Stenting of the Pancreatic Duct to Aid in Common Bile Duct Cannulation During Endoscopic Retrograde Cholangiopancreatography

Abstract

Background and aims: Cannulation of the common bile duct (CBD) can be exceedingly difficult in certain instances. In addition, difficult CBD cannulation has been shown to be a risk factor for pancreatitis. Many techniques and devices have been utilized to improve rates of CBD cannulation. One such technique is stenting of the pancreatic duct (PD), yet this maneuver has been described in only a few case reports. The goal of this study was to assess the efficacy of stenting the pancreatic duct as an aid in difficult CBD cannulation. Methods: A search of all ERCP cases (#1159) done at our institution from July 1, 2000 to October 15, 2003 was performed using our endoscopy computer database. We retrospectively reviewed all cases which involved pancreatic stenting to aid in CBD cannulation. Results: We reviewed twenty cases in which PD stenting was performed as an aid to CBD cannulation. The group included 15 female and 5 male patients ranging in age from 18 to 83 years. The reason for ERCP varied amongst the patients. Most cases were performed for malignant biliary strictures or for papillary stenosis. Nine (45%) of the patients had undergone failed ERCP outside of our institution because of inability to cannulate the CBD. During each case, standard techniques of CBD cannulation including a sphincterotome and wire were attempted without success. In all cases, a 5 French plastic stent with external flaps only was placed over a wire into the ventral pancreatic duct. Successful CBD cannulation was then accomplished in 19 of the 20 patients (95%). In the majority of cases (11/20), CBD cannulation was performed over the existing stent without the need for a needle knife sphincterotomy. In 7 cases, a precut papillotomy was performed following the PD stenting, and in 1 case a precut was made to aid in placement of the PD stent. There was one case of mild post ERCP pancreatitis (5%) as the sole complication. All patients received abdominal films to ensure stent passage, or repeat ERCP to remove pancreatic stents. Conclusions: In difficult cases, pancreatic stenting appears to be an effective method for selective cannulation of the common bile duct. Often bile duct access can be obtained without the need for pre-cut techniques. The low complication rate is compatible with other data looking at pancreatic stenting to decrease the incidence of pancreatitis. This method for obtaining CBD cannulation would appear effective in selected cases and should be considered when bile duct access has failed using standard techniques.