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Endoscopic Stenting for Pancreatic Diseases

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.

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Endoscopic Stenting for Pancreatic Diseases

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  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 • 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. 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 Optimal design of stents Size (small) Material (soft) Less irritation to ductal epithelium Migrate out spontaneously Pancreatic Stents – Design and Application

  4. Deep cannulation with guide wire across papilla or stricture + Pancreatic papillotomy Stent inserted over wire and positioned with pusher Technique of Pancreatic Stent Placement

  5. Stenting with Fusion system External wire lock anchors guide wire allowing minimal exchange over guide wire Stent deployment is easily coordinated Pancreatic Stenting using Mechanical Simulator

  6. 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 Post-ERCP Pancreatitis

  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. 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 Who Will Benefit from PD Stenting?

  12. Risks 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 Potential Risks of Pancreatic Stenting

  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. Double wires Balloon sphincteroplasty Double stents for drainage PD stent for prophylactic drainage Balloon Sphincteroplasty & Double Stents

  15. PD stent protects pancreas Needle knife precut along biliary axis Assisted Precut Biliary Sphincterotomy

  16. Pancreas DivisumMinor 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. Guide wire (hydrophilic) across stricture Dilators Graded dilators Pneumatic balloons (4-6 mm) Short-term pancreatic stenting to insure drainage Dilation/Stenting of Pancreatic Stricture

  20. Dilation of Tight PD Stricture with Soehendra Stent Retriever

  21. Dilation of Pancreatic Stricture via Minor Papilla

  22. Basket Stone Extraction

  23. 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 Pancreatic Stone Extraction

  24. Endoscopic Stenting for Chronic PancreatitisInitial Technical Success N Stent Succ Comp Improv Surg Mean F/U (Fr) (%) (%) (%) (n) (months) Cremer (91) 76 10 99 16 94 11 37 Ponchon (95) 23 10 100 43 91 3 12 Smits (95) 51 5,7 96 22 82 4 34 Binmoeller (95) 93 5,7,10 100 6 74 24 3-12 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 PancreatitisOutcome after Stent Removal Author Continuous Mean F/U Stricture improvement (month) resolved Cremer (91) 7/64 (11%) 25 11% Ponchon (95) 12/21 (57%) 14 38% Smits (95) 23/33 (70%) 29 20% Binmoeller (95) 41/69 (59%) 33 ND Total 83/187(44%) 25.3 23%

  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%) Partial clearance135 (38%) Complete clearance178 (50%) Failure 43 (12%) Reddy DN, Rao GV, Trop Gastroenterol 2001

  28. Management of Pancreatic Stones ESWL + Endotherapy MPD Painclearance relief Complete 178 170 Partial 135 102 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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