Pancreatic Stenting for Prophylaxis of Post-ERCP Pancreatitis

Abstract

Purpose: Long (>7cm) 3F pancreatic stents without internal flaps (IF) are increasingly being used for prophylaxis against post-ERCP pancreatitis (PEP). 3F stents rarely cause ductal changes and typically do not require endoscopic removal. However, 3F stents can only be placed over more difficult to use guidewires (0.018 in dia) and long stents may be inappropriate for patients with tortuous ducts. Duration of pancreatic drainage using stents without IF is inconsistent and there are limited efficacy data for 3F stents. Randomized-controlled trials which first demonstrated protection against PEP used short (<3cm) 5F stents with IF but study groups were small. The purpose of this study was to further evaluate the efficacy of 5F pancreatic stents for prophylaxis of PEP. Methods: From a prospective database, we identified all patients who had pancreatic stents placed for prophylaxis of PEP. Data collected included stent configuration (size, shape, ± internal flap) and incidence and severity of PEP. Results: From 1999–2004, pancreatic stents were placed for prophylaxis of PEP during 251 of 1260 (20%) procedures. Dorsal duct stents were placed in 25 cases of which 23 had accessory papillotomy. Another 2 patients underwent stenting and sphincterotomy of both the main and minor pancreatic papillae. 224 procedures involved main pancreatic stenting alone (n = 68) or stenting plus pancreatic sphincterotomy (n = 156). Sphincter manometry was performed in 162 of 224 (72%) cases. Access (precut) biliary papillotomy was performed in 57 of 224 (25%) cases. 5F stents were placed in 205 patients: 152 straight 5F (n = 110 <or = 3cm, n = 42 >3cm) and 53 single pigtail 5F (n = 26 <or = 3cm, n = 27 >3cm) pancreatic stents. Post-ERCP pancreatitis occurred in 12 of 205 (5.9%) cases after placement of a 5F pancreatic stents (7 mild, 4 moderate, 1 severe). The risk of PEP for 5F pancreatic stents was similar for all stent configurations: straight (10/152, 6.6%) vs. single pigtail (2/53, 3.8%), <or = 3cm long (8/136, 5.9%) vs. >3cm long (4/69, 5.8%), and No IF (2/38, 5.3%) vs. +IF (10/167, 6.0%); p>0.6 for all comparisons. Conclusions: 5F pancreatic stents effectively protect against PEP. The risk of pancreatitis after treatment with 5F pancreatic stents is independent of stent configuration. Comparative studies are needed to evaluate efficacy, safety, and ease of use between 5F and 3F pancreatic stents for prophylaxis of PEP.