Percutaneous Placement of Metal Stents in the Main Pancreatic Duct

Abstract

In clinical practice, percutaneous catheter drainage of pancreatic pseudocysts is a well-established, minimally invasive technique. Access is gained by an extragastric or transgastric approach under cross-sectional imaging guidance. In the transgastric approach, internal pseudocyst and gastric drainage can be performed with a short, plastic, double-pigtail stent that is left in place for several months to prevent pseudocyst recurrence and make the patient more comfortable. Although similar techniques are applicable, percutaneous access to the pancreatic ducts is only rarely performed, and catheterization is almost exclusively carried out by an endoscopic approach. Therapeutic endoscopic techniques are largely facilitated by pancreatic duct sphincterotomy, which was ABSTRACT Catheterization of the pancreatic ducts is almost exclusively carried out by an endoscopic approach. Percutaneous pancreatic duct stenting is advocated as a last resort, when endoscopy has failed. The main indication for pancreatic duct stenting is a primary or intermediate treatment of pain, related to chronic pancreatitis and a therapeutic test prior to major surgery. A solitary or dominant ductal stricture, located in the head of the pancreas, represents the best indication. Other indications are intractable pain in pancreatic cancer, with dilated ducts or a postoperative anastomotic stenosis. A prerequisite for percutaneous puncture of the main pancreatic duct, with CT guidance, is a minimal diameter of 3 to 5 mm. The access route is predominantly anterior and transgastric. Stents with a diameter of 5 to 6 mm and a length of 2 to 4 cm are placed. Only a few case reports of the percutaneous stenting technique are available. The endoscopic literature reported an immediate pain relief in 94% and a long term benefit in 64% of the cases with chronic pancreatitis. The main drawback of placement of metal stents in the pancreatic duct is clogging, which is not significantly improved compared to the use of plastic stents.Objectives: On completion of this article, the reader should understand the various uses of metallic stents in several pancreatic diseases. Accreditation: Tufts University School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. Tufts University School of Medicine takes full responsibility for the content, quality, and scientific integrity of this continuing education activity. Credit: Tufts University School of Medicine designates this education activity for a maximum of 1.0 hour credit toward the AMA Physicians Recognition Award in category one. Each physician should claim only those hours that he/she actually spent in the educational activity.