ERCP – Pancreatic

Prophylaxis of post-endoscopic retrograde cholangiopancreatography pancreatitis by an endoscopic pancreatic spontaneous dislodgement stent. (Sofuni et al. Clin Gastroenterol Hepatol 2007 [1])

This prospective controlled multicenter trial studied the placement of 5-Fr plastic pancreatic stents to prevent pancreatitis following endoscopic retrograde cholangiopancreatography (ERCP). A total of 201 consecutive patients who required ERCP (excluding those with pancreatic cancer, pancreas divisum, and those requiring pancreatic duct drainage) were randomized into a stent placement group (n = 98) and a nonstent placement group (n = 103). The success rate of pancreatic stent placement was 96 %, and the rate of spontaneous dislodgement at day 3 was 95.7 %. The primary end point was rate of post-ERCP pancreatitis, which was lower in the stent group (3/94, 3.2 %) compared with the nonstent group (14/103, 13.6 %) (P = 0.019).

Prevention of post-ERCP pancreatitis by pancreatic stent placement has been a hot topic in the past few years. Recent studies have confirmed the efficacy of this approach in high-risk patients [2]. Consequently, Freeman [3] proposed the use of prophylactic pancreatic stents in the following high-risk situations: sphincter of Oddi dysfunction, history of post-ERCP pancreatitis, difficult cannulation, precut sphincterotomy, pancreatic sphincterotomy, aggressive instrumentation of the pancreatic duct, biliary balloon sphincter dilatation, and endoscopic ampullectomy. However, the particular weight of each risk factor for post-ERCP pancreatitis remains largely unknown, and there is currently no consensus among the experts on the appropriate approach [4]. Because it reports results obtained in a large non-high-risk patient group this study is quite interesting. Should we systematically place a pancreatic stent after ERCP? Probably not, but present data suggest that non-high-risk patients may benefit as well from prophylactic pancreatic stent placement. Indeed, but which ones? Only tissue sampling and initial pancreatography significantly correlated with pancreatitis in univariate analysis (multivariate analysis could not be carried out due to the small number of pancreatitis cases). Currently, it is still too early to recommend post-ERCP systematic prophylactic pancreatic stent placement, even for nonexperienced endoscopists in pancreatic duct cannulation. As suggested by the authors, a large trial is necessary to identify patient groups who would benefit from this endoscopic post-ERCP approach to pancreatitis prevention.

Another interesting point of this study was the high spontaneous migration rate. Here, 3-cm length 5-Fr polyethylene stents unflaged on the pancreatic ductal side were used. The optimal stent type has not been established, but these ones appear to be suitable, as the spontaneous dislodgement rate was 95.7 % after 3 days.

References

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