Prospective pilot study of fully covered self-expandable metal stents for refractory benign pancreatic duct strictures: long-term outcomes

Abstract

Background and study aims: Temporary placement of a fully covered self-expandable metal stent (FCSEMS) has recently emerged as a treatment option for pancreatic duct strictures due to chronic pancreatitis refractory to conventional plastic stenting. However, there are no data about long-term outcomes with this therapeutic option. The aims of the current study were to estimate the feasibility, safety, efficacy, and long-term outcomes of temporary FCSEMS placement for refractory pancreatic duct strictures. Patients and methods: This was a prospective, single-center feasibility study. Ten patients with refractory pancreatic duct strictures due to chronic pancreatitis underwent FCSEMS placement for 3 months. We evaluated the rate of recurrent symptoms after stent removal during long-term follow-up, as well as adverse events (AEs). Results: Two patients required early (within 1 week) stent removal because of intolerable pain or pancreatitis. In the remaining 8 patients, the recurrence rate of any symptoms after FCSEMS removal was 63% during 35 months of follow up. The causes of recurrent symptoms were as follows: recurrence of stricture in 2; stent-induced stricture in 1; impaction of pancreatic stones in 1; and development of a pseudocyst in 1. When limited to stricture, the recurrence rate was 38%. Additional endoscopic treatments were required in 4 patients: a second FCSEMS placement in 1; plastic stent (PS) placement in 1; stone extraction in 1; and endoscopic ultrasound?guided pseudocyst drainage in 1. Asymptomatic stent migration occurred in 2 patients. Suppurative pancreatic ductitis due to food impaction in the FCSEMS occurred in 2 patients, and endoscopic pancreatic duct drainage was performed. Stent-induced ductal changes developed in 2 patients and PS treatment was required in 1 patient for pain relief. Conclusion: The FCSEMS appears to be a feasible and potentially effective option for the management of refractory pancreatic duct strictures due to chronic pancreatitis during long-term follow-up. AEs including post-procedure pain, stent-induced ductal changes, migration, and ductitis are issues that need to be resolved.

Endoscopic ultrasound-guided pancreatic duct drainage

“…The use of covered metal stents has been investigated in ERCP approach. [2627] While its large diameter appears to have an advantage of better stricture resolution, a covered metal stent placed in the pancreatic duct can potentially occlude side branches of the pancreatic duct and tissue hyperplasia at the proximal stent end is a concern. Therefore, long-term outcomes should be further evaluated to justify the routine use of covered mental stents in EUS-PD.…”

Management of Benign and Malignant Pancreatic Duct Strictures

“…Patients in whom conventional ERCP endoscopic therapy for benign strictures fails should be offered EUS-PD as a safe, minimally invasive, and effective alternative to surgery, according to the availability of endoscopic expertise. Patients with malignant pancreatic strictures might benefit from palliation provided by the decompression of the pancreatic ductal obstruction, for which both plastic stents ( Table 1 ) and metal stents ( Table 2 ) have been used [ 10 , 15 , 16 , 32 - 43 ]. However, more data and longer follow up periods are needed to establish the superiority of one type of stent over the other.…”

Treatment of Chronic Obstructive Pancreatitis

“…The stent chosen should be just long enough to bridge the stricture in order to occlude as few side branches as possible. Multiple small case series have demonstrated excellent technical success for placement and removal of these stents [40][41][42][43][44]. However, adverse events including severe pain, cholestasis, stent migration, and the formation of new upstream pancreatic strictures…”