Prophylactic Pancreatic Duct Stents: Survey of Physician Practices

Abstract

Background: Pancreatitis is the most common complication of ERCP. Several prospective studies and one meta-analysis confirm that prophylactic temporary stenting of the pancreatic duct (PD) during high-risk procedures decreases the risk of post-ERCP pancreatitis. However, there is no consensus on the indications or the techniques for stent placement, including: type of stent, methods of placement, and follow-up. The purpose of this study is to survey the practice methods of expert biliary endoscopists to identify areas of consensus and areas of disagreement. Methods: An anonymous survey on the use of prophylactic PD stents was sent by mail to 54 expert biliary endoscopists in the United States and Canada. The survey assessed volume of procedures, indications for prophylactic stent placement, type of stent, methods of placement, and follow-up. 61% (33/54) surveys were returned and analyzed. Results: 3% (1/33) of respondents did not perform prophylactic PD stenting. All of the remainder (32 respondents) agreed on prophylactic PD stenting for the following indications: pancreatic sphincterotomy and ampullectomy. There was disagreement on other potential indications, including prior history of post-ERCP pancreatitis, traumatic biliary sphincterotomy, confirmed Sphincter of Oddi (SO) dysfunction, suspected SO dysfunction, minor papilla sphincterotomy, and pre-cut papillotomy. There were a variety of stent designs used, including straight (41%), single pigtail (25%), or a combination (31%), while 3% (1/33) used naso-pancreatic drains exclusively. Stents with (13%), or without internal flanges (62%), or a combination (25%), were used. There was wide variation in the length of time stents were left in place: 1 day (6%); 2-4 days (28%), 5-8 days (47%), 9-14 days (22%), and >14 days (13%). The use of radiographs to monitor stent position and the timing of endoscopic retrieval also varied widely. Conclusions: Most expert biliary endoscopists use prophylactic PD stenting during ERCP in high-risk patients. However, there is wide variation in indications and stenting technique, which indicates the need for further study to define optimal indications and technique. Background: Pancreatitis is the most common complication of ERCP. Several prospective studies and one meta-analysis confirm that prophylactic temporary stenting of the pancreatic duct (PD) during high-risk procedures decreases the risk of post-ERCP pancreatitis. However, there is no consensus on the indications or the techniques for stent placement, including: type of stent, methods of placement, and follow-up. The purpose of this study is to survey the practice methods of expert biliary endoscopists to identify areas of consensus and areas of disagreement. Methods: An anonymous survey on the use of prophylactic PD stents was sent by mail to 54 expert biliary endoscopists in the United States and Canada. The survey assessed volume of procedures, indications for prophylactic stent placement, type of stent, methods of placement, and follow-up. 61% (33/54) surveys were returned and analyzed. Results: 3% (1/33) of respondents did not perform prophylactic PD stenting. All of the remainder (32 respondents) agreed on prophylactic PD stenting for the following indications: pancreatic sphincterotomy and ampullectomy. There was disagreement on other potential indications, including prior history of post-ERCP pancreatitis, traumatic biliary sphincterotomy, confirmed Sphincter of Oddi (SO) dysfunction, suspected SO dysfunction, minor papilla sphincterotomy, and pre-cut papillotomy. There were a variety of stent designs used, including straight (41%), single pigtail (25%), or a combination (31%), while 3% (1/33) used naso-pancreatic drains exclusively. Stents with (13%), or without internal flanges (62%), or a combination (25%), were used. There was wide variation in the length of time stents were left in place: 1 day (6%); 2-4 days (28%), 5-8 days (47%), 9-14 days (22%), and >14 days (13%). The use of radiographs to monitor stent position and the timing of endoscopic retrieval also varied widely. Conclusions: Most expert biliary endoscopists use prophylactic PD stenting during ERCP in high-risk patients. However, there is wide variation in indications and stenting technique, which indicates the need for further study to define optimal indications and technique.