Usefulness of an algorithm for endoscopic retrieval of proximally migrated 5Fr and 7Fr pancreatic stents

BACKGROUND:Proximal migration of pancreatic stent (PMPS)is an infrequent event but its management can be technically challenging and there are no standard retrieval methods.This study aimed to determine the results of an endoscopic stent retrieval algorithm in terms of feasibility and efficacy of the endoscopic procedure. METHODS:During the period from January 2008 to December 2009,15 patients(8 women and 7 men with a mean age of 51.9 years)with PMPS were included in this study.Stent retrieval was approached initially with balloon extraction followed by rat-tooth forceps and basket.A rescue approach such as using a stent retriever was attempted when other approaches failed. RESULTS:All the PMPSs(six 5Fr,nine 7Fr)were retrieved successfully within one ERCP session.Balloon extraction was successful in 9(60%)patients.In the 6 failed cases of balloon extraction,wire-guided rat-tooth forceps grasp was successful in 4,and stone extraction basket grasp was successful in 1 in whom forceps grasp failed.One stent was finally rescued with a stent retriever when balloon extraction,forceps and basket grasp all failed.In patients with successful balloon extraction,44.4% (4/9)developed post-ERCP hyperamylasemia but none of them developed post-procedure pancreatitis. CONCLUSIONS:With this algorithm,5Fr and 7Fr PMPS were successfully retrieved in all of the patients.Most PMPSs can be safely retrieved with the commonly-used approaches in this study.Those less used approaches can be used as a rescue method.

Endoscopic ultrasound-guided tissue sampling induced pancreatic duct leak resolved by the placement of a pancreatic stent:A case report

BACKGROUND Pancreatic ductal leaks complicated by endoscopic ultrasonography-guided tissue sampling(EUS-TS)can manifest as acute pancreatitis.CASE SUMMARY A 63-year-old man presented with persistent abdominal pain and weight loss.Diagnosis:Laboratory findings revealed elevated carbohydrate antigen 19-9(5920 U/mL)and carcinoembryonic antigen(23.7 ng/mL)levels.Magnetic resonance imaging of the pancreas revealed an approximately 3 cm ill-defined space-occupying lesion in the inferior aspect of the head,with severe encasement of the superior mesenteric artery.Pancreatic ductal adenocarcinoma was confirmed after pathological examination of specimens obtained by EUS-TS using the fanning method.Interventions and outcomes:The following day,the patient experienced severe abdominal pain with high amylase(265 U/L)and lipase(1173 U/L)levels.Computed tomography of the abdomen revealed edematous wall thickening of the second portion of the duodenum with adjacent fluid collections and a suspicious leak from either the distal common bile duct or the main pancreatic duct in the head.Endoscopic retrograde cholangiopancreatography revealed dye leakage in the head of the main pancreatic duct.Therefore,a 5F 7 cm linear plastic stent was deployed into the pancreatic duct to divert the pancreatic juice.The patient’s abdominal pain improved immediately after pancreatic stent insertion,and amylase and lipase levels normalized within a week.Neoadjuvant chemotherapy was then initiated.CONCLUSION Using the fanning method in EUS-TS can inadvertently cause damage to the pancreatic duct and may lead to clinically significant pancreatitis.Placing a pancreatic stent may immediately resolve acute pancreatitis and shorten the waiting time for curative therapy.When using the fanning method during EUSTS,ductal structures should be excluded to prevent pancreatic ductal leakage.

Stent A pancreaticojejunostomy after pancreatoduodenectomy:Is it always necessary?

The establishment of a postoperative pancreatic fistula(POPF)is considered the most common and,concomitantly,the most serious complication associated with pancreaticoduodenectomy(PD).The search for either technical modifications of the operative technique or pharmaceutical interventions that could possibly aid in decreasing the incidence of this often-devastating complication appears justified.The stenting of the pancreatic duct,with the use of either internal or external stents,has been evaluated in this direction.In theory,it is an approach that could eliminate many pathophysiological factors responsible for the occurrence of a POPF.The purpose of the present study was to review the current data regarding the role of pancreatic duct stenting on the incidence of POPF,after PD,by using PubMed and Reference Citation Analysis.In general,previous studies seem to highlight the superiority of external stents over their internal counterparts in regard to the incidence of POPF;this is at the cost,however,of increased morbidity associated mainly with the stent removal.Certainly,the use of an internal stent is a less invasive approach with acceptable results and is definitely deprived of the drawbacks arising through the complete diversion of pancreatic juice from the gastrointestinal tract.Bearing in mind the scarcity of high-quality data on the subject,an approach of reserving stent placement for the high-risk for POPF patients and individualizing the selection between the use of an internal or an external stent according to the distinct characteristics of each individual case scenario appears appropriate.

Traumatic pancreatic ductal injury treated by endoscopic stenting in a 9-year-old boy:A case report

BACKGROUND Traumatic pancreatic injury is relatively rare in children,accounting for approximately 3%-12%of blunt abdominal trauma cases.Most traumatic pancreatic injuries in boys are related to bicycle handlebars.Traumatic pancreatic injuries often result in delayed presentation and treatment,leading to high morbidity and mortality.The management of children with traumatic main pancreatic duct injuries is still under debate.CASE SUMMARY We report the case of a 9-year-old boy who was presented at our institution with epigastric pain after being stuck with his bicycle handlebar at the upper abdomen and then treated with endoscopic stenting because of a pancreatic ductal injury.CONCLUSION We believe that endoscopic stenting of pancreatic ductal injuries may be a feasible technique in certain cases of children with traumatic pancreatic duct injuries to avoid unnecessary operations.

Comment on “Updated meta-analysis of pancreatic stent placement in preventing post-endoscopic retrograde cholangiopancreatography pancreatitis”

I read with interest an article "Updated meta-analysis of pancreatic stent placement in preventing post-endoscopic retrograde cholangiopancreatography pancreatitis" by Fan and colleagues in World J Gastroenterol 2015;21(24): 7577-7583. Although I appreciate their work, I have found problems with the data extracted and analyzed by the authors, and will give my comment in this letter. It would be valuable if the authors could provide an accurate estimation of their extracted data.

Comparison of postoperative complications between internal and external pancreatic duct stenting during pancreaticoduodenectomy: a meta-analysis

Background：Two types of pancreatic duct stents are used to improve postoperative outcomes of pancreatic anastomosis.The aim of this meta-analysis was to evaluate and compare the postoperative outcomes of patients with internal or external stenting during pancreaticoduodenectomy（PD）.Methods：We searched Pub Med,EMBASE,the Cochrane Library and Web of Science databases until the end of December,2014.Studies comparing outcomes of external vs.internal stent placement in PD were eligible for inclusion.Included literature was extracted and assessed by two independent reviewers.Results：Seven articles were identified for inclusion：three randomized controlled trials（RCTs）and four observational clinical studies（OCS）.The meta-analyses revealed that use of external stents had advantage on reducing the incidences of pancreatic fistula（PF）in total[odds ratio（OR）=0.69;95%confidence interval（CI）,0.48-0.99;P=0.04],PF in soft pancreas（OR=0.30;95%CI,0.16-0.56;P=0.0002）and delayed gastric emptying（DGE）（OR=0.58;95%CI,0.38-0.89;P=0.01）compared with internal stents.There were no significant differences in other postoperative outcomes between two stenting methods,including postoperative morbidity（OR=0.93;95%CI,0.39-2.23;P=0.88）,overall mortality（OR=0.70;95%CI,0.22-2.25;P=0.55）,and intra-abdominal collections（OR=0.67;95%CI,0.26-1.71;P=0.40）.Conclusions：Based upon this meta-analysis,the use of external pancreatic stents might have potential benefit in reducing the incidence of PF and DGE.Due to the limited number of original studies,more RCTs are needed to further support our result and clarify the issue.

Endoscopic ultrasound-guided pancreaticogastrostomy for symptomatic pancreatic duct obstruction caused by migrated pancreatic stent

Endoscopic pancreatic stenting has been widely used in various pancreatic conditions. With the increasing use of pancreatic stents, many complications have been recognized. Especially, proximal stent migration presents a serious condition because of subsequent pancreatic duct obstruction, impaired drainage, ductal dilation, and pancreatic pain. Although endoscopic retrieval is the preferred treatment for proximally migrated pancreatic stents, it is not always successful, resulting in conversion to surgery. To date, endoscopic ultrasound-guided pancreatic duct drainage(EUS-PD) has never been reported for treatment of pancreatic duct obstruction caused by proximally migrated pancreatic stent. We herein describe a case of pancreatic duct rupture and obstruction caused by proximally migrated pancreatic stent that was successfully treated by EUS-guided pancreaticogastrostomy while keeping the former stent in situ after failed endoscopic retrograde cholangiopancreatography. We believe that this report adds to the increasing evidence of symptomatic pancreatic duct obstruction being successfully treated by EUS-PD.

Long-term follow-up of endoscopic papillectomy and the value of preventive pancreatic stent placement(with videos)

Background:Early-stage ampullary adenomas have only been reported in a small case series on endoscopic management.Hence,this study aimed to evaluate the long-term outcomes of early ampullary adenoma with endoscopic management and identify the risk factors for acute pancreatitis after endoscopic papillectomy(EP).Methods:In this study,115 patients who underwent EP at Changhai Hospital(Shanghai,China)between January 2012 and December 2018 were retrospectively analysed.Endoscopy was performed at 1,3,6,and 12months after EP.Data were statistically analysed using the t-test or the Mann–Whitney U test.Results:A total of 107 patients were included in this study and the follow-up period was 75643 months.The average age of the 107 patients was 54.6 years and the average tumor size was 17mm.The average age of the patients(53.7610.7 years vs 55.2610.5 years,P=0.482),minimum tumor size(13 vs 19mm,P=0.063),and complete resection rate(84.78%vs 85.25%,P=0.947)did not differ significantly between the stent placement and non-stent placement groups.Post-EP acute pancreatitis rates in the non-stent placement and stent placement groups were 11.48%and 4.35%,respectively.The risk of post-EP acute pancreatitis was significantly associated with the preoperative carcinoembryonic antigen level in univariate analysis,but not in multivariate analysis.The risk of post-EP acute pancreatitis was not significantly associated with the placement of the pancreatic stent in either univariate or multivariate analysis.Moreover,delayed proximal pancreatic duct stenosis was not noted in either group during long-term follow-up.Conclusions:EP is a satisfactory option for treating adenomas of the ampulla of the duodenum.