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Endoscopic Stenting for Pancreatic Diseases Joseph Leung, MD., FRCP., FACP., MACG., FASGE., FHKCP., FHKAM Chief, Section of Gastroenterology, VA Northern.

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Presentation on theme: "Endoscopic Stenting for Pancreatic Diseases Joseph Leung, MD., FRCP., FACP., MACG., FASGE., FHKCP., FHKAM Chief, Section of Gastroenterology, VA Northern."— Presentation transcript:

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 –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 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 Optimal design of stents  Size (small)  Material (soft) –Less irritation to ductal epithelium  Migrate out spontaneously

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 2 nd 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 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

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 NStentSucc CompImprovSurgMean F/U (Fr)(%)(%)(%)(n)(months) Cremer (91) Ponchon(95) Smits (95)515, Binmoeller (95)935,7, 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 AuthorContinuousMean F/UStricture improvement(month) resolved Cremer (91)7/64 (11%)2511% Ponchon (95)12/21 (57%)1438% Smits (95)23/33 (70%)2920% Binmoeller(95)41/69 (59%)33ND Total83/187(44%)25.323%

26 ESWL for Pancreatic Stone Courtesy of Dr. N Reddy

27 Management of Pancreatic Stones primary extraction 20 stenting 356 (88%) Complete clearance 178 (50%) Partial clearance 135 (38%) Failure 43 (12%) ESWL + Endotherapy Reddy DN, Rao GV, Trop Gastroenterol 2001

28 Management of Pancreatic Stones Complete Partial None /356 (76%) ESWL + Endotherapy MPD Pain clearancerelief 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


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