Use Of Pancreatic Duct Stents Research Articles

Increased Risk of Pancreatitis after Endoscopic Retrograde Cholangiopancreatography Following a Positive Intraoperative Cholangiogram: A Single-Center Experience.

Background/AimsTo determine if patients with a positive intraoperative cholangiogram (IOC) who undergo a subsequent endoscopic retrograde cholangiopancreatography (ERCP) have an increased risk of post-ERCP pancreatitis (PEP) compared to those who undergo ERCP directly for suspected common bile duct stones. MethodsA retrospective case-control study was performed from 2010 to 2016. Cases included inpatients with a positive IOC at cholecystectomy who underwent subsequent ERCP. The control group included age-sex matched cohorts who underwent ERCP for choledocholithiasis. Multivariate logistic regression was used to assess the association between PEP and positive IOC, adjusting for matching variables and additional potential confounders. ResultsOf the 116 patients that met the inclusion criteria, there were 91 women (78%) in each group. Nine patients (7.8%) developed PEP in the IOC group, compared to 3 patients in the control group (2.6%). The use of pancreatic duct stents and rectal indomethacin was similar in both groups. After adjusting for age, sex, total bilirubin levels, and any stent placement, patients with a positive IOC had a significantly increased risk of PEP (odds ratio, 4.79; 95% confidence interval, 1.05–21.89; p<0.05). ConclusionsIn this single-center case-control study, there was a five-fold increased risk of PEP following a positive IOC compared to an age-sex matched cohort.

Endoscopic and pharmacological treatment for prophylaxis against postendoscopic retrograde cholangiopancreatography pancreatitis: a meta-analysis and systematic review.

Postendoscopic retrograde cholangiopancreatography (post-ERCP) pancreatitis (PEP) is the most common complication following ERCP. We carried out a systematic review and meta-analysis of the global literature on PEP prevention to provide clinical guidance and a framework for future research in this important field. PubMed, Embase, Science Citation Index, Ovid, and the Cochrane Controlled Trials Register were searched by two independent reviewers to identify full-length, prospective, randomized controlled trials (RCTs) published up until March 2016 investigating the use of pancreatic duct stents and pharmacological agents to prevent PEP. Twelve RCTs comparing the risk of PEP after pancreatic duct stent placement (1369 patients) and 30 RCTs comparing pharmacological agents over placebo (10251 patients) fulfilled the inclusion criteria and were selected for final review and analysis. Meta-analysis showed that prophylactic pancreatic stents significantly decreased the odds of post-ERCP pancreatitis [odds ratio (OR), 0.28; 95% confidence interval (CI), 0.18-0.42]. Significant OR reduction of PEP was also observed in relation to rectal administration of diclofenac (OR, 0.24; 95% CI, 0.12-0.48) and rectal administration of indometacin (OR, 0.59; 95% CI, 0.44-0.79) compared with placebo. Subgroup analysis showed a significant reduction with bolus-administered somatostatin (OR, 0.23; 95% CI, 0.11-0.49). Subgroup analysis showed a significant reduction with bolus-administered somatostatin (OR, 0.23; 95% CI, 0.11-0.49). Pancreatic stent placement, rectal diclofenac, and bolus administration of somatostatin appear to be most effective in preventing post-ERCP pancreatitis.

PWE-161 Preventing Post-ERCP Pancreatitis (PEP): The Role of Prophylactic Pancreatic Duct Stenting In The Rectal NSAID era

Introduction Post ERCP pancreatitis (PEP) is an important complication. Rectal NSAIDs at ERCP is the standard of care to reduce the risk. Pancreatic duct (PD) stenting also reduces the risk of PEP in high risk patients, but placement can be technically challenging. Failed PD stenting carries reported PEP rates of at least 35%. We aimed to assess whether prophylactic pancreatic stenting is still justified in the current rectal NSAID era. Methods Between January 2013 and June 2015, we retrospectively evaluated the use of PD stents in a UK tertiary referral centre. Rectal NSAIDs were used universally for all cases post-ERCP, except in those contraindicated to NSAIDs. Prophylactic PD stenting (unflanged 5Fr 5–7 cm single pigtail stents, Cook Medical) was attempted in predicted high risk PEP cases. Indications for therapeutic PD stents included patients with chronic pancreatitis. Data was collected from our prospective database, completed following each ERCP. Follow-up information was reviewed through electronic records and telephone enquiry. Results 1633 ERCPs were performed during the study period. Pancreatic stenting was attempted in 324 cases (20%); successful placement was achieved in 307 cases (95%). Prophylactic PD stenting failed in 12 cases, one case developed PEP (1/12 = 8%). This patient had sphincter of Oddi dysfunction (SOD) and a contraindication to NSAIDs. 65% (201/307), of successfully placed pancreatic stents were inserted prophylactically, in whom 9% (18/201) developed PEP. PEP occurred in 1.4% (18/1309) of cases who did not undergo attempted PD stenting. The relative risk of PEP was 8.4 (p = 0.04) in the stented group. Conclusion PEP rates in failed PD stenting were low (8%) compared to past studies, and comparable to PEP rates in successful prophylactic PD stenting. This suggests a protective role of rectal NSAIDs, as previously shown by Choksi et al.1 The higher rate of PEP in the PD stenting/attempted stenting group, compared to the unstented group, likely reflects the higher perceived risk of PEP in the PD stenting group. The low rate of recorded PEP in the unstented group may, in part, be due to under-reporting. Our data suggests that increased rates of PEP continue to be seen in perceived high risk cases, even in a universal NSAID use setting. The overall risk appears lower than in the pre-NSAID era, and in our series a lack of difference in the PEP rate between successful and failed PD stenting suggests there is less need for prophylactic PD stenting in the NSAID era. Reference 1 Choksi, et al. The risk of post-ERCP pancreatitis and the protective effect of rectal indomethacin in cases of attempted but unsuccessful prophylactic pancreatic stent placement Gastrointest Endosc 2015;81(1):150–155. Disclosure of Interest None Declared

Stents for the prevention of pancreatic fistula following pancreaticoduodenectomy.

Several studies have demonstrated that the use of pancreatic duct stents following pancreaticoduodenectomy is associated with a lower risk of pancreatic fistula. However, to date there is a lack of accord in the literature on whether the use of stents is beneficial and, if so, whether internal or external stenting, with or without replacement, is preferable. This is an update of a systematic review. To determine the efficacy of pancreatic stents in preventing pancreatic fistula after pancreaticoduodenectomy. We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, Web of Science, and four major Chinese biomedical databases up to November 2015. We also searched several major trials registers. Randomized controlled trials (RCTs) comparing the use of stents (either internal or external) versus no stents, and comparing internal stents versus external stents, replacement versus no replacement following pancreaticoduodenectomy. Two review authors independently extracted the data. The outcomes studied were incidence of pancreatic fistula, need for reoperation, length of hospital stay, overall complications, and in-hospital mortality. We showed the results as risk ratio (RR) or mean difference (MD), with 95% confidence interval (CI). We assessed the quality of evidence using GRADE (http://www.gradeworkinggroup.org/). We included eight studies (1018 participants). The average age of the participants ranged from 56 to 68 years. Most of the studies were conducted in single centers in Japan (four studies), China (two studies), France (one study), and the USA (one study). The risk of bias was low or unclear for most domains across the studies. Stents versus no stentsThe effect of stents on reducing pancreatic fistula in people undergoing pancreaticoduodenectomy was uncertain due to the low quality of the evidence (RR 0.67, 95% CI 0.39 to 1.14; 605 participants; 4 studies). The risk of in-hospital mortality was 3% in people who did receive stents compared with 2% (95% CI 1% to 6%) in people who had stents (RR 0.73, 0.28 to 1.94; 605 participants; 4 studies; moderate-quality evidence). The effect of stents on reoperation was uncertain due to wide confidence intervals (RR 0.67, 0.36 to 1.22; 512 participants; 3 studies; moderate-quality evidence). We found moderate-quality evidence that using stents reduces total hospital stay by just under four days (mean difference (MD) -3.68, 95% CI -6.52 to -0.84; 605 participants; 4 studies). The risk of delayed gastric emptying, wound infection, and intra-abdominal abscess was uncertain (gastric emptying: RR 0.75, 95% CI 0.24 to 2.35; moderate-quality evidence) (wound infection: RR 0.73, 95% CI 0.40 to 1.32; moderate-quality evidence) (abscess: RR 1.38, 0.49 to 3.85; low-quality evidence). Subgroup analysis by type of stent provided limited evidence that external stents lead to lower risk of fistula compared with internal stents. External versus internal stentsThe effect of external stents on the risk of pancreatic fistula, reoperation, delayed gastric emptying, and intra-abdominal abscess compared with internal stents was uncertain due to low-quality evidence (fistula: RR 1.44, 0.94 to 2.21; 362 participants; 3 studies) (reoperation: RR 2.02, 95% CI 0.38 to 10.79; 319 participants; 3 studies) (gastric emptying: RR 1.65, 0.66 to 4.09; 362 participants; 3 studies) (abscess: RR 1.91, 95% CI 0.80 to 4.58; 362 participants; 3 studies). The rate of in-hospital mortality was lower in studies comparing internal and external stents than in those comparing stents with no stents. One death occurred in the external-stent group (RR 0.33, 0.01 to 7.99; low-quality evidence). There were no cases of pancreatitis in participants who had internal stents compared with three in those who had external stents (RR 0.15, 0.01 to 2.73; low-quality evidence). The difference between internal and external stents on total hospital stay was uncertain due to the wide confidence intervals around the average effect of 1.7 days fewer with internal stents (9.18 days fewer to 5.84 days longer; 262 participants; 2 studies; low-quality evidence). The analysis of wound infection could not exclude a protective effect with either approach (RR 1.41, 0.44 to 4.48; 319 participants; 2 studies; moderate-quality evidence). Operative replacement of pancreatic juice versus not replacing pancreatic juice There was insufficient evidence available from a small trial to ascertain the effect of replacing pancreatic juice. This systematic review has identified limited evidence on the effects of stents. We have not been able to identify convincing direct evidence of superiority of external over internal stents. We found a limited number of RCTs with small sample sizes. Further RCTs on the use of stents after pancreaticoduodenectomy are warranted.

Pancreatic Fistula After Pancreaticoduodenectomy Is Iatrogenic in Nature.

Pancreatic fistula after pancreaticoduodenectomy (PD) is a dreaded complication not easily accepted by the operative surgeons to be iatrogenic in nature. How then measures to prevent postoperative pancreatic fistula (POPF) are in equal measure effective or ineffective be it use of octreotide, pancreaticogastrostomy (PG), or different avatars of pancreaticojejunostomy (PJ), and use of pancreatic duct stents [1]. Vilification of texture of the pancreas in to soft or firm/hard in nature as the cause of POPF is the lament of many pancreatic surgeons.

Pancreatic Duct Stents at Pancreaticoduodenectomy: A Meta-Analysis

Background and Objective: Several studies suggested that pancreatic stents had some benefit during pancreatoduodenectomy (PD), but others disagree. Whether pancreatic duct stents could prevent postoperative pancreatic fistula (POPF) is still under controversy. Methods: Randomized controlled trials published before November 2012 were all aggregated, focusing on the evaluation of pancreatic duct stents during PD. Trial data was reviewed and extracted independently by two reviewers. The quality of the including studies was assessed by the Cochrane handbook 5.1.0. Results: Seven studies were included, with a total of 793 patients. The results showed that compared with nonstents, stents during PD was associated with a significant difference on overall POPF rate (OR = 0.65, 95% CI 0.45-0.95, p = 0.02), POPF grades B and C (OR = 0.45, 95% CI 0.27-0.76, p = 0.003), and hospital stay (MD = -4.28, 95% CI -6.81, -1.75, p = 0.0009). Subgroup analyses showed that the external stent had a significant difference in the incidence of overall POPF (OR = 0.46, 95% CI 0.29-0.73, p = 0.0009), POPF grades B and C (OR = 0.49, 95% CI 0.30-0.79, p = 0.003), postoperative morbidity (OR = 0.63, 95% CI 0.42-0.96, p = 0.03), as well as hospital stay. Conclusions: Based upon this meta-analysis, there might be potential benefit in reducing POPF thanks to the use of pancreatic duct stents.

Pancreatic surgery

To summarize published research on pancreatic surgery over the past year. A number of studies aiming to reduce the costs associated with pancreatic surgery were reported. Retrospective analyses confirmed previous findings that neither the routine use of pancreatic duct stents decreases the rate of fistula formation nor does placement of a drain at the time of surgery change the morbidity in patients who develop one. Minimally invasive approaches, both laparoscopic and robot-assisted, are being performed more frequently to remove pancreatic cancers. A randomized trial confirmed that reinforcement of stapled closure during distal pancreatectomy reduces the rate of fistula formation. Controversy remains over whether small pancreatic neuroendocrine tumors need to be surgically resected or can be treated nonoperatively. Patients with chronic pancreatitis should be screened thoroughly before being offered surgical treatment; two studies reported preoperative factors that can be used to identify those most likely to experience pain relief. Studies published on pancreatic surgery last year focused on a wide-range of topics. The morbidity and mortality of patients undergoing pancreatic surgery continues to improve, and we anticipate that incorporation of these new findings will lead to even better outcomes.

Endoscopic papillectomy

Although few controlled trials exist in the field, endoscopic papillectomy has evolved over the recent years with new data on preoperative staging and improved methods for its safe and successful completion. In 2006, a consensus guideline was published by the American Society of Gastrointestinal Endoscopy evaluating the role of endoscopy in managing ampullary adenomas. The recent literature of endoscopic papillectomy has focused on the preoperative management of ampullary tumors, with a paper evaluating the role of endoscopic ultrasound. Also, a randomized controlled trial has shown that the use of pancreatic duct stents is associated with less incidence of postendoscopic papillectomy pancreatitis, although the study was probably underpowered. Several methods can be used to help locate the pancreatic duct postendoscopic papillectomy (endoscopic ultrasound-guided rendezvous and methylene blue injection). The recurrence and complication rate in more recent papers continue to be acceptable, at about 30 and 20%, respectively. Endoscopic papillectomy is a reasonable alternative to transduodenal surgical excision, but more controlled studies with long-term data are needed to evaluate preoperative staging accuracy and recurrence rates.

Pancreatic Duct Stent Insertion for Functional Smoldering Pancreatitis

Background: Some patients with smoldering pancreatitis in the absence of necrosis, pseudocyst, and ductal disruption experience unremitting abdominal pain caused by persistent pancreatic inflammation. Experience with the use of pancreatic duct stents in this patient population was reviewed. Patients and Methods: Data for 11 patients with smoldering pancreatitis who underwent ERCP with pancreatic duct stent placement were reviewed retrospectively. All patients had severe, daily pain that worsened with ingestion of food, had required narcotic analgesics for control of pain, had lost weight, and had persistently elevated serum levels of pancreatic enzymes as well as pancreatic inflammatory changes on CT (without necrosis or pseudocyst). Six patients were being treated with parenteral nutrition. Observations: The mean duration of symptoms from the onset of pancreatitis until pancreatic duct stent insertion was 74 days (range 14-151 days). Stents were placed for a mean of 7 weeks (range 2-19 weeks). Pancreatic stent placement provided permanent pain relief in 10 (91%) patients within a mean of 9 days (range 3-20 days); one patient had persistent symptoms requiring celiac plexus blockade after 5 months. Parenteral nutrition and treatment with narcotic agents were discontinued for 10 patients within a mean of 15 days (range 7-39 days) after pancreatic duct insertion. Conclusions: Smoldering pancreatitis may result from functional obstruction, possibly caused by edema or spasm, of the papillary orifice. Insertion of a stent into the pancreatic duct alleviates pain, enables early resumption of oral intake of food, and facilitates pancreatic duct drainage. It also may help to prevent complications arising from persistent pancreatic inflammation.

4687 Pancreatic duct stent therapy for “smoldering” pancreatitis.

Introduction: During recovery from acute pancreatitis, a small group of patients experience unremitting abdominal pain, intolerance to oral feeds, elevated enzymes, and inflammatory changes on CT scan. This clinical syndrome has been termed "smoldering" pancreatitis. Continued inflammation typically results from pancreatic necrosis, pseudocysts, pancreatic duct (PD) strictures, or PD disruption. Occasionally, however, no explanation exist for the persistent inflammation. Functional obstruction of the papillary orifice may account for the unremitting course seen in these patients.We report our experience with the use of PD stents in this patient population. Methods: Thirteen patients were evaluated for "smoldering" pancreatitis. Nine patients had no identifiable etiology despite extensive evaluation. Each of the other 4 patients had a recognized risk factor (1- hypertriglyceridemia, 1-cystic fibrosis, 1-pancreas divisum, and 1 patient with pancreas divisum and post-ERCP pancreatitis). The patients (8 male, 5 female), age 11-55 years (mean 35 years), had persistent symptoms for 10-60 days (mean 41 days) from the onset of pancreatitis until PD stent placement. Each patient had severe daily pain, exacerbated by oral intake, and requiring intravenous narcotics. Parenteral nutrition was administered in 12 patients. At ERCP, the amylase was normal in 3 patients, elevated < 2x in 8 patients, and >5x in 2 patients. CT scan revealed pancreatic and peripancreatic inflammation, without necrosis or pseudocyst formation. The pancreatogram was normal in 8 patients, revealed chronic pancreatitis in 2 patients, mild diffuse narrowing in 2 patients, and diffuse irregular narrowing with a distal CBD stricture in 1 patient. Follow-up ERCP revealed a normal PD in all patients, except for the 2 patients with chronic pancreatitis whose pancreatograms were unchanged. A PD stent (5-7 Fr, 2-3 cm) was placed in all 13 patients for a period of 2-12 weeks (mean 6 weeks). Results: PD stent placement resulted in significant relief of abdominal pain within 1-10 days (mean 2.8 days). Parenteral analgesics and nutrition were discontinued within 1-10 days (mean 3.0 days). Patients were discharged home within 2-11 days (mean 4.0 days) after stent placement. Conclusions: "Smoldering" pancreatitis may result from functional obstruction, possibly caused by edema or spasm of the papillary orifice. Pancreatic duct stent placement can effectively treat this entity, and allow rapid relief of symptoms, resumption of oral intake, and hospital discharge.