Use Of Pancreatic Stents Research Articles

Use of Pancreatic Stenting along with Indomethacin to Reduce Post-ERCP Pancreatitis

Use of Pancreatic Stenting along with Indomethacin to Reduce Post-ERCP Pancreatitis

Robotic pancreatoduodenectomy. Lessons after 126 cases in a single Brazilian center

Background: The first robotic pancreatic resection in Brazil was performed by our team in 2008. Since March 2018, due to a new policy, we have moved to systematically use the robot in all minimally invasive pancreatic surgery procedures. The purpose of this article is to describe our experience with 126 consecutive robotic pancreatoduodenectomies. Our standardized technique included pylorus-preserving pancreatoduodenectomy, artery-first access for malignant cases (Fig. 1), no use of pancreatic stenting, and double drainage of the abdominal cavity.

Effect of pancreatic stent combined with somatostatin on the prevention of acute pancreatitis after endoscopic retrograde cholangiopancreatography

Objective: To explore whether the use of pancreatic stent combined with somatostatin can produce the synergistic effect of preventing acute pancreatitis (AP) and hyperamylasemia (HP) after endoscopic retrograde cholangiopancreatography (ERCP). Methods: From January 2019 to December 2019, the clinical data of 325 patients with ERCP were analyzed retrospectively in cholelithic center of Shanghai East Hospital Affiliated to Tongji University. According to the different methods of AP prevention, the patients were divided into the observation group (pancreatic stent and somatostatin) and the control group (pancreatic stent) and the incidence of AP and HP were compared. Results: In the observation group, there were 5 cases of AP (3.65%) and 10 cases of HP (7.30%). In the control group, there were 7 cases of AP (3.72%) and 19 cases of HP (10.11%). The incidence of AP and HP in the observation group was lower than that in the control group, but the differences were not statistically significant (χ²=0.001, P=0.972; χ²=0.768, P=0.381). Conclusion: The use of pancreatic stent combined with somatostatin will not produce the synergistic effect of preventing AP and HP after ERCP.

Propensity score-matched analysis of internal stent vs external stent for pancreatojejunostomy during pancreaticoduodenectomy: Japanese-Korean cooperative project

BackgroundSeveral studies comparing internal and external stents have been conducted with the aim of reducing pancreatic fistula after PD. There is still no consensus, however, on the appropriate use of pancreatic stents for prevention of pancreatic fistula. This multicenter large cohort study aims to evaluate whether internal or external pancreatic stents are more effective in reduction of clinically relevant pancreatic fistula after pancreaticoduodenectomy (PD). MethodsWe reviewed 3149 patients (internal stent n = 1,311, external stent n = 1838) who underwent PD at 20 institutions in Japan and Korea between 2007 and 2013. Propensity score matched analysis was used to minimize bias from nonrandomized treatment assignment. The primary endpoint was the incidence of clinically relevant pancreatic fistula. This study was registered on the UMIN Clinical Trials Registry (UMIN000032402). ResultsAfter propensity score matched analysis, clinically relevant pancreatic fistula occurred in more patients in the external stents group (280 patients, 28.7%) than in patients in the internal stents group (126 patients, 12.9%) (OR 2.713 [95% CI, 2.139–3.455]; P < 0.001). In subset analysis of a high-risk group with soft pancreas and no dilatation of the pancreatic duct, clinically relevant pancreatic fistula occurred in 90 patients (18.8%) in internal stents group and 183 patients (35.4%) in external stents group. External stents were significantly associated with increased risk for clinically relevant pancreatic fistula (OR 2.366 [95% CI, 1.753–3.209]; P < 0.001). ConclusionPropensity score matched analysis showed that, regarding clinically relevant pancreatic fistula after PD, internal stents are safer than external stents for pancreaticojejunostomy.

Perioperative Net Fluid Balance Predicts Pancreatic Fistula After Pancreaticoduodenectomy

BackgroundOur goal was to evaluate the relationship between perioperative fluid administration and the development of clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreaticoduodenectomy (PD). MethodsRetrospectively, we analyzed fluid balance over the first 72 h in 104 consecutive patients who underwent PD between 2013 and 2017. Patients were categorized into tertiles (low, medium, and high) by net fluid balance. ResultsPOPF was identified in 17.3% of patients (n=18). No significant demographic differences were identified among tertiles. Similarly, there were no differences in ASA, smoking status, hemoglobin A1C, pathologic findings, operative time, blood loss, intraoperative fluid administration, use of pancreatic stents, use of epidurals, or postoperative lactate. Patients with high 72-h net fluid balance had significantly increased rates of POPF compared with those in the medium and low tertiles (31.4% vs. 11.4% vs. 8.8%, p=0.02). On multivariate analysis, increasing net fluid balance remained associated with CR-POPF (OR 1.26, CI 1.03–1.55, p=0.03). ConclusionHigh net 72-h fluid balance is an independent predictor of POPF after PD. Given ongoing efforts to minimize PD morbidity, net fluid balance may represent a clinical predictor and, possibly, a modifiable target for prevention of POPF.

Technical aspects of pancreaticoduodenectomy and their outcomes.

Pancreatic cancer is the fourth leading cause of cancer-related death in the Unites States and is rising in incidence. For the 15-25% of patients who do not have either metastatic or locally advanced disease, surgical resection with pancreaticoduodenectomy is the standard of care and results in improved 5-year survival of 15-25%. While mortality at high-volume centers is less than 5%, morbidity remains high at approximately 30-45%. This paper reviews technical aspects of pancreaticoduodenectomy and their outcomes. Specifically, we review technique and the outcome literature on vascular reconstruction, attempts to decrease delayed gastric emptying (DGE), including pylorus-preserving versus classic pancreaticoduodenectomy and gastrojejunostomy (GJ) technique, as well as attempts to decrease the rate of pancreatic fistula, including the use of pancreatic stents, fibrin sealant, and pancreaticojejunostomy (PJ) technique. Vascular resection and reconstruction have been associated with increased morbidity and mortality. However, the literature suggests that if it allows for an R0 resection, the survival is improved with comparable complication rates. DGE, one of the most common post-pancreaticoduodenectomy complications, has not been reliably decreased with various technical modifications of the GJ. The incidence of pancreatic fistula, one of the most morbid postoperative complications, is not definitively reduced by either the use of pancreatic stents or fibrin sealant. Additional research is needed to determine methods to further decrease rates of morbidity.

Management of the pancreatic stump after pancreaticoduodenectomy

The aim of the present study was to review the current evidence in the management of the pancreatic stump after pancreaticoduodenectomy (PD). A literature search was conducted using the following key words: PD, Whipple's operation, pancreaticojejunostomy (PJ), pancreaticogastrostomy (PG), dunking, duct to mucosa (DTM) and pancreatic stent. Emphasis was made on randomized, controlled trials and meta-analyses. Simple ligation or occlusion of the pancreatic duct was abandoned due to a high complication rate. Most surgeons fashioned a PJ or PG to restore drainage of pancreatic juice. Dunking and DTM were the two major ways to construct anastomosis. The superiority of the binding technique still needs to be proved. However, Blumgart's modified DTM technique achieved a favourable outcome in some non-randomized trials. Pancreatic fistula was not decreased by internal stent, but an external stent might be helpful. No single type or technique of pancreaticoenteric anastomosis is able to demonstrate significant superiority to others. Similar controversy also occurs in the use of pancreatic stent. For the successful management of the pancreatic stump, no matter which type of anastomosis is employed, a meticulous surgical technique with optimization of blood supply to the anastomosis cannot be overemphasized.

Endoscopic removal technique of migrated pancreatic plastic stents

Endoscopic pancreatic stenting (EPS) is used for various pancreatic conditions. With the increasing use of pancreatic stents, many complications have been observed. Especially, proximal stent migration presents a more serious condition because of the possibility of pancreatic duct (PD) damage. However, the removal of proximally migrated stents is technically challenging because of the small PD diameter, the bended PD course, the presence of PD strictures, and the lack of suitable devices for stent removal. Thus, few cases of surgical intervention have been encountered. In this study, we review the endoscopic treatment of proximally migrated pancreatic plastic stents. We classify migrated stent conditions into four types according to stent and PD conditions. In Type A, the main pancreatic duct (MPD) has no stricture. In Type B, the stent is positioned across the stricture on the MPD. In Type C, the stent is positioned further away from the stricture on the MPD. The tip of the proximal stent is located in the MPD in types A thru C. In Type D, the tip of the proximal stent is located in a branch duct. We introduced the strategy of endoscopic removal technique of each type of migrated plastic stents.

Prevention of postendoscopic retrograde cholangiopancreatography pancreatitis: the endoscopic technique.

Pancreatitis is the most frequent and distressing complication of endoscopic retrograde cholangiopancreatography (ERCP). Many recent studies have reported the use of pharmacological agents to reduce post-ERCP pancreatitis (PEP); however, the most effective agents have not been established. Reduction in the incidence of PEP in high-risk patients has been reported through specific cannulation techniques such as guide wire-assisted cannulation and the use of pancreatic stents. The present review focuses on ERCP techniques for the prevention of PEP.

Nonsteroidal anti-inflammatory drugs for prevention of post-ERCP pancreatitis: a meta-analysis

The use of nonsteroidal anti-inflammatory drugs (NSAIDs) in the prevention of post-ERCP pancreatitis (PEP) is still controversial. We performed a meta-analysis to evaluate the efficacy and safety of NSAIDs for PEP prophylaxis. We systematically searched PubMed, EMBASE, Web of Science, and the Cochrane Library for relevant studies published updated to June 2012. Meta-analysis. Patients undergoing ERCP. NSAIDs use for the prevention of PEP. Overall incidence of PEP, incidence of moderate to severe PEP, and adverse events. Ten RCTs involving 2269 patients were included. Meta-analysis showed that NSAID use decreased the overall incidence of PEP (risk ratio [RR], 0.57; 95% CI, 0.38-0.86; P = .007). The absolute risk reduction was 5.9%. The number needed to treat was 17. Heterogeneity among the studies was substantial. However, after removing the main source of heterogeneity, the prophylactic efficacy was similar (RR, 0.53; 95% CI, 0.41-0.68; P < .001). NSAID use also decreased the incidence of moderate to severe PEP (RR 0.46; 95% CI, 0.28-0.75; P = .002). The absolute risk reduction was 3.0%. The number needed to treat was 34. No differences of the adverse events attributable to NSAIDs were observed. Inclusion of low-quality studies, different type and route of administration of the NSAIDs, study heterogeneity, inconsistent use of pancreatic stenting. Prophylactic use of NSAIDs reduces the incidence and severity of PEP.

Pancreatic endoscopic retrograde cholangiopancreatography (ERCP)

Several important papers published recently investigated the prophylactic use of pancreatic stents against the development of pancreatitis following endoscopic retrograde cholangiopancreatography (ERCP).

Optimizing pancreatectomy outcomes: Follow the evidence

A PubMed search of “pancreatectomy” reveals 10,376 articles, and a fraction of these represent randomized controlled trials (n = 81) [ [1] Available at: http://www.ncbi.nlm.nih.gov/pubmed. Accessed Feb 8, 2012. Google Scholar ]. The number of randomized trials performed to date by surgeons to optimize outcomes in pancreatic resection is remarkable. Some of the recent major trials are shown in Table 1. These trials form the basis for many discussions on teaching rounds and include some of the most debatable topics in surgical Morbidity and Mortality conference, such as the routine use of intraperitoneal drains and when to remove them, preoperative biliary drainage, the use of pancreatic stents, intraoperative fluid restriction, preoperative biliary stent versus no drainage, or how to close the pancreatic stump. Table 1Recent randomized controlled trials in pancreatectomy outcomes. Variable Study, year Randomization Outcome PBD van der Gaag et al., 2010 [8] van der Gaag N.A. Rauws E.A. van Eijck C.H. et al. Preoperative biliary drainage for cancer of the head of the pancreas. N Engl J Med. 2010; 362: 129 Crossref PubMed Scopus (758) Google Scholar PBD versus surgery alone 46% complication rate from PBD procedures performed preoperativelyNo difference in operative complications Anastomotic technique Berger et al., 2009 [9] Berger A.C. Howard T.J. Kennedy E.P. et al. Does type of pancreaticojejunostomy after pancreaticoduodenectomy decrease rate of pancreatic fistula? A randomized, prospective, dual-institution trial. J Am Coll Surg. 2009; 208 (discussion 47): 738 Abstract Full Text Full Text PDF PubMed Scopus (277) Google Scholar Invagination versus duct to mucosa anastomosis for pancreaticojejunostomy Statistically significant decrease in fistula rate in invagination group Pancreatic stump closure Diener et al., 2011 [10] Diener M.K. Seiler C.M. Rossion I. et al. Efficacy of stapler versus hand-sewn closure after distal pancreatectomy (DISPACT): A randomised, controlled multicentre trial. Lancet. 2011; 377: 1514 Abstract Full Text Full Text PDF PubMed Scopus (396) Google Scholar Hand sewn versus stapler after distal pancreatectomy No difference in pancreatic fistula or operative mortality Duration of intraperitoneal drainage Bassi et al., 2010 [11] Bassi C. Molinari E. Malleo G. et al. Early versus late drain removal after standard pancreatic resections: Results of a prospective randomized trial. Ann Surg. 2010; 252: 207 Crossref PubMed Scopus (353) Google Scholar Early drain removal (POD 3) versus late drain removal (POD ≥ 5) Significant reduction in pancreatic fistulae, overall complications, and hospital stay and associated costs in early drain removal group Pancreatic stent Pessaux et al., 2011 [12] Pessaux P. Sauvanet A. Mariette C. et al. External pancreatic duct stent decreases pancreatic fistula rate after pancreaticoduodenectomy: Prospective multicenter randomized trial. Ann Surg. 2011; 253: 879 Crossref PubMed Scopus (194) Google Scholar External pancreatic stent versus no stent Significant decrease in pancreatic fistulae, wound infections, and delayed gastric emptying in stented group Intraoperative fluid management Fischer et al., 2010 [13] Fischer M. Matsuo K. Gonen M. et al. Relationship between intraoperative fluid administration and perioperative outcome after pancreaticoduodenectomy: Results of a prospective randomized trial of acute normovolemic hemodilution compared with standard intraoperative management. Ann Surg. 2010; 252: 952 Crossref PubMed Scopus (87) Google Scholar Acute normovolemic hemodilution versus standard fluid management No difference in transfusions between groupsHemodilution group had a significant increase in pancreatic anastomotic complications likely because of increased fluid administration PBD = Preoperative biliary drainage; POD = Post-operative day. Open table in a new tab PBD = Preoperative biliary drainage; POD = Post-operative day. Perioperative Surgical Care Bundle Reduces Pancreaticoduodenectomy Wound InfectionsJournal of Surgical ResearchVol. 174Issue 2PreviewPancreaticoduodenectomy (PD) is a complex surgical procedure with a historically high morbidity rate. The goal of this study was to determine if the implementation of a 12-measure perioperative surgical care bundle (SCB) was successful in reducing infectious and other complications in patients undergoing PD compared with a routine preoperative preparation group (RPP). Full-Text PDF

Pancreatic stents for prophylaxis against post-ERCP pancreatitis: a meta-analysis and systematic review

Acute pancreatitis is a common complication of ERCP. Several randomized, controlled trials (RCTs) have evaluated the use of pancreatic stents in the prevention of post-ERCP pancreatitis with varying results. We conducted a meta-analysis and systematic review to assess the role of prophylactic pancreatic stents for prevention of post-ERCP pancreatitis. MEDLINE, Cochrane Central Register of Controlled Trials and Database of Systematic Reviews, PubMed, and recent abstracts from major conference proceedings were searched. RCTs and retrospective or prospective, nonrandomized studies comparing prophylactic stent with placebo or no stent for post-ERCP pancreatitis were included for the meta-analysis and systematic review. Standard forms were used to extract data by 2 independent reviewers. The effect of stents (for RCTs) was analyzed by calculating pooled estimates of post-ERCP pancreatitis, hyperamylasemia, and grade of pancreatitis. Separate analyses were performed for each outcome by using the odds ratio (OR) or weighted mean difference. Random- or fixed-effects models were used. Publication bias was assessed by funnel plots. Heterogeneity among studies was assessed by calculating I(2) measure of inconsistency. Systematic review and meta-analysis of patients undergoing pancreatic stent placement for prophylaxis against post-ERCP pancreatitis. Adult patients undergoing ERCP. Pancreatic stent placement for the prevention of post-ERCP pancreatitis. Post-ERCP pancreatitis, hyperamylasemia, and complications after pancreatic stent placement. Eight RCTs (656 subjects) and 10 nonrandomized studies met the inclusion criteria (4904 subjects). Meta-analysis of the RCTs showed that prophylactic pancreatic stents decreased the odds of post-ERCP pancreatitis (odds ratio, 0.22; 95% CI, 0.12-0.38; P<.01). The absolute risk difference was 13.3% (95% CI, 8.8%-17.8%). The number needed to treat was 8 (95% CI, 6-11). Stents also decreased the level of hyperamylasemia (WMD, -309.22; 95% CI, -350.95 to -267.49; P≤.01). Similar findings were also noted from the nonrandomized studies. Small sample size of some trials, different types of stents used, inclusion of low-risk patients in some studies, and lack of adequate study of long-term complications of pancreatic stent placement. Pancreatic stent placement decreases the risk of post-ERCP pancreatitis and hyperamylasemia in high-risk patients.

Prophylaxis of post-ERCP pancreatitis: a practice survey

Prophylactic pancreatic stenting is widely used by expert biliary endoscopists to prevent post-ERCP pancreatitis (PEP); nonsteroidal anti-inflammatory drugs (NSAIDs) are thought to prevent PEP. To assess the use of pancreatic stenting and NSAIDs for PEP prophylaxis among endoscopists and its determinants. A survey was distributed to 467 endoscopists attending a course on therapeutic digestive endoscopy. Completed surveys were collected from 141 endoscopists performing ERCP in 29 countries (answer rate 30.2%); practices were most often located in community hospitals with an annual hospital volume of < or = 500 ERCPs (in Belgium, Spain, Italy, and France in about half of cases). For all conditions listed, including needle-knife precut, previous PEP, suspected sphincter of Oddi dysfunction, and ampullectomy, less than half of the endoscopists reported attempting prophylactic pancreatic stenting in > or = 75% of cases. Thirty (21.3%) survey respondents did not perform prophylactic pancreatic stenting in any circumstance; this was mainly ascribed to lack of experience. Measurement of PEP incidence and an annual hospital volume of > 500 ERCPs were independently associated with the use of prophylactic pancreatic stenting (P = .005 and P = .030, respectively). Most survey respondents (n = 118, 83.7%) did not use NSAIDs for PEP prophylaxis. This was mainly ascribed to lack of scientific evidence of its benefits. Proportion of cases in which pancreatic stenting is attempted during ERCP; reasons for not using prophylactic pancreatic stenting or NSAIDs. Survey, not an audit of practice. Despite scientific evidence of its benefits, use of prophylactic pancreatic stenting is not as widely adopted as previously thought; use of NSAIDs for PEP prophylaxis is marginal.

Can endoscopic palliation of large neoplasm increase the risk of pancreatitis after endoscopic retrograde cholangiopancreatography?

Recently, a patient presented with severe acute pancreatitis after biliary self-expandable metallic stent (SEMS) placement for palliation of an unresectable pancreatic cancer. This case induced us to consider the risk of acute pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP). The use of biliary SEMS represents the best therapeutic option for the treatment of neoplastic obstructive jaundice because it has a lower mortality and morbidity than surgery. It does not pose as a risk factor for inducing postERCP acute pancreatitis (PEAP) or other complications but increases only the risk of cholangitis [1]. However, SEMS is considered to be the first therapeutic palliation procedure for patients with unresectable pancreatic cancer. It offers better results than surgical palliation in terms of lower procedure-related complications and improves life quality [2, 3] Moreover, studies have shown the feasibility of simultaneous SEMS positioning for treating combined biliary and duodenal obstructions [4, 5]. We thought the PEAP in our case may have been attributable either to obstruction of the Wirsung caused by SEMS positioning or to direct damage due to the stent expansion, although no evidence for this exists in the literature. However, the causes more likely were a prolonged manipulation of the papilla due to a difficult cannulation or an excessive main pancreatic duct opacification. In a recent study, Cotton et al. [6] showed that the cited maneuvers can increase fatal post-ERCP complications. Although Schutz and Abbott [7] state that only technical success depend on the ERCP degree of difficulty and that complications do not, Cotton et al. [6] think that complicated procedures (grade 3 of the modified Madhotra classification [8]) pose higher risk for the development of complications because the approach to the papilla can be extremely complex. We think that large neoplasms (diameter, [4 cm) modifying the common bile duct (CBD) anatomy (kinking, coiling, stretching) also should be considered as a factor increasing the complexity of ERCP and thus the possibility of procedure-related pancreatitis. However, but at this writing, no author considers this to be a risk factor. To simplify the CBD cannulation, Ito et al. [9] recently have suggested inserting a pancreatic guidewire to achieve a selective biliary cannulation. This still needs a randomized study. Several authors have stated that the use of pancreatic stents probably is the best way to prevent PEAP [10–16]. Different series have shown that the use of this device reduces the incidence of PEAP from a range of 11.1% to 66.7% for patients with no stent to a range of 5% to 14.4% for patients with a stent. When the main pancreatic duct cannulation is obtained first, as often happens if the neoplastic lesion does not involve the duct, the clinician should place a pancreatic stent at once before proceeding to the CBD. The use of small-caliber (maximum, 5 Fr) short (2–3 cm) stents [17] and elimination of flaps before insertion [18] allow a spontaneous migration in 2 to 3 weeks without the need for endoscopic removal. Pancreatic stent positioning G. Fanello (&) M. Benedetti G. Martino M. Marengo R. L. Meniconi F. Papini P. Chirletti Department of Surgery, ‘‘F. Durante’’–General Surgery Unit, ‘‘Sapienza’’ University of Rome, Policlinico Umberto I, Viale del Policlinico, 155, 00161 Rome, Italy e-mail: gianfranco.fanello@uniroma1.it

Good stents gone bad: endoscopic treatment of proximally migrated pancreatic duct stents

Pancreatic duct stents are used for a variety of endoscopic pancreatic manipulations, and small surgical stents are used prophylactically to bridge pancreatic-enteric anastomoses. With increasing use of pancreatic stents, many complications have been recognized. To determine the complications and outcomes of pancreatic stent migration. Case series from a retrospective review of all cases of upstream or proximally migrated pancreatic duct stents, placed either endoscopically or surgically, identified between 2000 and 2007. Tertiary referral center. This study involved 33 patients; 23 postendoscopic and 10 postsurgical stents. Retrieval rates, minor/major complications. Endoscopic stents had a successful retrieval rate of 78%. Most patients were asymptomatic. The most common procedure was balloon extraction (8 of 18; 44%). Nine patients required multiple procedures (3 patients, 2 attempts; 5 patients, 3 attempts; 1 patient, 4 attempts). Five stents could not be retrieved. Of these, 4 were associated with downstream stenosis. Four patients underwent surgery, and 1 patient was treated with observation. Complications included pancreatic duct disruption (1 of 23), stent fragmentation (1 of 23), and postprocedure pancreatitis (1 of 23). Surgically placed stents had a successful retrieval rate of 80%. Most surgical stents had migrated into the biliary tree (8 of 10). All of these patients were symptomatic with pain or fever. Two stents could not be retrieved; 1 of those patients underwent surgery. Retrospective study. The majority of upstream-migrated stents can be endoscopically removed. Despite manipulation of the pancreatic duct, pancreatitis was infrequent. Surgically placed pancreatic stents migrate downstream and into the open biliary anastomosis and are associated with pain, cholangitis, or liver abscesses.

Endotherapy for Pancreatic Fistulae: Inside Out or Outside In?

How therapeutic endoscopy has changed! As participants and observers of the evolution of endotherapy, one has to marvel at the progress we have made in this field. We have withstood mild outrage of our description of precut sphincterotomy, to questions regarding the efficacy of balloon dilators for the bile and pancreatic duct sphincters, to outspoken objections at national meetings of our presentations describing the use of pancreatic stents for the treatment of various forms of pancreatitis, to the expectation of greater progress and advancement in the field. We routinely drain pseudocysts, stent disrupted pancreatic ducts, but, now, we commend the innovators from Erasme Hospital in Brussels for their newly described technique of completing an endoscopic rendezvous procedure performed through an external pancreatic fistula (EPF). In this new technique, an endoscopist, who is observing the progress of a percutaneous puncture through an EPF, positions an endoscope in the stomach or small bowel lumen while assisting another endoscopist (not a radiologist) who is advancing catheters and guide wires through the fistulous tract (a virtual cyst demonstrated by EUS) so that the assistant can guide the operator's puncture through the gut wall into the bowel lumen in order to deploy an internal stent to allow the normal flow or egress of pancreatic juices into the gut facilitating the closure of the fistula. Although the procedure is time-consuming and probably not cost-effective for the free enterprise reimbursement system in the United States, the results of this procedure, in a small number of patients over a long time period, were as effective as surgery. Our hats are off to those who continue to explore the outer limits of endotherapy, and we look forward to more exciting, unquestioned developments in the field. This is progress.

Precut (access) sphincterotomy

Precut sphincterotomy, or access papillotomy, refers to a variety of endoscopic sphincterotomy techniques used to gain access to the bile (and occasionally pancreatic) duct(s) when conventional cannulation methods have failed. This article reviews indications, patient selection, techniques, and outcomes of precut sphincterotomy. Major techniques for biliary access include freehand needle-knife sphincterotomy, needle-knife sphincterotomy after placement of a pancreatic stent, and the Erlangen pull-type precut. Success and complication rates of precut techniques are highly variable and depend heavily on the experience and skill of the endoscopist; the indication for the procedure; anatomic variations between patients; and probably on technique-related factors, such as the use of pancreatic stents in certain settings.

Toward improving outcomes of ERCP

Toward improving outcomes of ERCP

Alterations in pancreatic ductal morphology following polyethylene pancreatic stent therapy

Background: Polyethylene stents placed in the main pancreatic duct induce morphologic alterations that may resemble chronic pancreatitis. Methods: We reviewed the sequential pancreatograms of stented patients who had long-term follow-up after stent removal. Results: Forty patients (66%) had a normal baseline pancreatogram, whereas 21 (34%) showed changes of chronic pancreatitis. In 49 of 61 patients (80.3%), one or more had new morphologic changes immediately after stent withdrawal graded as mild (69%), moderate (29%), or severe (2%). Changes included ductal irregularity (49%), narrowing (35.5%), and side branch change(15.5%). Sixteen of the 21 patients (76.1%) with an abnormal baseline pancreatogram had worsening of the baseline abnormality or additional changes while stented, whereas 33 of 40 (82.5%) with a normal baseline developed new morphologic changes. Correlation of stent-induced changes with stent size, length, patency at removal, and duration of stenting failed to show an association. Twenty-five patients with stent-induced changes had a follow-up pancreatogram at a mean of 192 days (10 to 740) after stent removal. There was complete resolution of the changes in 64%, partial resolution in 32%, and no improvement in 5%. Conclusion: Morphologic changes induced by polyethylene pancreatic duct stents occurred in 80% of patients. More than one third of these changes did not resolve during the follow-up period. Because of concern over stent-induced fibrosis, the use of pancreatic stents should remain largely experimental. (Gastrointest Endosc 1996;44:268-75.)