Small-caliber rescue pancreatic stenting for severe post-ERCP pancreatitis: a useful tool to pull the pancreas out of the fire

We read with great interest the recent article from the Freeman group by Kerdsirichairat et al. [1]. Pancreatitis is the most common complication of endoscopic retrograde cholangiopancreatography (ERCP), which can be severe or even life threatening in about 10 % of cases [2]. Prophylactic pancreatic stent (PPS) placement is effective in the prevention of post-ERCP pancreatitis (PEP), as demonstrated by several randomized controlled trials and meta-analyses, including the most recent one [3].

It is a generally accepted theory that mechanical or thermal trauma during ERCP can cause papillary edema obstructing the pancreatic duct, which could lead to a rise in intraductal pressure and early intrapancreatic enzyme activation resulting in PEP. PPS placement can prevent PEP by maintaining the outflow of the pancreatic juice. In the early course of severe PEP, marked papillary and duodenal edema is often observed. Rescue ERCP and PPS placement can be effective as a treatment option in these cases.

The basic idea and technique of such a rescue ERCP with small-caliber pancreatic stenting was first published by our group in 2009 [4]. We performed rescue ERCP within 8 – 20 hours after the initial ERCP in the early course of clinically severe PEP. Moderate to severe papillary edema was observed, and a small-caliber PPS was successfully placed in every patient, resulting in prompt relief of abdominal pain and symptoms; all patients recovered quickly without any short- or long-term complications.

In the recent article, the authors reported the data from five patients who were similar to those in our published series, with convincing results for PPS placement. More interestingly, they successfully treated nine patients who developed PEP despite PPS placement at the initial ERCP. PEP was considered to have been caused by premature PPS dislodgement or stent obstruction. This observation also strengthens the proposed mechanism of rescue ERCP and PPS placement. Two of the nine patients had obstructed PPSs, one caused by blood and the other by purulent material from concurrent cholangitis. The other seven patients with PEP had early stent dislodgement. Premature stent dislodgement before 24 hours may result in PEP. In the recent article, four patients were initially stented with unflanged PPSs. The onset of PEP was 0 – 22 hours after initial ERCP, except for one patient who astonishingly developed PEP after 68 hours. Spontaneous stent dislodgement of unflanged stents occurs in 95 % of all cases within 2 days without any consequences [5]. This latter patient had a history of recurrent acute pancreatitis, and therefore we strongly suspect that this patient had another attack of acute pancreatitis rather than a complication of premature stent dislodgement, although the therapy for this attack was brilliant with the “double barrel” method described.

The remaining five patients with initial stenting received PPSs with inner flanges. The two patients with PPS obstruction were among them. As these stents were originally designed to prevent unwanted dislodgement, it would be very interesting to know whether the other three patients had any risk factors (e. g. post-papillotomy bleeding, pancreatic sphincterotomy or dilated pancreatic duct) that could explain the premature stent dislodgement.

The concept of rescue or salvage ERCP with PPS placement and the initial results are very promising, so we would also urge a randomized trial on this topic. As a relatively low case number would be expected, international multicenter collaboration would be ideal.

Finally, attempted but unsuccessful PPS placement dramatically increases the risk of PEP, to up to 66 %. Therefore, we must emphasize that failure of rescue or salvage ERCP and PPS placement in patients who are already at a risk for further progression of an ongoing PEP might be extremely dangerous in the hands of inexperienced endoscopists [6].

• References

• 1 Kerdsirichairat T, Attam R, Arain M et al. Urgent ERCP with pancreatic stent placement or replacement for salvage of post-ERCP pancreatitis. Endoscopy 2014; 46: 1085-1094
• 2 Dumonceau JM, Andriulli A, Deviere J et al. European Society of Gastrointestinal Endoscopy (ESGE) guideline: prophylaxis of post-ERCP pancreatitis. Endoscopy 2010; 42: 503-515
• 3 Mazaki T, Mado K, Masuda H et al. Prophylactic pancreatic stent placement and post-ERCP pancreatitis: an updated meta-analysis. J Gastroenterol 2014; 49: 343-355
• 4 Madácsy L, Kurucsai G, Joó I et al. Rescue ERCP and insertion of a small-caliber pancreatic stent to prevent the evolution of severe post-ERCP pancreatitis: a case-controlled series. Surg Endosc 2009; 23: 1887-1893
• 5 Sofuni A, Maguchi H, Itoi T et al. Prophylaxis of post-endoscopic retrograde cholangiopancreatography pancreatitis by an endoscopic pancreatic spontaneous dislodgement stent. Clin Gastroenterol Hepatol 2007; 5: 1339-1346
• 6 Freeman ML, Overby C, Qi D. Pancreatic stent insertion: consequences of failure and results of a modified technique to maximize success. Gastrointest Endosc 2004; 59: 8-14