Stenting bei chronischer Pankreatitis - Fehler und Limitationen

Abstract

Endoscopic treatment of chronic pancreatitis using pancreatic duct stents was first described 15 years ago. Considering our own experience and the data of the literature we describe indications, contraindications, risks and limitations of the procedure and on the other hand its therapeutic effects. According to the actual experience an indication for pancreatic duct stenting can be seen in patients with a solitary prepapillary stenosis without stenosis of side branches or as success control for a planned surgical intervention. Contraindications are suspected malignancy, multiple pancreatic duct stenosis in the main duct or stenosis in small ducts and chronic calcifying pancreatitis with pancreatic duct stones. From 6/92 until 5/97 189 patients were operated for chronic pancreatitis in the Ulm University Hospital. Of these patients 35 (18.7%) were unsuccessfully treated preoperatively in other hospitals by pancreatic duct stent. Because of frequent complications like stent dislocation and stent occlusion repeated ERCPs (4.5/patient) and stent exchanges (3.7/patient) were performed. A therapeutical long-term benefit of pancreatic duct stenting is questionable, a definitive therapy can only be achieved in a small group of patients. However stent-induced changes of the pancreatic duct similar to chronic pancreatitis can be observed in up to 80% of all patients. Long-term observations of the reversibility of these stent-induced changes are missing, persisting chronic pancreatitis in the stented region is reported in animal models and in humans. The rates in the literature for stent dislocation and stent occlusion rate are 10-18% and 39-100% respectively. Induction of acute pancreatitis (up to 10%), duodenal reflux into the pancreatic duct, and bacterial infection with abscess formation are further severe and frequent complications of pancreatic duct stenting (1, 2). Lethal courses are reported (3, 4). Endoscopic pancreatic duct stenting in chronic pancreatitis at present is not indicated because of low success rate and a substantial risk of complications.

Percutaneous Placement of Metal Stents in the Main Pancreatic Duct

“…Diffuse pancreatitis with multiple stenoses in the main duct and secondary ducts, chronic calcified pancreatitis with multiple ductal stones, and an elective stenosis in the tail of the pancreas are considered relative contraindications to stent placement. 10 A small number of associated intraductal stones can be extracted with a basket or balloon or electrohydraulically, or they can be fragmented by extracorporeal shock wave lithotripsy (ESWL) before the duct is stented. It is common practice to place 10F plastic stents after pancreatic sphincterotomy.…”

“…9 Plastic stent dislocation is reported in 5 to 18% of cases, but most patients remain asymptomatic. 10,28 Stents that have migrated upstream can be extracted endoscopically with a basket or a balloon. 29 Stent occlusion occurs in 39 to 100% of cases, and episodes of acute pancreatitis in 10%.…”

“…29 Stent occlusion occurs in 39 to 100% of cases, and episodes of acute pancreatitis in 10%. 10,28 Of major concern in pancreatic stenting are stent-induced changes of chronic pancreatitis, which are probably irreversible in 80% of patients. Even shortterm stenting of the pancreatic duct induced both ductal and parenchymal changes of chronic pancreatitis in more than half of patients.…”

Pancreatic duct stenting in chronic pancreatitis - controversies

“…In dieser Au s gabe der Zeitsch ri ft für Gast ro e n te ro l o g i e b e faßt sich eine ch i ru r g i s che Arbeitsgruppe mit der endos ko p i s chen Proth e s e nve rsorgung des Pa n k re a s ga n ges bei ch ro n i s cher Pa n k reatitis (12). In einer ret ro s p e k t i ven Analyse wurden aus einem Gesamtkollektiv von 189 Pa t i e nten, die einer Pa n k re a s o p e ration we gen ch ro n i s cher Pa nk reatitis unte rz o gen wurden, 35 Pa t i e n ten identifi z i e rt , die (in ve rs chiedenen zuweisenden Kliniken) erfo l glos end o s ko p i s ch mit Pa n k re a s ga n g p rothesen behandelt wurden.…”

Stenting the pancreatic duct

“…However, others have reported negative effects of pancreatic stenting on postoperative morbidity and complications [22 Á 24]. Several studies have reported that stenting the pancreatic duct per se may induce alterations in ductal morphology, changes similar to those occurring after chronic pancreatitis [25,22,19]. Morphologic changes induced by polyethylene stents placed in the main pancreatic duct were seen in 80% of the patients, and during a mean follow-up of 6 months one-third of these changes did not resolve [25].…”