1. 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

2. Pancreatic Stents Shape Size 3,5,7 or 10 Fr Length 3,5,7,9,12 cm
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

3. 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

4. Technique of Pancreatic Stent Placement
Deep cannulation with guide wire across papilla or stricture
+ Pancreatic papillotomy
Stent inserted over wire and positioned with pusher

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. Potential Risks of Pancreatic Stenting
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

13. 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

14. Balloon Sphincteroplasty & Double Stents
Double wires
Balloon sphincteroplasty
Double stents for drainage
PD stent for prophylactic drainage

15. Assisted Precut Biliary Sphincterotomy
PD stent protects pancreas
Needle knife precut along biliary axis

16. Pancreas Divisum Minor Papillotomy with PD Stenting

17. Chronic Pancreatitis - Stone & Stricture

18. EndoTherapy for Chronic Pancreatitis
Less invasive than surgery
Results comparable to surgery
Surgery is still possible after failed endotherapy
? Predicts outcome after surgery

19. 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

20. Dilation of Tight PD Stricture with Soehendra Stent Retriever

21. Dilation of Pancreatic Stricture via Minor Papilla

22. Basket Stone Extraction

23. 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

24. Endoscopic Stenting for Chronic Pancreatitis Initial Technical Success
N Stent Succ Comp Improv Surg Mean F/U
(Fr) (%) (%) (%) (n) (months)
Cremer (91)
Ponchon (95)
Smits (95) 51 5,
Binmoeller (95) 93 5,7,
Stent ex-change mean 2-6 months
Complications included pancreatitis (15), cholangitis (3), bleeding (3), pain (4), fever (3), infection (8) and abscess (2)

25. Endoscopic Stenting for Chronic Pancreatitis Outcome after Stent Removal
Author Continuous Mean F/U Stricture improvement (month) resolved
Cremer (91) 7/64 (11%) %
Ponchon (95) 12/21 (57%) %
Smits (95) 23/33 (70%) %
Binmoeller (95) 41/69 (59%) 33 ND
Total 83/187(44%) %

26. ESWL for Pancreatic Stone
Courtesy of Dr. N Reddy

27. 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

28. Management of Pancreatic Stones
ESWL + Endotherapy
MPD Pain clearance relief
Complete
Partial
None 43 0
272/356 (76%)
Reddy DN, Rao GV, Trop Gastroenterol 2001

29. 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