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Endoscopic Stenting for Pancreatic Diseases

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Presentation on theme: "Endoscopic Stenting for Pancreatic Diseases"— 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 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

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