Endoscopic biliary sphincterotomy and small-caliber pancreatic stenting versus sphincterotomy alone in patients with acute gallstone pancreatitis – A prospective nonrandomized study

Introduction: Patients (pts) with acute biliary pancreatitis (ABP) may benefit from early endoscopic sphincterotomy (EST) and pancreatic ductal decompression. The aim of the present pilot study was to assess the feasibility and safety of emergency ERCP and pancreatic duct (PD) stenting with small-caliber stents in ABP patients (pts) after biliary EST.

Methods: 88 consecutive non-alcoholic pts with ABP (gallbladder stones or dilated CBD or CBD stones and concomitant early elevations (>1.5N) of obstructive LFTs) were referred for emergency ERCP. In 60 of these ABP pts, ERCP, EST and stone extraction were performed without PD stenting. In the remaining 28 pts, small-caliber (4–5 F, 4cm, Geenen) pancreatic stent insertion was applied after biliary EST. All pts were hospitalized for medical therapy with best supportive care and were followed up.

Results: The mean ages, the initial symptom to ERCP times, the Ranson scores, and the peak amylase and CRP levels at initial presentation were not significantly different in the ERCP+EST with PD stent group vs. ERCP+EST without PD stent group: 59+15 vs. 65+15 years; 22+24 vs. 28+20h; 3,0+1,2 vs. 3,1+1,2; 1617+1198U/l vs. 1300+1145U/l; and 114+92 vs. 125+123U/l, respectively. More importantly, the complication rate was significantly lower in the EST with PD stent group vs. the EST without PD stent group (7.1% vs. 25%); while the mortality rates (0% vs. 6.7%) were comparable and reasonably low. Removal of the PD stents was successfully done a week after the resolution of the ABP in all pts.

Conclusions: Temporary PD stenting with small-caliber stents after biliary EST is a feasible procedure that may improve PD decompression to reverse the process of ABP, and not only serve as a bridging procedure in severe ABP pts with failed or contraindicated biliary EST, but also may improve the overall outcome after successful EST and gallstone extraction. Prospective, randomized, controlled trials are awaited to support this innovative approach.