Pancreatic stent placement for prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis: do we need further evidence? No, the defense rests

Abstract

Editorial 870The exact mechanisms that contribute to the development of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) have not been fully elucidated. However, several factors are known to promote PEP, the most important of which appears to be manipulations of the ampulla, which result in decreased outflow of secretions through the main pancreatic duct, either by inducing sphincter of Oddi spasm or by causing mechanical obstruction by edema formation. The latter concept is supported by data suggesting that a patent minor papilla in the absence of pancreas divisum is protective against PEP [1], presumably because pancreatic drainage can be sustained in the face of relative obstruction at the level of the major papilla. Thus, the idea of placing a temporary pancreatic duct stent to prevent PEP is supported by its role in maintaining the integrity of pancreatic outflow. The concept that stent placement in the pancreatic duct may reduce the risk of PEP was introduced in the early 1990s [2], and the first randomized trial to demonstrate its efficacy was shown by Tarnasky et al. [3] in patients with known or suspected sphincter of Oddi dysfunction (SOD), a group deemed to be at especially high risk for PEP due to increased pancreatic duct sphincter hypertension. Since that time a number of studies have shown that pancreatic duct stents are effective in preventing PEP, not only in patients with SOD but also in a subset of individuals found to be at high risk for PEP due to one of the following technical risk factors: difficult biliary cannulation, multiple pancreatic duct injections, precut sphincterotomy (particularly when the cut involves the papillary orifice), pancreatic duct sphincterotomy (both major and minor, the latter in the setting of pancreas divisum), pancreatic duct brush cytology, balloon dilation of the papilla for stone extraction (without biliary sphincterotomy), and endoscopic ampullectomy.Temporary pancreatic duct stent placement for prevention of PEP in high risk patients is recommended by ERCP experts and has been included as a grade A recommendation in a 2010 guideline for PEP prophylaxis by the European Society of Gastrointestinal Endoscopy [4]. Thus, it appears that the practice of pancreatic duct stent placement is now firmly accepted in the academic domain although there remains a discrepancy as it has yet to gain widespread acceptance in the community [5]. The question remains: do we still need more evidence? In this month's issue of Endoscopy, Mazaki et al. [6] publish the latest systematic review and meta-analysis of randomized controlled trials evaluating pancreatic duct stent placement vs. no stent placement for PEP prophylaxis. Eight studies were identified involving a total of 680 patients, 336 of whom had a pancreatic duct stent placed. The majority of patients were deemed to be at high risk although two studies enrolled patients who were not considered high risk by most criteria. Overall, 19 % in the no-stent group developed PEP compared with only 6 % in...

Role of immunosuppression in post-endoscopic retrograde cholangiopancreatography pancreatitis after liver transplantation: A retrospective analysis

“…Post–endoscopic retrograde cholangiopancreatography acute pancreatitis (PEP) remains the most common major adverse event after ERCP in patients with a native papilla. The inciting event in the development of PEP is likely ampullary manipulation, which results in a sphincter of Oddi spasm or ampullary edema, both of which can lead to decreased secretory outflow from the main pancreatic duct (PD) . Most endoscopists acknowledge a 5% to 10% rate of PEP in low‐risk populations, but an incidence as high as 30% has been reported for high‐risk populations .…”

Risk factors of post‐endoscopic retrograde cholangiopancreatography pancreatitis among living‐donor liver transplant recipients with biliary complications

“…The incidence of PEP among liver transplant patients ranges from 0% to 17.1%. 5,[8][9][10][16][17][18][19][20][21][22] Several risk factors that predispose to PEP were reported in the literature such as EST, presence of native papilla, use of mTORi, serum creatinine >2 mg/dl, pancreatic duct injections, and pre-ERCP cholangitis. 9,10,17,20 In contrast, there have been conflicting results in the protective effects of prednisolone use against PEP.…”

“…One of the most common procedure‐related adverse effects is PEP. The incidence of PEP among liver transplant patients ranges from 0% to 17.1% 5,8–10,16–22 . Several risk factors that predispose to PEP were reported in the literature such as EST, presence of native papilla, use of mTORi, serum creatinine >2 mg/dl, pancreatic duct injections, and pre‐ERCP cholangitis 9,10,17,20 .…”

Does removal of prophylactic pancreatic stents induce acute pancreatitis?

“…[2][3][4] In addition, the nature and diameter of the CBD orifice do not allow for passage of basket-entrapped bile duct stones, leading to a situation of difficult-to-treat CBD stones. At present, there does not seem to be a definitive method for extracting difficult-to-treat CBD stones.…”