Stenting the pancreatic duct

For more than 25 years endoscopists have expanded the use of tubes and stents to bypass strictures and stenotic lesions in the gastrointestinal tract in order to alleviate burdensome obstructive symptoms such as dysphagia, gastric outlet obstruction, obstructive jaundice and colorectal obstruction. Lessons learnt from experience with bile-duct stenting have inspired the use of stenting of the pancreatic duct in an increasing number of conditions characterized by pain caused by impaired flow of pancreatic juice to the duodenum or leakage of pancreatic juice in the case of ductal disruption. After the initial courageous experimental therapy carried out in a few centres, pancreatic endotherapy (PE) has come of age and evidence-based treatment can now be offered to carefully selected patients. Because of the low number of patients and the high level of technical skill required, PE is best carried out in centres with multidisciplinary teams caring for these patients. In an editorial published in 2002, Schutz & Leung stated that ‘‘If removing bile duct stones is like riding a bicycle, then PE is equivalent to flying a fighter jet’’ [1]. Acute pancreatitis is the most common complication after endoscopic retrograde cholangiopancreatography (ERCP), and many studies have identified the risk factors for the development of post-ERCP pancreatitis, patient factors (age, Sphincter of Oddi dyskinesia, prior post-ERCP pancreatitis) and technical factors (number of contrast injections, minor papillary sphincterotomy, operator experience, failed attempts at pancreatic stent placement) [2 4]. PostERCP pancreatitis can be prevented by prophylactic administration of certain drugs such as gabexate mesilate, somatostatin and recombinant interleukin10 [3], but temporary stent placement across the main pancreatic-duct orifice [4 7] is a more costeffective method of prevention. In a meta-analysis of controlled trials involving 481 patients the nonstented group had a 3-fold higher risk of developing pancreatitis than the group with prophylactic stent insertion [6]. Small-calibre plastic stents (3 4 FG) are effective and there is less need for endoscopic removal than with 5 6 FG stents [7]. A similar type of protective stenting is reported in patients undergoing endoscopic snare excision of the ampulla of Vater [8]. The ampulla of Vater is the site that is prone to severe dysplastic polyps in the familial adenomatous polyposis (FAP) syndrome, and endoscopic ampulectomy is now offered to young FAP patients in many centres. In patients with idiopathic recurrent pancreatitis and hereditary pancreatitis stenting, the main pancreatic duct prevents recurrent attacks, but long-term outcomes are still not known [9,10]. Furthermore, patients with pancreas divisum and recurrent pancreatitis have had positive outcomes of insertion of stents across the minor papilla in a randomized, controlled study [11]. Pancreatic ductal disruption may be successfully healed after stenting of the main pancreatic duct, especially when the disruption is incomplete and when the stent bridges the disruption [12,13]. Blunt abdominal trauma may be complicated by pancreatic ductal disruption, a serious condition which is difficult to demonstrate by computed tomography (CT) or magnetic resonance imaging (MRI). Early ERCP may detect ductal injury, and stenting the pancreatic duct may promote healing [14]. On the assumption that ductal hypertension caused by obstructive lesions of the main pancreatic duct may contribute to the pain often encountered in benign as well as malignant pancreatic disorders, stent insertion beyond the obstruction to decompress the hypertension has gained a place in the therapeutic armamentarium of centres managing