Prophylactic pancreatic stents to prevent ERCP-induced pancreatitis: When do you use them?
- Stuart Sherman, MD
Stuart Sherman, MD
- Professor of Medicine and Radiology
- Indiana University School of Medicine
- Glen Lehman Professor of Gastroenterology
- Director Of ERCP Services
- Clinical Director, Division of Gastroenterology and Hepatology
Endoscopic placement of polyethylene stents is a well-established therapy for treating a variety of benign and malignant biliary tract diseases. Application of similar techniques in the pancreas is emerging. Pancreatic duct stents have been placed to bridge dominant strictures, bypass obstructing pancreatic duct stones, drain pseudocysts, seal duct disruptions, treat symptomatic minor (ie, pancreas divisum) and/or major (ie, sphincter of Oddi dysfunction) sphincter stenosis, prevent procedure-induced pancreatitis, serve as a guide for sphincterotomy, and facilitate bile duct cannulation (table 1).
This topic review will focus on the indications and efficacy of placing a pancreatic stent to prevent post-ERCP pancreatitis. An overview of pancreatic stenting and its complications is provided separately. (See "Overview of pancreatic stenting and its complications".)
RISK FACTORS FOR POST-ERCP PANCREATITIS
Pancreatitis is the most common complication of diagnostic and therapeutic ERCP occurring in 1 to 15 percent of patients. (See "Endoscopic retrograde cholangiopancreatography: Indications, patient preparation, and complications".)
The pancreas is subjected to many types of potential injury during ERCP and endoscopic sphincterotomy: mechanical, chemical, hydrostatic, enzymatic, microbiological, allergic, and thermal . These mechanisms of injury may act independently or in concert to induce post-procedure pancreatitis. Several patient and procedure-related risk factors for post-ERCP pancreatitis have been found, which are described separately. (See "Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis".)
Recognition of risk factors associated with post-ERCP pancreatitis provided the rationale for evaluating a number of measures for preventing post-ERCP pancreatitis. A possible approach is to use prophylactic pancreatic stents.
- Sherman S. ERCP and endoscopic sphincterotomy-induced pancreatitis. Am J Gastroenterol 1994; 89:303.
- Fazel A, Quadri A, Catalano MF, et al. Does a pancreatic duct stent prevent post-ERCP pancreatitis? A prospective randomized study. Gastrointest Endosc 2003; 57:291.
- Smithline A, Silverman W, Rogers D, et al. Effect of prophylactic main pancreatic duct stenting on the incidence of biliary endoscopic sphincterotomy-induced pancreatitis in high-risk patients. Gastrointest Endosc 1993; 39:652.
- Tarnasky PR, Palesch YY, Cunningham JT, et al. Pancreatic stenting prevents pancreatitis after biliary sphincterotomy in patients with sphincter of Oddi dysfunction. Gastroenterology 1998; 115:1518.
- Harewood GC, Pochron NL, Gostout CJ. Prospective, randomized, controlled trial of prophylactic pancreatic stent placement for endoscopic snare excision of the duodenal ampulla. Gastrointest Endosc 2005; 62:367.
- Sofuni A, Maguchi H, Itoi T, et al. Prophylaxis of post-endoscopic retrograde cholangiopancreatography pancreatitis by an endoscopic pancreatic spontaneous dislodgement stent. Clin Gastroenterol Hepatol 2007; 5:1339.
- Singh P, Das A, Isenberg G, et al. Does prophylactic pancreatic stent placement reduce the risk of post-ERCP acute pancreatitis? A meta-analysis of controlled trials. Gastrointest Endosc 2004; 60:544.
- Sofuni A, Maguchi H, Mukai T, et al. Endoscopic pancreatic duct stents reduce the incidence of post-endoscopic retrograde cholangiopancreatography pancreatitis in high-risk patients. Clin Gastroenterol Hepatol 2011; 9:851.
- Brackbill S, Young S, Schoenfeld P, Elta G. A survey of physician practices on prophylactic pancreatic stents. Gastrointest Endosc 2006; 64:45.
- Freeman ML. Pancreatic stents for prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis. Clin Gastroenterol Hepatol 2007; 5:1354.
- Choudhary A, Bechtold ML, Arif M, et al. Pancreatic stents for prophylaxis against post-ERCP pancreatitis: a meta-analysis and systematic review. Gastrointest Endosc 2011; 73:275.
- Mazaki T, Mado K, Masuda H, Shiono M. Prophylactic pancreatic stent placement and post-ERCP pancreatitis: an updated meta-analysis. J Gastroenterol 2014; 49:343.
- Fan JH, Qian JB, Wang YM, et al. Updated meta-analysis of pancreatic stent placement in preventing post-endoscopic retrograde cholangiopancreatography pancreatitis. World J Gastroenterol 2015; 21:7577.
- Dumonceau JM, Andriulli A, Elmunzer BJ, et al. Prophylaxis of post-ERCP pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - updated June 2014. Endoscopy 2014; 46:799.
- Das A, Singh P, Sivak MV Jr, Chak A. Pancreatic-stent placement for prevention of post-ERCP pancreatitis: a cost-effectiveness analysis. Gastrointest Endosc 2007; 65:960.
- Lee TH, Moon JH, Choi HJ, et al. Prophylactic temporary 3F pancreatic duct stent to prevent post-ERCP pancreatitis in patients with a difficult biliary cannulation: a multicenter, prospective, randomized study. Gastrointest Endosc 2012; 76:578.
- Fogel EL, Eversman D, Jamidar P, et al. Sphincter of Oddi dysfunction: pancreaticobiliary sphincterotomy with pancreatic stent placement has a lower rate of pancreatitis than biliary sphincterotomy alone. Endoscopy 2002; 34:280.
- Saad AM, Fogel EL, McHenry L, et al. Pancreatic duct stent placement prevents post-ERCP pancreatitis in patients with suspected sphincter of Oddi dysfunction but normal manometry results. Gastrointest Endosc 2008; 67:255.
- Cha SW, Leung WD, Lehman GA, et al. Does leaving a main pancreatic duct stent in place reduce the incidence of precut biliary sphincterotomy-associated pancreatitis? A randomized, prospective study. Gastrointest Endosc 2013; 77:209.
- Elton E, Howell DA, Parsons WG, et al. Endoscopic pancreatic sphincterotomy: indications, outcome, and a safe stentless technique. Gastrointest Endosc 1998; 47:240.
- Sherman S, Lehman GA. Endoscopic pancreatic sphincterotomy: techniques and complications. Gastrointest Endosc Clin N Am 1998; 8:115.
- Aizawa T, Ueno N. Stent placement in the pancreatic duct prevents pancreatitis after endoscopic sphincter dilation for removal of bile duct stones. Gastrointest Endosc 2001; 54:209.
- Goldberg E, Titus M, Haluszka O, Darwin P. Pancreatic-duct stent placement facilitates difficult common bile duct cannulation. Gastrointest Endosc 2005; 62:592.
- Zolotarevsky E, Fehmi SM, Anderson MA, et al. Prophylactic 5-Fr pancreatic duct stents are superior to 3-Fr stents: a randomized controlled trial. Endoscopy 2011; 43:325.
- Pahk A, Rigaux J, Poreddy V, et al. Prophylactic pancreatic stents: does size matter? A comparison of 4-Fr and 5-Fr stents in reference to post-ERCP pancreatitis and migration rate. Dig Dis Sci 2011; 56:3058.
- Afghani E, Akshintala VS, Khashab MA, et al. 5-Fr vs. 3-Fr pancreatic stents for the prevention of post-ERCP pancreatitis in high-risk patients: a systematic review and network meta-analysis. Endoscopy 2014; 46:573.
- Fujisawa T, Kagawa K, Ochiai K, et al. Prophylactic Efficacy of 3- or 5-cm Pancreatic Stents for Preventing Post-ERCP Pancreatitis: A Prospective, Randomized Trial. J Clin Gastroenterol 2016; 50:e30.
- Smith MT, Sherman S, Ikenberry SO, et al. Alterations in pancreatic ductal morphology following polyethylene pancreatic stent therapy. Gastrointest Endosc 1996; 44:268.
- Sherman S, Hawes RH, Savides TJ, et al. Stent-induced pancreatic ductal and parenchymal changes: correlation of endoscopic ultrasound with ERCP. Gastrointest Endosc 1996; 44:276.
- Derfus GA, Geenen JE, Hogan WJ. Effect of endoscopic pancreatic duct stent placement on pancreatic ductal morphology (abstract). Gastrointest Endosc 1990; 36:206A.
- Kozarek RA. Pancreatic stents can induce ductal changes consistent with chronic pancreatitis. Gastrointest Endosc 1990; 36:93.
- Rossos PG, Kortan P, Haber GB. Complications associated with pancreatic duct stenting (abstract). Gastrointest Endosc 1992; 38:252A.
- Burdick JS, Geenen JE, Venue RP, et al. Ductal morphological changes due to pancreatic stent therapy: A randomized controlled study (abstract). Am J Gastroenterol 1992; 87:155A.
- Lehman GA, Sherman S, Nisi R, Hawes RH. Pancreas divisum: results of minor papilla sphincterotomy. Gastrointest Endosc 1993; 39:1.
- Eisen G, Coleman S, Troughton A, Cotton PB. Morphological changes in the pancreatic duct after stent placement for benign pancreatic disease (abstract). Gastrointest Endosc 1994; 40:107A.
- Lawrence C, Cotton PB, Romagnuolo J, et al. Small prophylactic pancreatic duct stents: an assessment of spontaneous passage and stent-induced ductal abnormalities. Endoscopy 2007; 39:1082.
- Freeman ML, Overby C, Qi D. Pancreatic stent insertion: consequences of failure and results of a modified technique to maximize success. Gastrointest Endosc 2004; 59:8.
- Choksi NS, Fogel EL, Cote GA, 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; 81:150.
- Kerdsirichairat T, Attam R, Arain M, et al. Urgent ERCP with pancreatic stent placement or replacement for salvage of post-ERCP pancreatitis. Endoscopy 2014; 46:1085.
- Rashdan A, Fogel EL, McHenry L Jr, et al. Improved stent characteristics for prophylaxis of post-ERCP pancreatitis. Clin Gastroenterol Hepatol 2004; 2:322.
- RISK FACTORS FOR POST-ERCP PANCREATITIS
- PROPHYLACTIC STENTING
- After excessive manipulations of the papilla
- Sphincter of Oddi dysfunction or a small bile duct
- Precut sphincterotomy
- Pancreatic sphincterotomy
- Balloon sphincter dilation
- Snare excision of the duodenal ampulla
- Routine prophylactic pancreatic duct stenting
- Facilitating bile duct cannulation
- WHICH PANCREATIC STENT TO USE
- COMPLICATIONS OF PANCREATIC STENTS
- SUMMARY AND RECOMMENDATIONS