Endoscopic Stenting for
Pancreatic Diseases
Joseph Leung, MD., FRCP., FACP., MACG., FASGE., FHKCP.,
FHKAM
Chief, Section of Gastroenterology,
VA Northern California Health Care System,
Mr. & Mrs. C.W. Law Professor of Medicine,
University of California, Davis Medical Center
Pancreatic Stents
 Shape
– Geenen - curve, multiple
side holes/distal flaps
– Sherman - straight,
multiple side holes,
proximal flap/distal pigtail
– Modified Cotton-Leung
stent – S-shaped with
distal flap
 Size 3,5,7 or 10 Fr
 Length 3,5,7,9,12 cm
Pancreatic Stents – Design and Application
Optimal design of stents
 Size (small)
 Material (soft)
– Less irritation to ductal
epithelium
 Migrate out spontaneously
Common Indications
 Acute pancreatitis
– Drainage to prevent post
ERCP pancreatitis
– Assist endoscopic therapy
 Papillotomy
 Leaks
 Malignancy
– Drainage to relief pain
 Chronic pancreatitis
– Adjuvant therapy for stone
and stricture
Technique of Pancreatic Stent Placement
 Deep cannulation
with guide wire
across papilla or
stricture
 + Pancreatic
papillotomy
 Stent inserted over
wire and positioned
with pusher
Pancreatic Stenting using
Mechanical Simulator
Stenting with Fusion
system
 External wire lock
anchors guide
wire allowing
minimal exchange
over guide wire
 Stent deployment
is easily
coordinated
Post-ERCP Pancreatitis
Incidence
 Most common
complication of ERCP
 Incidence 5-10%, 1%
severe, 0.1% fatal
 Significant medical/
social/economic and
liability problem
Possible causes
 Acinarization – overfilling
 Hyperosmolarity /
contrast allergy
 Trauma – guide wire
 Coagulation injury
 Impaired drainage from
pancreas
 Bacterial contamination
 Bile contamination
Mechanism of Post ERCP Pancreatitis
 Papillary manipulation results in edema and
sphincter spasm obstructing PD flow, leading to
intracellular activation of enzymes
 Improving drainage with PD stent may prevent
post ERCP pancreatitis
PD Stenting Prevents PEP in SOD Pts
 80 Pts with pancreatic SOD after biliary EST
were randomized to PD stent or no stent
 Post ERCP pancreatitis occurred in
– 10/39 (26%) with “No stent”
– 1/41 (2.4%) with “Stent”
 2 Pts (7%) developed PEP after stent removal
Tarnasky Gastroenterol 1998
PD Stenting for High Risk Patients
 76 high-risk pts: SOM or difficult cannulation +
EST were randomized
 Post ERCP pancreatitis occurred in
– 10/36 (28%) with “No stent” (5 mild, 2 moderate, 3
severe)
– 2/38 (5%) with “Stent” (mild pancreatitis)
 PD cannulation failed in 2/40 pts (5%)
Fazel GIE 2003
Is PD Stent Necessary for Every ERCP?
Probably NOT
 Increased time and difficulty
 Increased risk
 Increased cost
 Risk of ductal changes from stent irritation
 Need follow–up to insure stent migration
 May need 2nd procedure for stent removal
Who Will Benefit from PD Stenting?
Patient Factors
 Suspected SOD
 Young female
 Prior post-ERCP
pancreatitis
 Normal serum bilirubin
Technical Factors
 Difficult cannulation
 Pre-cut sphincterotomy
 Pancreatic sphincterotomy
 Ampullectomy
 Balloon sphincteroplasty
Potential Risks of Pancreatic Stenting
Risks
 Failed stent placement
 Proximal tip of stent
damages PD
 Stent occlusion causing
pancreatitis
 Chronic ductal changes
 Inward stent migration
Dilemma
 To consider PD stent
placement in a “high-risk”
patient is a serious
decision
 If successful, risk of PEP
is reduced.
 However, failed attempt
INCREASES the risks
Outcome of Failed PD Stenting
225 high-risk therapeutic ERCP’s
PEP 32/222 (14%) with successful PD stents
PEP in 2/3 (67%) with failed PD stent insertion
Severe pancreatitis occurred only in failed stents
Multivariate analysis: failed stent RR 16, SOD RR
3.2, prior PEP RR 3.2
 Not significant: EST, NK precut, # PD injections or
difficult cannulation





Freeman GIE 2004
Balloon Sphincteroplasty & Double Stents
 Double wires
 Balloon
sphincteroplasty
 Double stents for
drainage
 PD stent for
prophylactic
drainage
Assisted Precut Biliary Sphincterotomy
 PD stent protects
pancreas
 Needle knife
precut along
biliary axis
Pancreas Divisum
Minor Papillotomy with PD Stenting
Chronic Pancreatitis - Stone & Stricture
EndoTherapy for Chronic Pancreatitis
 Less invasive than surgery
 Results comparable to
surgery
 Surgery is still possible
after failed endotherapy
 ? Predicts outcome after
surgery
Dilation/Stenting of Pancreatic Stricture
 Guide wire (hydrophilic)
across stricture
 Dilators
– Graded dilators
– Pneumatic balloons (4-6 mm)
 Short-term pancreatic stenting
to insure drainage
Dilation of Tight PD Stricture with
Soehendra Stent Retriever
Dilation of Pancreatic Stricture
via Minor Papilla
Basket Stone Extraction
Pancreatic Stone Extraction




Pancreatic sphincterotomy
.035” guide wire
Dilation of orifice/stricture
Stone extraction with wire
basket (e.g. 22Q)
 ? Mechanical lithotripsy
– limitations
 PD stent for drainage
 ESWL to fragment large
(calcified) stone
Endoscopic Stenting for Chronic Pancreatitis
Initial Technical Success
Cremer
Ponchon
Smits
Binmoeller
(91)
(95)
(95)
(95)
N
Stent
Succ
Comp
Improv Surg
Mean F/U
76
23
51
93
(Fr)
10
10
5,7
5,7,10
(%)
99
100
96
100
(%)
16
43
22
6
(%)
94
91
82
74
(months)
37
12
34
3-12
(n)
11
3
4
24
Stent ex-change mean 2-6 months
Complications included pancreatitis (15), cholangitis (3), bleeding (3),
pain (4), fever (3), infection (8) and abscess (2)
Endoscopic Stenting for Chronic Pancreatitis
Outcome after Stent Removal
Author
Cremer
Ponchon
Smits
Binmoeller
Total
(91)
(95)
(95)
(95)
Continuous
improvement
Mean F/U
(month)
Stricture
resolved
7/64 (11%)
12/21 (57%)
23/33 (70%)
41/69 (59%)
25
14
29
33
11%
38%
20%
ND
83/187(44%)
25.3
23%
ESWL for Pancreatic Stone
Courtesy of Dr. N Reddy
Management of Pancreatic Stones
ESWL + Endotherapy
405
29 primary
extraction
20 stenting
356 (88%)
Complete
clearance
178 (50%)
Partial
clearance
135 (38%)
Failure 43
(12%)
Reddy DN, Rao GV, Trop Gastroenterol 2001
Management of Pancreatic Stones
ESWL + Endotherapy
MPD
clearance
Pain
relief
Complete
178
170
Partial
135
102
None
43
0
272/356 (76%)
Reddy DN, Rao GV, Trop Gastroenterol 2001
Summary
 Successful pancreatic stenting and drainage
prevents post ERCP pancreatitis
 Pancreatic stenting is a useful adjunct for assisted
papillotomy
 Pancreatic stenting provides drainage in patients
undergoing ESWL for stone obstruction
 Stenting helps to improve stricture post dilation
and provides short term pancreatic drainage