Endoscopic Stenting for Pancreatic Diseases

Joseph Leung, MD., FRCP., FACP., MACG., FASGE., Joseph Leung, MD., FRCP., FACP., MACG., FASGE., FHKCP., FHKAMFHKCP., FHKAM

Chief, Section of Gastroenterology,Chief, Section of Gastroenterology,VA Northern California Health Care System,VA Northern California Health Care System,Mr. & Mrs. C.W. Law Professor of Medicine,Mr. & Mrs. C.W. Law Professor of Medicine,

University of California, Davis Medical CenterUniversity of California, Davis Medical Center

Pancreatic Stents ShapeShape

– Geenen - curve, multiple Geenen - curve, multiple side holes/distal flapsside holes/distal flaps

– Sherman - straight, Sherman - straight, multiple side holes, multiple side holes, proximal flap/distal pigtailproximal flap/distal pigtail

– Modified Cotton-Leung Modified Cotton-Leung stent – S-shaped with stent – S-shaped with distal flapdistal flap

Size 3,5,7 or 10 Fr Size 3,5,7 or 10 Fr Length 3,5,7,9,12 cmLength 3,5,7,9,12 cm

Pancreatic Stents – Design and Application Pancreatic Stents – Design and Application

Common IndicationsCommon Indications Acute pancreatitisAcute pancreatitis

– Drainage to prevent post Drainage to prevent post ERCP pancreatitisERCP pancreatitis

– Assist endoscopic therapyAssist endoscopic therapy PapillotomyPapillotomy LeaksLeaks

MalignancyMalignancy– Drainage to relief painDrainage to relief pain

Chronic pancreatitisChronic pancreatitis– Adjuvant therapy for stone Adjuvant therapy for stone

and stricture and stricture

Optimal design of stentsOptimal design of stents Size (small)Size (small) Material (soft)Material (soft)

– Less irritation to ductal Less irritation to ductal epitheliumepithelium

Migrate out spontaneouslyMigrate out spontaneously

Technique of Pancreatic Stent PlacementTechnique of Pancreatic Stent Placement

Deep cannulation Deep cannulation with guide wire with guide wire across papilla or across papilla or stricturestricture

++ Pancreatic Pancreatic papillotomypapillotomy

Stent inserted over Stent inserted over wire and positioned wire and positioned with pusherwith pusher

Pancreatic Stenting using Pancreatic Stenting using Mechanical SimulatorMechanical Simulator

Stenting with Fusion Stenting with Fusion systemsystem

External wire lock External wire lock anchors guide anchors guide wire allowing wire allowing minimal exchange minimal exchange over guide wireover guide wire

Stent deployment Stent deployment is easily is easily coordinated coordinated

Post-ERCP PancreatitisPost-ERCP Pancreatitis

IncidenceIncidence Most common Most common

complication of ERCPcomplication of ERCP Incidence 5-10%, 1% Incidence 5-10%, 1%

severe, 0.1% fatalsevere, 0.1% fatal Significant medical/ Significant medical/

social/economic and social/economic and liability problemliability problem

Possible causesPossible causes Acinarization – overfillingAcinarization – overfilling Hyperosmolarity / Hyperosmolarity /

contrast allergy contrast allergy Trauma – guide wireTrauma – guide wire Coagulation injuryCoagulation injury Impaired drainage from Impaired drainage from

pancreas pancreas Bacterial contaminationBacterial contamination Bile contaminationBile contamination

Mechanism of Post ERCP PancreatitisMechanism of Post ERCP Pancreatitis

Papillary manipulation results in edema and Papillary manipulation results in edema and sphincter spasm obstructing PD flow, leading to sphincter spasm obstructing PD flow, leading to intracellular activation of enzymesintracellular activation of enzymes

Improving drainage with PD stent may prevent Improving drainage with PD stent may prevent post ERCP pancreatitispost ERCP pancreatitis

PD Stenting Prevents PEP in SOD PtsPD Stenting Prevents PEP in SOD Pts

80 Pts with pancreatic SOD after biliary EST 80 Pts with pancreatic SOD after biliary EST were randomized to PD stent or no stent were randomized to PD stent or no stent

Post ERCP pancreatitis occurred in Post ERCP pancreatitis occurred in – 10/39 (26%) with “No stent” 10/39 (26%) with “No stent” – 1/41 (2.4%) with “Stent” 1/41 (2.4%) with “Stent”

2 Pts (7%) developed PEP after stent removal2 Pts (7%) developed PEP after stent removal

Tarnasky Gastroenterol 1998

PD Stenting for High Risk Patients

76 high-risk pts: SOM or difficult cannulation 76 high-risk pts: SOM or difficult cannulation ++ EST were randomized EST were randomized

Post ERCP pancreatitis occurred in Post ERCP pancreatitis occurred in – 10/36 (28%) with 10/36 (28%) with “No stent” “No stent” (5 mild, 2 moderate, 3 (5 mild, 2 moderate, 3

severe)severe)– 2/38 (5%) with 2/38 (5%) with “Stent”“Stent” (mild pancreatitis) (mild pancreatitis)

PD cannulation failed in 2/40 pts (5%)PD cannulation failed in 2/40 pts (5%)

Fazel GIE 2003

Is PD Stent Necessary for Every ERCP?Is PD Stent Necessary for Every ERCP?

Probably NOTProbably NOT Increased time and difficultyIncreased time and difficulty Increased riskIncreased risk Increased costIncreased cost Risk of ductal changes from stent irritationRisk of ductal changes from stent irritation Need follow–up to insure stent migrationNeed follow–up to insure stent migration May need 2May need 2ndnd procedure for stent removal procedure for stent removal

Who Will Benefit from PD Stenting?

Patient FactorsPatient Factors Suspected SODSuspected SOD Young femaleYoung female Prior post-ERCP Prior post-ERCP

pancreatitispancreatitis Normal serum bilirubinNormal serum bilirubin

Technical FactorsTechnical Factors Difficult cannulationDifficult cannulation Pre-cut sphincterotomyPre-cut sphincterotomy

Pancreatic sphincterotomyPancreatic sphincterotomy AmpullectomyAmpullectomy Balloon sphincteroplastyBalloon sphincteroplasty

Potential Risks of Pancreatic Stenting

RisksRisks Failed stent placementFailed stent placement Proximal tip of stent Proximal tip of stent

damages PDdamages PD Stent occlusion causing Stent occlusion causing

pancreatitispancreatitis Chronic ductal changesChronic ductal changes Inward stent migrationInward stent migration

DilemmaDilemma To consider PD stent To consider PD stent

placement in a “high-risk” placement in a “high-risk” patient is a serious patient is a serious decisiondecision

If successful, risk of PEP If successful, risk of PEP is reduced. is reduced.

However, failed attempt However, failed attempt INCREASES the risksINCREASES the risks

Outcome of Failed PD Stenting

225 high-risk therapeutic ERCP’s225 high-risk therapeutic ERCP’s PEP 32/222 (14%) with successful PD stentsPEP 32/222 (14%) with successful PD stents PEP in 2/3 (67%) with failed PD stent insertionPEP in 2/3 (67%) with failed PD stent insertion Severe pancreatitis occurred only in failed stentsSevere pancreatitis occurred only in failed stents Multivariate analysis: failed stent RR 16, SOD RR Multivariate analysis: failed stent RR 16, SOD RR

3.2, prior PEP RR 3.23.2, prior PEP RR 3.2 Not significant: EST, NK precut, # PD injections Not significant: EST, NK precut, # PD injections

or difficult cannulationor difficult cannulation

Freeman GIE 2004

Balloon Sphincteroplasty & Double StentsBalloon Sphincteroplasty & Double Stents

Double wiresDouble wires Balloon Balloon

sphincteroplastysphincteroplasty Double stents for Double stents for

drainagedrainage PD stent for PD stent for

prophylactic prophylactic drainagedrainage

Assisted Precut Biliary SphincterotomyAssisted Precut Biliary Sphincterotomy

PD stent protects PD stent protects pancreas pancreas

Needle knife Needle knife precut along precut along biliary axisbiliary axis

Pancreas DivisumPancreas DivisumMinor Papillotomy with PD StentingMinor Papillotomy with PD Stenting

Chronic Pancreatitis - Stone & Stricture

EndoTherapy for Chronic Pancreatitis

Less invasive than surgery Results comparable to

surgery Surgery is still possible

after failed endotherapy ? Predicts outcome after

surgery

Dilation/Stenting of Pancreatic Stricture

Guide wire (hydrophilic) Guide wire (hydrophilic) across stricture across stricture

DilatorsDilators– Graded dilators Graded dilators – Pneumatic balloons (4-6 mm) Pneumatic balloons (4-6 mm)

Short-term pancreatic stenting Short-term pancreatic stenting to insure drainage to insure drainage

Dilation of Tight PD Stricture with Soehendra Stent Retriever

Dilation of Pancreatic Stricture via Minor Papilla

Basket Stone Extraction

Pancreatic Stone Extraction

Pancreatic sphincterotomy Pancreatic sphincterotomy .035” guide wire.035” guide wire Dilation of orifice/stricture Dilation of orifice/stricture Stone extraction with wire Stone extraction with wire

basket (e.g. 22Q)basket (e.g. 22Q) ? Mechanical lithotripsy? Mechanical lithotripsy

– limitations limitations

PD stent for drainage PD stent for drainage ESWL to fragment large ESWL to fragment large

(calcified) stone (calcified) stone

Endoscopic Stenting for Chronic PancreatitisEndoscopic Stenting for Chronic PancreatitisInitial Technical SuccessInitial Technical Success

NN StentStent Succ CompSucc Comp ImprovImprov SurgSurg Mean Mean F/UF/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 monthsStent ex-change mean 2-6 months

Complications included pancreatitis (15), cholangitis (3), bleeding (3), Complications included pancreatitis (15), cholangitis (3), bleeding (3), pain (4), fever (3), infection (8) and abscess (2)pain (4), fever (3), infection (8) and abscess (2)

Endoscopic Stenting for Chronic PancreatitisEndoscopic Stenting for Chronic PancreatitisOutcome after Stent RemovalOutcome after Stent Removal

AuthorAuthor ContinuousContinuous Mean F/UMean F/U StrictureStrictureimprovementimprovement (month) (month) resolvedresolved

Cremer Cremer (91)(91) 7/64 (11%)7/64 (11%) 2525 11%11%

Ponchon Ponchon (95)(95) 12/21 (57%)12/21 (57%) 1414 38%38%

Smits Smits (95)(95) 23/33 (70%)23/33 (70%) 2929 20%20%

BinmoellerBinmoeller (95)(95) 41/69 (59%)41/69 (59%) 3333 NDND

TotalTotal 83/187(44%)83/187(44%) 25.325.3 23%23%

ESWL for Pancreatic Stone

Courtesy of Dr. N Reddy

Management of Pancreatic Stones

405405

29 primary extraction29 primary extraction 20 stenting20 stenting

356 (88%)356 (88%)

Complete Complete clearanceclearance178 (50%)178 (50%)

Partial Partial clearanceclearance135 (38%)135 (38%)

Failure 43 Failure 43 (12%)(12%)

ESWL + Endotherapy

Reddy DN, Rao GV, Trop Gastroenterol 2001Reddy DN, Rao GV, Trop Gastroenterol 2001

Management of Pancreatic Stones

CompleteComplete 178178 170170

PartialPartial 135135 102102

NoneNone 4343 00

272/356 (76%)272/356 (76%)

ESWL + Endotherapy

MPD Painclearance relief

Reddy DN, Rao GV, Trop Gastroenterol 2001Reddy DN, Rao GV, Trop Gastroenterol 2001

Summary

Successful pancreatic stenting and drainage Successful pancreatic stenting and drainage prevents post ERCP pancreatitisprevents post ERCP pancreatitis

Pancreatic stenting is a useful adjunct for assisted Pancreatic stenting is a useful adjunct for assisted papillotomypapillotomy

Pancreatic stenting provides drainage in patients Pancreatic stenting provides drainage in patients undergoing ESWL for stone obstructionundergoing ESWL for stone obstruction

Stenting helps to improve stricture post dilation Stenting helps to improve stricture post dilation and provides short term pancreatic drainageand provides short term pancreatic drainage