Prophylactic Pancreatic Stent Research Articles

Placement of an intra-arterial stent-graft for a pseudoaneurysm after pancreatic resection

Background: Endoscopic snare papillectomy(ESP) is an efficient treatment for benign tumors of the duodenal major papilla. However, acute pancreatitis is the most common and serious complication following an ESP. Aims: The aim was to compare the rate of post-ESP pancreatitis in patients who did or did not receive prophylactic pancreatic stent placement after ESP. Patients & methods: From March 2010 to February 2014, consecutive patients who were to undergo ESP were randomized to pancreatic stent placement group or to no stent placement group. The overall outcomes after ESP including complications were compared between two groups. Results: The 36 patients who received ESP of major duodenal papillary tumors were enrolled. 20 patients were assigned to the stent group and 16 patients to the no stent group. Post-ESP pancreatitis developed in 9 patients (25%, 9/36), 6 cases occurred in the stent group and 3 cases occured in the no stent group. One case in the stent group was considered moderate grade pancreatitis and the others were considered mild grade pancreatitis. The overall incidence of post-EPS pancreatitis were 30% (6/20) in the stent group and 18.8% (3/16) in the no stent group (p1⁄40.700). The rates of hyperamylasemia were 5% (1/20) in the stent group and 6.3% (1/16) in the no stent group (p1⁄40.700). Conclusion: The development of post-ESP pancreatitis and hyperamylasemia were not significantly different in patients with prophylactic pancreatic stent placement compared to those without it. Our data suggest that the effectiveness of prophylactic pancreatic stent placement after ESP may be doubtful. Therefore, more large scaled prospective, randomized controlled studies are needed.

PTU-177 Duodenal Adenomas: A Review Of Their Management And The High Risk Of Co-existing Colon Cancer

IntroductionWe reviewed the management of Duodenal adenomas at James Paget University Hospital, Great Yarmouth between 2001 and 2013.Methods20 patients were included in this study. A standardised proforma was completed for...

The role of nonsteroidal anti-inflammatory drugs in the prevention of post endoscopic retrograde cholangiopancreatography pancreatitis.

Post-ERCP pancreatitis (PEP) is the most common major complication associated with ERCP. Beginning with an overview of the risk factors for the development of PEP, this review introduces the mechanism of injury in PEP and the role of pharmacological prevention. NSAIDs are increasingly found to offer prevention against the development of PEP, and their mechanism and supportive data are summarized, especially in relationship to the practice of prophylactic pancreatic duct stenting.

Endoscopic treatment of refractory post-sphincterotomy bleeding with forceps electrocoagulation combined with prophylactic pancreatic stenting – a case series

Endoscopic treatment of refractory post-sphincterotomy bleeding with forceps electrocoagulation combined with prophylactic pancreatic stenting – a case series

Complications of prophylactic pancreatic stenting used for the prevention of post-ERCP pancreatitis with regards to stent types: Results of a prospective, controlled study

Complications of prophylactic pancreatic stenting used for the prevention of post-ERCP pancreatitis with regards to stent types: Results of a prospective, controlled study

Su1681 Timing of Prophylactic Pancreatic Duct Stent Placement Can Affect the Risk of Post ERCP Pancreatitis in High-Risk Patient Population

Post ERCP pancreatitis (PEP) can be as high as 30% in high-risk patients. Prophylactic pancreatic duct (PD) stent placement has been shown to decrease the risk of PEP in high-risk patients. The aim of our study is to investigate if the risk of PEP is reduced with earlier placement of prophylactic PD stent following PD cannulation or injection in high-risk patient population.

Transpancreatic Precut Sphincterotomy for Biliary Access: The Relation of Sphincterotomy Size to Immediate Success Rate of Biliary Cannulation

Background. Transpancreatic precut sphincterotomy (TPS) is an option for difficult common bile duct (CBD) access, and the reports are few, with immediate success rate varying from 60 to 96%. The description of relation between the size of TPS and the immediate success rate of CBD cannulation was not found in the literature. The Aim of the Study. To evaluate the relation of large TPS to immediate success rate of CBD cannulation. Methods. A retrospective analysis was performed in prospectively collected data of 20 patients. TPS was performed with traction papillotome in the main pancreatic duct (MPD) directing towards 11 o'clock. Needle knife (NK) was used to enlarge TPS in five patients, and the other 15 cases had large TPS from the beginning of sphincterotomy. Prophylactic pancreatic stent was inserted in 18 cases, with diclofenac given in 12 cases. Results. The immediate success rate of CBD cannulation was 90% and with an eventual success rate of 100%. The failure in one immediate CBD cannulation with large TPS was due to atypical location of CBD orifice, and the other failed immediate CBD cannulation was due to inadequate size of TPS. Complications included 3 cases of post-TPS bleeding and 3 cases of mild pancreatitis. Conclusion. TPS is an effective procedure in patients with difficult biliary access and can have high immediate success rate with large TPS.

Placement of prophylactic pancreatic stents to prevent post-endoscopic retrograde cholangiopancreatography pancreatitis in high-risk patients: a meta-analysis.

To assess the effectiveness of pancreatic stents for preventing pancreatitis in high-risk patients after endoscopic retrograde cholangiopancreatography (ERCP). PubMed, Embase, Science Citation Index, and Cochrane Controlled Trials Register were searched to identify relevant trials published in English. Inclusion and exclusion criteria were used to screen for suitable studies. Two reviewers independently judged the study eligibility while screening the citations. The methodological quality of the included trials was assessed using the Jadad scoring system. All results were expressed as OR and 95%CI. Data were analyzed using Stata12.0 software. Ten eligible randomized controlled trials were selected, including 1176 patients. A fixed-effects model in meta-analysis supported that pancreatic duct stents significantly decreased the incidence of post-ERCP pancreatitis (PEP) in high-risk patients (OR = 0.25; 95%CI: 0.17-0.38; P < 0.001). Pancreatic stents also alleviated the severity of PEP (mild pancreatitis after ERCP: OR = 0.33; 95%CI: 0.21-0.54; P < 0.001; moderate pancreatitis after ERCP: OR = 0.30; 95%CI: 0.13-0.67; P = 0.004). The result of severe pancreatitis after ERCP was handled more rigorously (OR = 0.24; 95%CI: 0.05-1.16; P = 0.077). Serum amylase levels were not different between patients with pancreatic stents and control patients (OR = 1.08; 95%CI: 0.82-1.41; P = 0.586). Placement of prophylactic pancreatic stents may lower the incidence of post-ERCP pancreatitis in high-risk patients and alleviate the severity of this condition.

Endoscopic prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis.

Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) is not an uncommon adverse event but may be an avoidable complication. Although pancreatitis of severe grade is reported in 0.1%-0.5% of ERCP patients, a serious clinical course may be lethal. For prevention of severe PEP, patient risk stratification, appropriate selection of patients using noninvasive diagnostic imaging methods such as magnetic resonance cholangiopancreatography or endoscopic ultrasonography (EUS), and avoidance of unnecessary invasive procedures, are important measures to be taken before any procedure. Pharmacological prevention is also commonly attempted but is usually ineffective. No ideal agent has not yet been found and the available data conflict. Currently, rectal non-steroidal anti-inflammatory drugs are used to prevent PEP in high-risk patients, but additional studies using larger numbers of subjects are necessary to confirm any prophylactic effect. In this review, we focus on endoscopic procedures seeking to prevent or decrease the severity of PEP. Among various cannulation methods, wire-guided cannulation, precut fistulotomy, and transpancreatic septostomy are reviewed. Prophylactic pancreatic stent placement, which is the best-known prophylactic method, is reviewed with reference to the ideal stent type, adequate duration of stent placement, and stent-related complications. Finally, we comment on other treatment alternatives, and make the point that further advances in EUS-guided techniques may afford useful PEP prophylaxis.

Prophylactic pancreatic stent placement for endoscopic duodenal ampullectomy: a single-center retrospective study.

Background/AimsWe investigated the efficacy of prophylactic pancreatic stent placement for preventing postprocedure pancreatitis in patients undergoing endoscopic papillectomy.MethodsThis retrospective study included 82 consecutive patients who underwent endoscopic papillectomy for benign ampullary neoplasm at Samsung Medical Center between August 2002 and June 2011. The patients were subdivided into two groups, namely, those who received prophylactic pancreatic stent placement and those who did not. Patient demographics, baseline blood test, tumor characteristics, and endoscopic treatment data were collected. The primary endpoint was postprocedure pancreatitis.ResultsThere was no difference in the development of postprocedure pancreatitis between the stent group and the no stent group (6/54, 10.5% and 2/28, 7.14%, respectively; p=1.00). At baseline, there were no significant differences between the two groups in terms of their risk factors for pancreatitis except pancreatic duct dye injection. The stent group was more likely to have dye injection than the nonstent group (100% vs 42.8%, p<0.001). However, in a logistic regression analysis, no significant difference was observed in the risk factors for pancreatitis including dye injection.ConclusionsOur data suggest that routine prophylactic pancreatic duct stent placement in all patients undergoing endoscopic papillectomy may not be necessary and that large-scale prospective studies are required to identify the subgroup of patients who would benefit.

Endoscopic Therapy of Refractory Post-Papillotomy Bleeding With Electrocautery Forceps Coagulation Method Combined With Prophylactic Pancreatic Stenting

IntroductionThe overall risk of clinically significant post-papillotomy bleeding is 1–4%, most of them manifest as a delayed hemorrhage 2–5 days after ERCP. Injection method with diluted epinephrine is the standard first line therapy of endoscopic hemostasis in these patients. In therapy resistant cases endoscopic hemocliping is effective, but optimal positioning of the hemoclips is difficult and sometimes impossible. Thermal coagulation method with coagulation forceps combined with prophylactic pancreatic duct stenting could be an alternative in these cases. Patients and methodsWe present 2 cases of recurrent post-papillotomy bleeding, both were detected in 1–6 days after the successful ERCP and EST. Standard endoscopic therapy with local injection of diluted epinephrine and/or application of hemoclips were ineffective. As a second line endoscopic therapy we used thermal coagulation of the bleeding vessels with coagulation forceps similarly to ESD. At the time of the thermal coagulation a 5F, 3–5 cm prophylactic pancreatic stent was applied to prevent pancreatitis. ResultsWe achieved complete hemostasis in all patients without signs of further rebleeding or need for surgery. None of our patients developed post-procedure pancreatitis or perforation. Prophylactic pancreatic stents were safely removed after a few days. ConclusionWe presented a new, effective and safe second line endoscopic hemostatic method in patients with therapy resistant post-papillotomy bleeding. Combination of prophylactic pancreatic stenting and thermal coagulation with coagulation forceps might be suggested as a rescue treatment in patients with severe post-papillotomy bleeding, resistant to standard endoscopic therapy.

Reply

We thank Elmunzer and Waljee for their excellent synopsis of our article, critical review of its methodology, and interpretation of the results. Of course our study was inspired by the randomized, controlled trial of nonsteroidal anti-inflammatory drugs (NSAIDs) versus placebo for prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP; N Engl J Med 2012;366:1414–1422). However, in that study >80% of patients in each arm underwent prophylactic stent placement (PSP) and thus it was not an NSAID alone versus placebo alone trial. Since the publication of a post hoc analysis of the NEJM data (Am J Gastroenterol 2013;108:410–415) and indirect network meta-analysis (Clin Gastroenterol Hepatol 2013;11:778–783), the approach to use of NSAIDs to prevent PEP has varied within our own practice at Mayo Clinic, Rochester. Our ERCP practice employs the services of 6 ERCPists, all of whom now administer rectal NSAIDs but without a uniform approach. Some believe in using NSAIDs alone, whereas others are uncomfortable withholding PSP. Among our group's practice, the approach to use of NSAIDs alone or PSP combined with NSAIDs varies not only between endoscopists, but within endoscopists, depending on the individual patient. Although we have not adopted the approach to administer NSAIDs to low-risk patients, one could argue that if ERCPists have a “zero tolerance policy” with regard to PEP, NSAIDs should be administered to all patients undergoing ERCP. In addition, one-time administration of rectal NSAIDs is low cost and low risk for adverse events, further supporting its potential for uniform administration. We eagerly await the results of the randomized trial of NSAIDs alone and stents alone, understanding that participating centers may find it difficult to enroll patients who may be randomized to not receive PSP. Not only do we encourage centers to participate in the randomized controlled trial, but also encourage centers to collect data prospectively during clinical practice that could also provide useful additional information on NSAIDS and PEP. Dr Baron is currently affiliated with the Division of Gastroenterology, University of North Carolina Chapel Hill, Chapel Hill, North Carolina. Can Rectal NSAIDs Replace Prophylactic Pancreatic Stent Placement for the Prevention of Post-ERCP Pancreatitis?GastroenterologyVol. 146Issue 1PreviewAkbar A, Abu Dayyeh BK, Baron TH, et al. Rectal nonsteroidal anti-inflammatory drugs are superior to pancreatic duct stents in preventing pancreatitis after endoscopic retrograde cholangiopancreatography: a network meta-analysis. Clin Gastroenterol Hepatol 2013;11:778–783. Full-Text PDF

The role of prophylactic transpapillary pancreatic stenting in distal pancreatectomy: a meta-analysis

Pancreatic fistula (PF) is the most frequent complication after distal pancreatectomy (DP). Prophylactic transpapillary pancreatic stenting (PTPS) has been proposed recently for the prevention of PF after DP. In this meta-analysis, a comprehensive search was performed in the PubMed, Embase, and Cochrane Library databases. Studies analyzing the results of PTPS in DP were considered eligible for this meta-analysis. The analyzed outcome variables included PF rate, postoperative morbidity, non-PF-related complications, mortality, operation duration, and hospital stay. Four studies with 200 patients were included in this review. Only one was a randomized controlled trial (RCT). The results showed that PTPS was associated with less PF formation (odds ratio, 0.45; 95% confidence interval [CI], 0.22-0.94; P = 0.03) and shorter hospital stay (mean difference, - 6.31; 95% CI, - 6.99 to - 5.62; P < 0.00001). There was no significant difference in terms of the other variables. In conclusion, current evidence indicates that PTPS could reduce PF incidence and hospital stay after DP, without increasing other complications or operative time. However, the evidence is not solid, because the single RCT conflicted with the other three retrospective reports. Thus, considering the limitation, more well-designed RCTs on this topic are needed in the future.

Ampullary Adenoma – Wire-Guided Ampullectomy

Adenomas involving the major duodenal papilla are being recognized more frequently as a result of the increased use of diagnostic upper endoscopy. They have the potential to progress from benign to malignant lesions and should be resected completely. Endoscopic ampullectomy as curative therapy has gained credibility as a safe and effective alternative to surgical resection. This is a demonstration of a wire-guided ampullectomy of a low-grade adenoma. Step-by-step information is provided for safe endoscopic ampullectomy with subsequent prophylactic pancreatic stenting. This article is part of an expert video encyclopedia.

UK wide survey on the prevention of post-ERCP pancreatitis

ObjectiveIn 2010, the European Society of Gastrointestinal Endoscopy delivered guidelines on the prophylaxis of postendoscopic retrograde cholangiopancreatography (post-ERCP) pancreatitis (PEP). These included Grade A recommendations advising the use of prophylactic...

What is the most adapted indication of prophylactic pancreatic duct stent within the high‐risk group of post‐endoscopic retrograde cholangiopancreatography pancreatitis? Using the propensity score analysis

Conducting randomized controlled trial (RCT) for each of the risk factors associated with prophylactic pancreatic duct stent (PPDS) for post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) is difficult owing to the volume of cases and ethical considerations. In this study, we tried to reveal the degree of preventive effects of PPDS for each individual risk factor within the high-risk group of PEP using the propensity score analysis. The clinical data of 1131 ERCP practices performed at Kobe University Hospital from April 2006 to February 2009 were collected prospectively. We investigated their clinical characteristics including the risk factors of PEP, the use of PPDS and complications of ERCP. We conducted the stratification analysis using the propensity score matching analysis. In 210 propensity score-matched ERCPs, PPDS proved to be effective in preventing PEP in patients with a history of pancreatitis (odds ratio 0.11, 95% CI 0.01-0.76, P = 0.01) and cases of difficult cannulation (requiring more than 30 min) (odds ratio 0.13, 95% CI 0.01-1.14, P = 0.08). Patients with a history of pancreatitis and cases of difficult cannulation are strongly recommended for PPDS placement. The propensity score analysis can be adapted to the ERCP-related analysis with many procedure-related factors with using retrospective data, and may be adapted to investigate the matters that are unsuitable for RCT by volume and ethical issue.

Prophylactic pancreatic duct stent placement after endoscopic snare papillectomy of duodenal major papillary tumors; prospective, randomized study, preliminary report

Prophylactic pancreatic duct stent placement after endoscopic snare papillectomy of duodenal major papillary tumors; prospective, randomized study, preliminary report

PWE-064 Uk Wide Survey On the Prevention of Post-Ercp Pancreatitis

IntroductionAcute pancreatitis is the most common complication following ERCP. In 2010, the European Society of Gastrointestinal Endoscopy delivered Guidelines on the Prophylaxis of post-ERCP pancreatitis (PEP).1 These included Grade A...

PTH-043 Difficult Biliary Access: Early Experience with the New Double Wire Technique Compared to Conventional Precut at Ercp

IntroductionSelective cannulation of the common bile duct (CBD) during endoscopic retrograde cholangiopancreatography (ERCP) can be technically challenging. The precut technique is a tried and tested method of gaining biliary access...

Analysis of risk factors for post-ERCP pancreatitis in patients who underwent prophylactic pancreatic duct stenting - Results of a prospective, multicenter, controlled study

Analysis of risk factors for post-ERCP pancreatitis in patients who underwent prophylactic pancreatic duct stenting - Results of a prospective, multicenter, controlled study