Prophylactic Pancreatic Duct Research Articles

Indomethacin for Post-ERCP Pancreatitis Prophylaxis: Another Attempt at the Holy Grail

Acute pancreatitis continues to be the most dreaded complication after ERCP. Various risk factors for post-ERCP pancreatitis have now been recognized including patient-related, procedure-related, and operator-related factors. Numerous attempts at finding the ideal pharmacological agent for prevention of this complication have been made but nearly all drugs evaluated have failed to demonstrate clinical efficacy. Predictably, these agents have shown promise in early single-center studies but met with disappointing results when tested in larger multicenter randomized controlled trials. As the quest for the "magic bullet" continues, selecting patients with appropriate indications for ERCP and prophylactic pancreatic duct stenting in high-risk cases appears to be the best approach to averting this complication.

Can Prophylactic Pancreatic Duct Stent Placement Reduce the Prevalence of Post-ERCP Pancreatitis in Patients with Difficult Cannulation of the Bile Duct?

Background and Aim: Pancreatitis remains a major complication of ERCP. Difficult cannulation of the bile duct is given as its risk factor. The aim of this study was to investigate the efficacy of prophylactic pancreatic duct stent placement in patients at high risk of post-ERCP pancreatitis. Patients and methods: Between July 2002 and July 2006, prophylactic pancreatic duct stenting were performed in 44 patients (20 men, 24 women; mean age, 69 yr; range, 44-91 yr) at high risk of post-ERCP pancreatitis. We developed a new pancreatic duct stent, which was a 5-Fr, 4-cm-long stent with a single duodenal pigtail (Pit-stent: Cathex, Co., Ltd., Tokyo, Japan). The Pit-stent employed is made of soft polyethylene without a flange and has side-holes for avoiding blockage of side branches of the pancreas. Indication for pancreatic duct stenting was difficult cannulation of the bile duct. Difficult cannulation of the bile duct was defined as which took more than 15 minutes. Abdominal radiographs were obtained to assess the stent position 2-14 days after the procedure. The frequency of post-ERCP pancreatitis and spontaneous migration of the stent were investigated. A diagnosis of post-ERCP pancreatitis was defined according to Cotton's criteria. Results: Pancreatic duct stent placement was successfully performed in 90% of the patients. Of 40 patients who successfully underwent stent placement, one patient developed mild pancreatitis (2.5%). Of four patients who failed stent placement, two patients developed mild pancreatitis (50%). Of the 35 patients with normal serum amylase level before the procedure, hyperamylasemia at 24 h after ERCP was observed in 60% (21 patients). Of these patients, the onset of an increase in the level of amylase was seen in 66% (14 patients) at 3 h, in 10% (2) at 6 h, and in 24% (5) at 24 h after ERCP. One patient who developed pancreatitis after ERCP manifested elevation of amylase level at 3 h after ERCP followed by a further increase at 6 h. The decrease of serum amylase level was observed at 48-72 h after ERCP in all patients associated with hyperamylasemia. Spontaneous migration of the stent was observed in 91% within one month (mean duration, 8 days). There were no other complications or procedure-related deaths. Conclusions: Pancreatic duct stent insertion can reduce the incidence of post-ERCP pancreatitis in patients with difficult cannulation of the bile duct. Spontaneous migration of a pancreatic stent that contributes to lessening of the need for additional ERCP can be expected with the use of a Pit-stent.

Success and complications of endoscopic removal of giant duodenal and ampullary polyps: a comparative series

Increasing reports suggest that endoscopic removal of benign ampullary and duodenal polyps is safe and frequently definitive; however, most reported polyps have been small in size (<3 cm). We have developed experience with endoscopic removal of increasingly large and complex polyps. Fifty-one cases of endoscopic removal were attempted and grouped according to size: group A (n = 22) polyps 1 to 3 cm and group B (n = 29) polyps 3 cm or larger, including 7 cases larger than 5 cm. When the ampulla was involved, biductal sphincterotomy and prophylactic pancreatic duct stent placement was performed first, followed by saline solution-assisted piecemeal polypectomy, argon plasma coagulation, selective endoclip placement, and recovery of all polyp fragments. Endoscopic removal of duodenal and ampullary adenomas. The outcomes of small and large adenoma removal include mean number of endoscopic retrograde cholangiopancreatographies required for complete removal (2.09 vs 2.56, P = .392), number of complications (4.5% vs 13.9%, P = .375), discovery of unsuspected cancer (0% vs 10.3%, P = .242), and final definitive resolution (100% vs 86.2%, P = .124). Complete removal was achieved in 92.2% of all patients. This was a single center retrospective study. Large (>/=3 cm) ampullary and duodenal polyps comprised 56.9% of our endoscopically treated cases and present special challenges to definitive endoscopic removal. Successful removal of even very large sessile lesions is possible with minimal increase in risk.

A survey of physician practices on prophylactic pancreatic stents

Several prospective studies confirm that prophylactic stent placement in the pancreatic duct (PD) during high-risk ERCP procedures decreases the risk of post-ERCP pancreatitis. Inconsistencies exist regarding the indications for prophylactic PD stent placement, the type of stent used, and stent follow-up. To assess the current practice patterns of expert biliary endoscopists regarding prophylactic pancreatic duct stents. An anonymous survey was mailed to 54 expert biliary endoscopists, assessing volume of procedures, stent indications, method of placement, and follow-up. A total of 91% (49/54) of surveys were returned and analyzed. Prophylactic PD stents were used by 96% of respondents. Stent use was universal during ampullectomy and pancreatic sphincterotomy. Most also used stents for minor papillotomy (93%) and sphincter of Oddi dysfunction (SOD) confirmed by manometry (82%). Endoscopists disagreed on the following: pre-cut sphincterotomy (71%), prior post-ERCP pancreatitis (64%), suspected SOD (58-69%), and traumatic sphincterotomy (44%). Endoscopists used straight stents (33%), pigtail stents (30%), or a combination (33%). Internal flanges were always used by 14%, never used by 54%, and sometimes used by 32%. Stent size and length varied widely, as did the time stents were left in place, and the retrieval method. Expert biliary endoscopists agree that prophylactic PD stenting is indicated during ERCP in high-risk patients. Wide variation exists in patient selection and stent placement technique.

Use of Prophylactic Pancreatic Duct Stenting in Case of Endoscopic Papillary Balloon Dilatation and Metallic Biliary Stenting

Use of Prophylactic Pancreatic Duct Stenting in Case of Endoscopic Papillary Balloon Dilatation and Metallic Biliary Stenting

Prophylactic Pancreatic Duct Stents: Survey of Physician Practices

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.

Post-ERCP Pancreatitis: Does Prophylactic Pancreatic Duct Stent Placement Reduce the Risk?

Background: Recently published data suggests that prophylactic placement of pancreatic duct stents (PS) can reduce the incidence and severity of post-ERCP pancreatitis in high-risk patients.

Prophylactic pancreatic duct stenting: a panacea?

Prophylactic pancreatic duct stenting: a panacea?

Sphincter of Oddi (pancreatic) hypertension and recurrent pancreatitis.

Major papilla pancreatic sphincter dysfunction, a variant of sphincter of Oddi dysfunction, causes pancreatitis and pancreatic-type pain. The gold standard for diagnosis is sphincter of Oddi manometry, most commonly performed at endoscopic retrograde cholangiopancreatography (ERCP). Noninvasive testing, such as secretin-stimulated transabdominal or endoscopic ultrasound assessment of pancreatic duct diameter, is less reliable and has relatively low sensitivity. Two thirds of patients with biliary sphincter of Oddi dysfunction have elevated pancreatic basal sphincter pressure. To maximize the diagnostic yield of sphincter of Oddi dysfunction, both the biliary and pancreatic sphincter pressures should be measured. Patients with sphincter of Oddi dysfunction may respond to biliary sphincterotomy alone, but evaluation of their pancreatic sphincter is warranted if symptoms persist after biliary therapy alone. Whether both biliary and pancreatic sphincters should be treated at the first ERCP session is controversial. Biliary and pancreatic endoscopic sphincterotomies are associated with two- to fourfold increased incidence of pancreatitis following the procedure in patients with pancreatic sphincter hypertension. Prophylactic pancreatic duct stenting reduces the frequency and severity of complications by greater than 50%.

Prophylactic Pancreatic Duct Stenting After Biliary Sphincter Dilation

Endoscopic balloon dilation of the biliary sphincter has been advocated as a useful alternative to sphincterotomy for bile duct stone extraction.

Effect of prophylactic main pancreatic duct stenting on the incidence of biliary endoscopic sphincterotomy-induced pancreatitis in high-risk patients

Pancreatitis is a common complication of endoscopic sphincterotomy. Cautery-induced papillary edema has been implicated as a possible cause. The objective of this study was to determine whether prophylactic stenting of the main pancreatic duct after endoscopic sphincterotomy in high-risk patients would reduce the incidence of pancreatitis. High-risk patients were defined as those with sphincter of Oddi dysfunction, small common bile duct diameter (< 10 mm), or those requiring pre-cut sphincterotomy. Patients were studied in a prospective fashion from October 1990 to April 1992 and were randomized to receive either a main pancreatic duct stent or no stent after biliary sphincterotomy. The stents were generally removed 10 to 14 days after placement. Fifty patients were randomized to the no-stent group and 48 patients were randomized to the stent group, but in five patients stent placement was unsuccessful. Pancreatitis occurred in 18% of patients in the no-stent group compared with 14% of patients in the stent group. Most cases of pancreatitis were mild, occurring in 10% of patients in the no-stent group and 12% of patients in the stent group. Moderate to severe pancreatitis occurred with an increased frequency in patients in the no-stent group (8%) compared with that in patients in the stent group (2%). Mean number of hospital days required to treat pancreatitis was 9.5 days in the no-stent group compared with 2.8 days in the stent group; however, none of these differences reached statistical significance. Small common bile duct diameter (< 6 mm) was found to be an independent risk factor for pancreatitis after endoscopic sphincterotomy.(ABSTRACT TRUNCATED AT 250 WORDS)