Multiple stents are not superior to single stent insertion for pain relief in patients with chronic pancreatitis: a retrospective comparative study

Abstract

Background and study aims Patients with painful chronic pancreatitis (CP) and distal main pancreatic duct (MPD) stricture are considered candidates for treatment using a single plastic stent insertion. Multiple side-by-side stents have been proposed as an alternative treatment but comparative studies are lacking. The aim of this retrospective study is to assess differences in characteristics and treatment outcomes in patients with CP and MPD strictures treated with a different number of stents during the stenting period.

Patients and methods Patients with painful CP and distal MPD obstruction requiring endoscopic treatment (01.2004 – 12.2012) were considered. The study population was divided in three groups: Patients treated with (A) exclusively one stent; (B) one or two stents; and (C) exclusively two stents during the stenting period. Patient characteristics and treatment outcomes were retrospectively assessed.

Results Among 284 patients, 85 were selected according to inclusion criteria (Group A: 18, Group B: 35, Group C: 32). Median follow-up duration was 84 months. The median number of endoscopic procedures needed was higher for group B [3 (A) vs. 3 (C) vs. 4 (B), P = 0.001]. Regarding outcome, successful endoscopic treatment was lower in Group C (50 % vs. 88.2 % and 74.2 % for groups A and B, respectively; P = 0.02). This difference was attributed to better clinical outcome in Group A compared to Group C patients [OR(95%CI): 7.50 (1.46 – 38.70); P = 0.04]. Moreover, group C patients experienced higher levels of pain at the end of follow-up period [median Izbicki Score 0 (group A) vs. 0 (group B) vs. 6 (group C), P = 0.03].

Conclusions In patients with painful CP and distal MPD obstruction, treatment with a single stent is associated with better clinical outcome compared to treatment with exclusively two stents during the stenting period.

• References

• 1 Mitchell RM, Byrne MF, Baillie J. Pancreatitis. Lancet 2003; 361: 1447-1455
• 2 Delhaye Μ, Matos C, Deviere J. Endoscopic technique for the management of pancreatitis and its complications. Best Practice & Research Clinical Gastroenterology 2004; 18: 165-173
• 3 Dumonceau JM, Delhaye M, Tringali A. et al. Endoscopic treatment of chronic pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline-Updated August 2018. Endoscopy 2019; 51: 179-193
• 4 Costamagna G, Bulajic M, Tringali A. et al. Multiple stenting of refractory pancreatic duct strictures in severe chronic pancreatitis: long-term results. Endoscopy 2006; 38: 254-259
• 5 Löhr JM, Dominguez-Munoz E, Rosendahl J. et al. United European Gastroenterology evidence-based guidelines for the diagnosis and therapy of chronic pancreatitis (HaPanEU). United European Gastroenterol J 2018; 18: 146-160
• 6 Bloechle C, Izbicki JR, Knoefel WT. et al. Quality of life in chronic pancreatitis--results after duodenum-preserving resection of the head of the pancreas. Pancreas 1995; 11: 77-85
• 7 Delhaye M, Matos C, Devière J. Endoscopic management of chronic pancreatitis. Gastrointest Endosc Clin N Am 2003; 13: 717-742
• 8 Binmoeller KF, Jue P, Seifert H. et al. Endoscopic pancreatic stent drainage in chronic pancreatitis and a dominant stricture: long-term results. Endoscopy 1995; 27: 638-644
• 9 Eleftheriadis N, Dinu F, Delhaye M. et al. Long-term outcome after pancreatic stenting in severe chronic pancreatitis. Endoscopy 2005; 37: 223-230
• 10 Weber A, Schneider J, Neu B. et al. Endoscopic stent therapy for patients with chronic pancreatitis: results from a prospective follow-up study. Pancreas 2007; 34: 287-294
• 11 Vitale GC, Cothron K, Vitale EA. et al. Role of pancreatic duct stentingin the treatment of chronic pancreatitis. Surg Endosc 2004; 18: 1431-1434
• 12 Cremer M, Devière J, Delhaye M. et al. Stenting in severe chronic pancreatitis: results of medium-term follow-up in seventy-six patients. Endoscopy 1991; 23: 171-176
• 13 Rösch T, Daniel S, Scholz M. et al. Endoscopic treatment of chronic pancreatitis: a multicenter study of 1000 patients with long-term follow-up. Endoscopy 2002; 34: 765-771
• 14 Bove V, Tringali A, Valerii G. et al. Endoscopic dilation of pancreatic duct strictures in chronic pancreatitis with multiple plastic stents: results in 48 patients. Gastrointest Endosc 2017; 85: AB236 (Suppl.)
• 15 Sherman S, Hawes R, Savides T. et al. Stent induced pancreatic ductal and parenchymal changes: correlation of endoscopic ultrasound with ERCP. Gastrointest Endosc 1996; 44: 276-282
• 16 Alvarez C, Robert M, Sherman S. et al. Histologic changes after stenting of the pancreatic duct. Arch Surg 1994; 129: 765-768
• 17 Devière J. Why do pancreatic stents become occluded?. Gastrointest Endosc 2005; 61: 867-868
• 18 Shen Y, Liu M, Chen M. et al. Covered metal stent or multiple plastic stents for refractory pancreatic ductal strictures in chronic pancreatitis: a systematic review. Pancreatology 2014; 14: 87-90
• 19 Giacino C, Grandval P, Laugier R. Fully covered self-expanding metal stents for refractory pancreatic duct strictures in chronic pancreatitis. Endoscopy 2012; 44: 874-877
• 20 Matsubara S, Sasahira N, Isayama H. et al. Prospective pilot study of fully covered self-expandable metal stents for refractory benign pancreatic duct strictures: long-term outcomes. Endoscopy International Open 2016; 4: E1215-E1222
• 21 Oh D, Lee JH, Song TJ. et al. Long-term outcomes of 6-mm diameter fully covered self-expandable metal stents in benign refractory pancreatic ductal stricture. Digestive Endoscopy 2018; 30: 508-515
• 22 Tringali A, Vadalà di Prampero SF. et al. Fully covered self-expandable metal stents to dilate persistent pancreatic strictures in chronic pancreatitis: long-term follow-up from a prospective study. Gastrointest Endosc 2018; 88: 939-946