary stenting for the treatment of post-cholecystectomy biliary leaks. Two uncontrolled series totaling 15 patients then suggested that endoscopic pancreatic stenting before DP was effective to prevent the development of POPF.4Abe N. Sugiyama M. Suzuki Y. et al.Preoperative endoscopic pancreatic stenting: a novel prophylactic measure against pancreatic fistula after distal pancreatectomy.J Hepatobiliary Pancreat Surg. 2008; 15: 373-376Crossref PubMed Scopus (26) Google Scholar, 5Hirota M. Kanemitsu K. Takamori H. et al.Local pancreatic resection with preoperative endoscopic transpapillary stenting.Am J Surg. 2007; 194: 308-310Abstract Full Text Full Text PDF PubMed Scopus (18) Google ScholarIn this issue of Gastrointestinal Endoscopy, Rieder et al6Rieder B. Krampulz D. Adolf J. et al.Endoscopic pancreatic sphincterotomy and stenting for preoperative prophylaxis of pancreatic fistula after distal pancreatectomy.Gastrointest Endosc. 2010; 72: 536-542Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar report on the first controlled series of endoscopic pancreatic stenting before DP for POPF prophylaxis. During a 4-year period, the authors included 25 patients with attempted prophylactic endoscopic pancreatic sphincterotomy (EPS) and insertion of a 5F pancreatic stent. Endoscopy was performed 1 to 18 days before DP with successful EPS in all patients and successful stent insertion in 23 (92%) patients. Stent removal was scheduled 8 weeks postoperatively, and, at this time, the stent had spontaneously passed in 5 patients. None of the patients in the intervention group had a POPF compared with 5 (22%) of 23 historical controls who had DP without prophylactic pancreatic stenting during the preceding 4 years (P = .02). Somatostatin or analogues were not administered prophylactically in any patient. The authors used a standard definition of POPF, ie, a drain output of any measurable volume of fluid on or after the third postoperative day with amylase concentration greater than 3 times the normal serum amylase activity. The severity of POPF in historical controls was classified according to the same definition as grades A, B, and C in 2, 1, and 2 cases, respectively. Interestingly, a POPF of grade A is defined as requiring little change in management or deviation from the normal clinical pathway and absence of delay in hospital discharge. This was the case in 2 of the 5 historical controls who had a POPF.This study has several strengths, in particular a controlled design—for the first time—and performance of all operations by a single surgeon using the same technique over a study period of 8 years. This is important because technical factors (eg, closure of the pancreatic remnant by using a stapler vs by hand sewing) are associated with different incidences of POPF. Other strengths of the study include analysis of the results according to intent-to-treat principles and a POPF incidence in the control group that is within normal range. Nevertheless, several aspects—apart from the nonrandomized design—limit the impact of this study.•Various factors known to influence the incidence of POPF, such as pancreatic texture as assessed preoperatively (soft or hard), were not reported.•Operation duration was significantly shorter in the intervention compared with the control group. Indeed, apart from POPF incidence, it was the single difference that was statistically significant between groups. This is of concern because in the largest series of DP reported to date (302 consecutive cases),7Kleeff J. Diener M.K. Z'graggen K. et al.Distal pancreatectomy: risk factors for surgical failure in 302 consecutive cases.Ann Surg. 2007; 245: 573-582Crossref PubMed Scopus (313) Google Scholar a long operation duration was the factor that presented the strongest independent association with POPF. In the Rieder et al study, significance levels for operation duration and POPF were similar (P = .02), raising the question of whether improved results were because of the surgeon's increased experience.•The definition of POPF used by the authors results from an attempt to standardize definitions that were too variable among studies. However, the definition used has been formally subjected to criticisms, 2 of which are relevant to the current study: (1) failure of occlusion of the transected pancreas may result in a fluid collection (usually an abscess) in addition to a fistula and (2) “this definition includes asymptomatic patients for whom no changes in management are instituted. Stated otherwise, many patients who have POPF do not have a postoperative complication.”8Strasberg S.M. Linehan D.C. Clavien P.-A. et al.Proposal for definition and severity grading of pancreatic anastomosis failure and pancreatic occlusion failure.Surgery. 2007; 141: 420-426Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar These criticisms are relevant to the present study because (1) the incidence of intra-abdominal abscess in the intervention group was relatively high at 12% compared with 4% in historical controls and 5% in the largest series of DP cited previously (in the current study, intra-abdominal abscesses in the intervention group were not considered as pancreatic leakages and they were not described in detail)6Rieder B. Krampulz D. Adolf J. et al.Endoscopic pancreatic sphincterotomy and stenting for preoperative prophylaxis of pancreatic fistula after distal pancreatectomy.Gastrointest Endosc. 2010; 72: 536-542Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar, 7Kleeff J. Diener M.K. Z'graggen K. et al.Distal pancreatectomy: risk factors for surgical failure in 302 consecutive cases.Ann Surg. 2007; 245: 573-582Crossref PubMed Scopus (313) Google Scholar and (2) 2 of the 5 POPFs that were reported in historical controls were grade A fistulae (asymptomatic fistulae requiring no change in patient management and with no delay in hospital discharge). If these POPFs had not been diagnosed as fistulae, the difference in POPF incidence between groups would not have been significant.•Finally, the overall morbidity was not significantly lower in the intervention group versus historical controls (32% vs 39%, respectively [8/25 vs 9/23 patients, respectively], with ERCP-related complications included; P = .82). This weakens the study conclusions because randomized, controlled trials (RCTs) that showed a reduced incidence of POPFs with octreotide also showed a significant reduction in overall morbidity.These weaknesses should make us cautious before accepting that prophylactic pancreatic stenting is beneficial before DP.Morbidity is particularly important for the acceptance of a prophylactic intervention. In the current study,6Rieder B. Krampulz D. Adolf J. et al.Endoscopic pancreatic sphincterotomy and stenting for preoperative prophylaxis of pancreatic fistula after distal pancreatectomy.Gastrointest Endosc. 2010; 72: 536-542Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar overall ERCP-related morbidity was acceptable at 4% with post-ERCP pancreatitis (PEP) reported in only 1 of 25 patients. This low incidence deserves comment because it is unusual after EPS in patients without chronic pancreatitis. In the large prospective multicenter study of risk factors for PEP conducted by Freeman et al,9Freeman M.L. DiSario J.A. Nelson D.B. et al.Risk factors for post-ERCP pancreatitis: a prospective, multicenter study.Gastrointest Endosc. 2001; 54: 425-434Abstract Full Text Full Text PDF PubMed Scopus (972) Google Scholar EPS was the procedure that carried the highest risk of PEP (30% compared with 23% for ERCP performed in patients with a suspected sphincter of Oddi dysfunction). That multicenter study also identified the absence of chronic pancreatitis as an independent risk factor for PEP. Successful pancreatic stenting after EPS in 23 of the 25 patients included in the intervention group by Rieder et al likely prevented PEP in some patients, but, even in these conditions, the incidence reported seems low compared with that of other studies. For example, in the largest series of EPS reported to date,10Hookey L.C. RioTinto R. Delhaye M. et al.Risk factors for pancreatitis after pancreatic sphincterotomy: a review of 572 cases.Endoscopy. 2006; 38: 670-676Crossref PubMed Scopus (40) Google Scholar PEP occurred in 8.8% of patients after EPS plus pancreatic drainage (vs 19.3% of patients with EPS and no drainage), but that study was retrospective (as opposed to prospective for the intervention group in the current study) and the study population included more than 80% of patients with chronic pancreatitis (vs 20% in the intervention group in the current study). Another factor that might have confused the detection of ERCP-related complications in some patients is the performance of DP during the days after ERCP. Finally, the authors did not look for anatomical changes that may complicate pancreatic stenting; these changes mimic those of chronic pancreatitis and are frequent after pancreatic stenting in a “normal” pancreas. They may be detected by magnetic resonance pancreatography.In this author's opinion, further trials of ERCP for POPF prophylaxis should build on the experience of pancreatic stenting that was recently gained in the setting of PEP prophylaxis. From that experience, it results that short (2-3 cm), 5F stents currently are most often used to bypass the sphincter of Oddi and that EPS is not required.11Dumonceau J.M. Andriulli A. Deviere J. Guidelines of the European Society of Gastrointestinal Endoscopy: prophylaxis of post-ERCP pancreatitis.Endoscopy. 2010; 42: 503-515Crossref PubMed Scopus (235) Google Scholar Rieder et al do not discuss why they routinely performed EPS, but even if this was intended to preserve some efficacy in case of early stent migration, it could be argued that EPS indeed favors the migration of such thin stents and that the sphincter of Oddi is not completely abolished after EPS according to manometry studies. Moreover, in previous uncontrolled series of pancreatic stenting for POPF prophylaxis, EPS was not performed. With regard to stent choice, the authors chose a stent with a length as long as possible to minimize the risk of spontaneous stent migration, but internal flanges may be sufficient to prevent the migration of short (2-3 cm) stents during the early postoperative period (short stents are usually preferred in normal pancreas to limit anatomical changes secondary to stenting).Prophylactic pancreatic stenting has the potential of being a great advance for patients undergoing DP. We are at a point where RCTs are needed to assess the efficacy of this strategy. This is urgent because pancreatic stenting is neither easy to perform nor without risk: if attempts at pancreatic stenting in a normal pancreas fail, PEP is frequent (up to 67% of cases in a prospective study), and it may be the severe form of the disease.12Freeman M.L. Overby C. Qi D. Pancreatic stent insertion: consequences of failure and results of a modified technique to maximize success.Gastrointest Endosc. 2004; 59: 8-14Abstract Full Text Full Text PDF PubMed Scopus (172) Google Scholar Lack of experience with pancreatic stenting is common among endoscopists performing ERCP and explains why many of them do not perform prophylactic pancreatic stenting in patients at high-risk of PEP despite scientific evidence supporting that measure.13Dumonceau J.-M. Rigaux J. Kahaleh M. et al.Prophylaxis of post-ERCP pancreatitis: a practice survey.Gastrointest Endosc. 2010; 71: 934-939Abstract Full Text Full Text PDF PubMed Scopus (83) Google Scholar Endoscopists working in hospitals with an annual volume of more than 500 ERCPs are more likely to use prophylactic pancreatic stenting, but such hospitals are a small minority.13Dumonceau J.-M. Rigaux J. Kahaleh M. et al.Prophylaxis of post-ERCP pancreatitis: a practice survey.Gastrointest Endosc. 2010; 71: 934-939Abstract Full Text Full Text PDF PubMed Scopus (83) Google Scholar This further emphasizes the interest of referring patients with pancreatic diseases to high-volume centers with radiological, endoscopic, and surgical expertise in that field.As pioneers exploring new territories, Rieder et al deliver more questions than answers. Their study will perhaps prompt the launch of RCTs in centers with the necessary expertise and case volume to assess (1) whether the benefits of pancreatic stenting for POPF prophylaxis outweigh its risks and (2) which patients would benefit the most because, for example, those with an intraductal papillary mucinous neoplasm may have their stent occluded preoperatively by mucus. Based on previous experience with pancreatic stenting for POPF and PEP prophylaxis, short, flanged stents inserted without EPS seem preferable. Positive results from well-designed RCTs and the dissemination of expertise in pancreatic stenting techniques within the endoscopy community may be decisive to convince surgeons to refer patients for ERCP before DP.DisclosureThe author disclosed no financial relationships relevant to this publication. Distal pancreatectomy (DP), the removal of the left portion of the pancreas, is less frequently performed than pancreatic head resection. It is mostly done to resect rare pancreatic tumors and, less frequently, to treat complicated chronic pancreatitis. After DP, the whole bile duct and the cephalic portion of the main pancreatic duct remain unaffected so that the pancreatic remnant is usually simply closed (by hand sewing or by using a stapler) with a percutaneous drain left close to the transected pancreas. A pancreaticojejunostomy is performed in a minority of cases. Both DP and pancreatic head resection currently carry an acceptable mortality rate in high-volume centers, but morbidity remains extremely high. Pancreatic fistula is the most frequent serious complication after DP, with an incidence of 32% in a recent meta-analysis that totaled 479 patients.1Knaebel H.P. Diener M.K. Wente M.N. et al.Systematic review and meta-analysis of technique for closure of the pancreatic remnant after distal pancreatectomy.Br J Surg. 2005; 92: 539-546Crossref PubMed Scopus (296) Google Scholar Although postoperative pancreatic fistulae (POPFs) may resolve spontaneously, they are associated with hospital readmissions in a majority of cases (mean of 1.7 readmissions per patient in a recent study) because they often cause other complications, including sterile intra-abdominal collections, abscesses, and wound disruptions.2Rodríguez J.R. Germes S.S. Pandharipande P.V. et al.Implications and cost of pancreatic leak following distal pancreatic resection.Arch Surg. 2006; 141 (discussion 6): 361-365Crossref PubMed Scopus (109) Google Scholar Management of POPFs requires multiple medical interventions such as repeated CT scans, percutaneous drainage, and visits for months after surgery, the total average cost of which was equal to that of an uncomplicated DP in a recent study.2Rodríguez J.R. Germes S.S. Pandharipande P.V. et al.Implications and cost of pancreatic leak following distal pancreatic resection.Arch Surg. 2006; 141 (discussion 6): 361-365Crossref PubMed Scopus (109) Google Scholar Therefore, strategies to prevent POPFs are needed and can even be costly and cost-effective at the same time. Various strategies have been attempted to prevent POPFs, including different surgical techniques (pancreatic transsection with a stapler, fibrin glue sealing of the pancreatic stump, Roux-en-Y pancreaticojejunostomy) and drugs (mainly octreotide). In 1993, Saeed et al3Saeed Z.A. Ramirez F.C. Hepps K.S. Endoscopic stent placement for internal and external pancreatic fistulas.Gastroenterology. 1993; 105: 1213-1217PubMed Google Scholar reported the successful treatment of internal and external pancreatic fistulae by endoscopic pancreatic stenting in a case series that included 1 POPF after the DP. The idea was to abolish the pressure gradient between the pancreatic duct and the duodenum to divert the outflow of pancreatic juice from the pancreas section plane to the duodenum. This would in turn quicken the sealing at the site of pancreatic leakage, as happens with biliary stenting for the treatment of post-cholecystectomy biliary leaks. Two uncontrolled series totaling 15 patients then suggested that endoscopic pancreatic stenting before DP was effective to prevent the development of POPF.4Abe N. Sugiyama M. Suzuki Y. et al.Preoperative endoscopic pancreatic stenting: a novel prophylactic measure against pancreatic fistula after distal pancreatectomy.J Hepatobiliary Pancreat Surg. 2008; 15: 373-376Crossref PubMed Scopus (26) Google Scholar, 5Hirota M. Kanemitsu K. Takamori H. et al.Local pancreatic resection with preoperative endoscopic transpapillary stenting.Am J Surg. 2007; 194: 308-310Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar In this issue of Gastrointestinal Endoscopy, Rieder et al6Rieder B. Krampulz D. Adolf J. et al.Endoscopic pancreatic sphincterotomy and stenting for preoperative prophylaxis of pancreatic fistula after distal pancreatectomy.Gastrointest Endosc. 2010; 72: 536-542Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar report on the first controlled series of endoscopic pancreatic stenting before DP for POPF prophylaxis. During a 4-year period, the authors included 25 patients with attempted prophylactic endoscopic pancreatic sphincterotomy (EPS) and insertion of a 5F pancreatic stent. Endoscopy was performed 1 to 18 days before DP with successful EPS in all patients and successful stent insertion in 23 (92%) patients. Stent removal was scheduled 8 weeks postoperatively, and, at this time, the stent had spontaneously passed in 5 patients. None of the patients in the intervention group had a POPF compared with 5 (22%) of 23 historical controls who had DP without prophylactic pancreatic stenting during the preceding 4 years (P = .02). Somatostatin or analogues were not administered prophylactically in any patient. The authors used a standard definition of POPF, ie, a drain output of any measurable volume of fluid on or after the third postoperative day with amylase concentration greater than 3 times the normal serum amylase activity. The severity of POPF in historical controls was classified according to the same definition as grades A, B, and C in 2, 1, and 2 cases, respectively. Interestingly, a POPF of grade A is defined as requiring little change in management or deviation from the normal clinical pathway and absence of delay in hospital discharge. This was the case in 2 of the 5 historical controls who had a POPF. This study has several strengths, in particular a controlled design—for the first time—and performance of all operations by a single surgeon using the same technique over a study period of 8 years. This is important because technical factors (eg, closure of the pancreatic remnant by using a stapler vs by hand sewing) are associated with different incidences of POPF. Other strengths of the study include analysis of the results according to intent-to-treat principles and a POPF incidence in the control group that is within normal range. Nevertheless, several aspects—apart from the nonrandomized design—limit the impact of this study.•Various factors known to influence the incidence of POPF, such as pancreatic texture as assessed preoperatively (soft or hard), were not reported.•Operation duration was significantly shorter in the intervention compared with the control group. Indeed, apart from POPF incidence, it was the single difference that was statistically significant between groups. This is of concern because in the largest series of DP reported to date (302 consecutive cases),7Kleeff J. Diener M.K. Z'graggen K. et al.Distal pancreatectomy: risk factors for surgical failure in 302 consecutive cases.Ann Surg. 2007; 245: 573-582Crossref PubMed Scopus (313) Google Scholar a long operation duration was the factor that presented the strongest independent association with POPF. In the Rieder et al study, significance levels for operation duration and POPF were similar (P = .02), raising the question of whether improved results were because of the surgeon's increased experience.•The definition of POPF used by the authors results from an attempt to standardize definitions that were too variable among studies. However, the definition used has been formally subjected to criticisms, 2 of which are relevant to the current study: (1) failure of occlusion of the transected pancreas may result in a fluid collection (usually an abscess) in addition to a fistula and (2) “this definition includes asymptomatic patients for whom no changes in management are instituted. Stated otherwise, many patients who have POPF do not have a postoperative complication.”8Strasberg S.M. Linehan D.C. Clavien P.-A. et al.Proposal for definition and severity grading of pancreatic anastomosis failure and pancreatic occlusion failure.Surgery. 2007; 141: 420-426Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar These criticisms are relevant to the present study because (1) the incidence of intra-abdominal abscess in the intervention group was relatively high at 12% compared with 4% in historical controls and 5% in the largest series of DP cited previously (in the current study, intra-abdominal abscesses in the intervention group were not considered as pancreatic leakages and they were not described in detail)6Rieder B. Krampulz D. Adolf J. et al.Endoscopic pancreatic sphincterotomy and stenting for preoperative prophylaxis of pancreatic fistula after distal pancreatectomy.Gastrointest Endosc. 2010; 72: 536-542Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar, 7Kleeff J. Diener M.K. Z'graggen K. et al.Distal pancreatectomy: risk factors for surgical failure in 302 consecutive cases.Ann Surg. 2007; 245: 573-582Crossref PubMed Scopus (313) Google Scholar and (2) 2 of the 5 POPFs that were reported in historical controls were grade A fistulae (asymptomatic fistulae requiring no change in patient management and with no delay in hospital discharge). If these POPFs had not been diagnosed as fistulae, the difference in POPF incidence between groups would not have been significant.•Finally, the overall morbidity was not significantly lower in the intervention group versus historical controls (32% vs 39%, respectively [8/25 vs 9/23 patients, respectively], with ERCP-related complications included; P = .82). This weakens the study conclusions because randomized, controlled trials (RCTs) that showed a reduced incidence of POPFs with octreotide also showed a significant reduction in overall morbidity. These weaknesses should make us cautious before accepting that prophylactic pancreatic stenting is beneficial before DP. Morbidity is particularly important for the acceptance of a prophylactic intervention. In the current study,6Rieder B. Krampulz D. Adolf J. et al.Endoscopic pancreatic sphincterotomy and stenting for preoperative prophylaxis of pancreatic fistula after distal pancreatectomy.Gastrointest Endosc. 2010; 72: 536-542Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar overall ERCP-related morbidity was acceptable at 4% with post-ERCP pancreatitis (PEP) reported in only 1 of 25 patients. This low incidence deserves comment because it is unusual after EPS in patients without chronic pancreatitis. In the large prospective multicenter study of risk factors for PEP conducted by Freeman et al,9Freeman M.L. DiSario J.A. Nelson D.B. et al.Risk factors for post-ERCP pancreatitis: a prospective, multicenter study.Gastrointest Endosc. 2001; 54: 425-434Abstract Full Text Full Text PDF PubMed Scopus (972) Google Scholar EPS was the procedure that carried the highest risk of PEP (30% compared with 23% for ERCP performed in patients with a suspected sphincter of Oddi dysfunction). That multicenter study also identified the absence of chronic pancreatitis as an independent risk factor for PEP. Successful pancreatic stenting after EPS in 23 of the 25 patients included in the intervention group by Rieder et al likely prevented PEP in some patients, but, even in these conditions, the incidence reported seems low compared with that of other studies. For example, in the largest series of EPS reported to date,10Hookey L.C. RioTinto R. Delhaye M. et al.Risk factors for pancreatitis after pancreatic sphincterotomy: a review of 572 cases.Endoscopy. 2006; 38: 670-676Crossref PubMed Scopus (40) Google Scholar PEP occurred in 8.8% of patients after EPS plus pancreatic drainage (vs 19.3% of patients with EPS and no drainage), but that study was retrospective (as opposed to prospective for the intervention group in the current study) and the study population included more than 80% of patients with chronic pancreatitis (vs 20% in the intervention group in the current study). Another factor that might have confused the detection of ERCP-related complications in some patients is the performance of DP during the days after ERCP. Finally, the authors did not look for anatomical changes that may complicate pancreatic stenting; these changes mimic those of chronic pancreatitis and are frequent after pancreatic stenting in a “normal” pancreas. They may be detected by magnetic resonance pancreatography. In this author's opinion, further trials of ERCP for POPF prophylaxis should build on the experience of pancreatic stenting that was recently gained in the setting of PEP prophylaxis. From that experience, it results that short (2-3 cm), 5F stents currently are most often used to bypass the sphincter of Oddi and that EPS is not required.11Dumonceau J.M. Andriulli A. Deviere J. Guidelines of the European Society of Gastrointestinal Endoscopy: prophylaxis of post-ERCP pancreatitis.Endoscopy. 2010; 42: 503-515Crossref PubMed Scopus (235) Google Scholar Rieder et al do not discuss why they routinely performed EPS, but even if this was intended to preserve some efficacy in case of early stent migration, it could be argued that EPS indeed favors the migration of such thin stents and that the sphincter of Oddi is not completely abolished after EPS according to manometry studies. Moreover, in previous uncontrolled series of pancreatic stenting for POPF prophylaxis, EPS was not performed. With regard to stent choice, the authors chose a stent with a length as long as possible to minimize the risk of spontaneous stent migration, but internal flanges may be sufficient to prevent the migration of short (2-3 cm) stents during the early postoperative period (short stents are usually preferred in normal pancreas to limit anatomical changes secondary to stenting). Prophylactic pancreatic stenting has the potential of being a great advance for patients undergoing DP. We are at a point where RCTs are needed to assess the efficacy of this strategy. This is urgent because pancreatic stenting is neither easy to perform nor without risk: if attempts at pancreatic stenting in a normal pancreas fail, PEP is frequent (up to 67% of cases in a prospective study), and it may be the severe form of the disease.12Freeman M.L. Overby C. Qi D. Pancreatic stent insertion: consequences of failure and results of a modified technique to maximize success.Gastrointest Endosc. 2004; 59: 8-14Abstract Full Text Full Text PDF PubMed Scopus (172) Google Scholar Lack of experience with pancreatic stenting is common among endoscopists performing ERCP and explains why many of them do not perform prophylactic pancreatic stenting in patients at high-risk of PEP despite scientific evidence supporting that measure.13Dumonceau J.-M. Rigaux J. Kahaleh M. et al.Prophylaxis of post-ERCP pancreatitis: a practice survey.Gastrointest Endosc. 2010; 71: 934-939Abstract Full Text Full Text PDF PubMed Scopus (83) Google Scholar Endoscopists working in hospitals with an annual volume of more than 500 ERCPs are more likely to use prophylactic pancreatic stenting, but such hospitals are a small minority.13Dumonceau J.-M. Rigaux J. Kahaleh M. et al.Prophylaxis of post-ERCP pancreatitis: a practice survey.Gastrointest Endosc. 2010; 71: 934-939Abstract Full Text Full Text PDF PubMed Scopus (83) Google Scholar This further emphasizes the interest of referring patients with pancreatic diseases to high-volume centers with radiological, endoscopic, and surgical expertise in that field. As pioneers exploring new territories, Rieder et al deliver more questions than answers. Their study will perhaps prompt the launch of RCTs in centers with the necessary expertise and case volume to assess (1) whether the benefits of pancreatic stenting for POPF prophylaxis outweigh its risks and (2) which patients would benefit the most because, for example, those with an intraductal papillary mucinous neoplasm may have their stent occluded preoperatively by mucus. Based on previous experience with pancreatic stenting for POPF and PEP prophylaxis, short, flanged stents inserted without EPS seem preferable. Positive results from well-designed RCTs and the dissemination of expertise in pancreatic stenting techniques within the endoscopy community may be decisive to convince surgeons to refer patients for ERCP before DP. DisclosureThe author disclosed no financial relationships relevant to this publication. The author disclosed no financial relationships relevant to this publication. Endoscopic pancreatic sphincterotomy and stenting for preoperative prophylaxis of pancreatic fistula after distal pancreatectomyGastrointestinal EndoscopyVol. 72Issue 3PreviewPancreatic fistula (PF) is the most common postoperative complication after distal pancreatectomy (DP). Endoscopic pancreatic sphincterotomy and drainage have been shown to be an effective treatment for PF. Recently, preoperative endoscopic pancreatic stenting was proposed to prevent PF, but there are no controlled trials so far. Full-Text PDF