Prophylactic pancreatic stent placement and post-ERCP pancreatitis: a systematic review and meta-analysis

Background and study aims: Pancreatitis is one of the most frequent complications of endoscopic retrograde cholangiopancreatography (ERCP). The placement of a prophylactic pancreatic stent after ERCP can help prevent post-ERCP pancreatitis (PEP). We aimed to provide an up-to-date meta-analysis regarding pancreatic stent placement for prevention of PEP and review the immediate adverse events associated with pancreatic stent placement.

Methods: We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) considering pancreatic stent placement and the subsequent incidence of PEP. The primary outcome measure was the incidence of PEP.

We also did a meta-analysis of RCTs and observational studies that reported on immediate adverse events, in order to estimate their incidence.

Results: Eight studies, involving 680 patients, were included in the meta-analysis; 336 patients had pancreatic stent placement, and 344 patients formed the control group. Pancreatic stent placement was associated with a statistically significant reduction in PEP (relative risk [RR] 0.32, 95 % confidence interval [CI] 0.19 – 0.52; P < 0.001). Subgroup analysis with stratification according to PEP severity showed that pancreatic stenting was beneficial in patients with mild to moderate PEP (RR 0.36, 95 %CI 0.22 – 0.60; P < 0.001) and in patients with severe PEP (RR 0.23, 95 %CI 0.06 – 0.91; P = 0.04). Subgroup analysis according to patient selection demonstrated that pancreatic stenting was effective for both high risk and mixed-case groups. Weighted pooled estimates from between one and 17 studies for incidences of immediate adverse events were: overall complications 4.4 %; any infection 3.0 %; bleeding 2.5 %; cholangitis or cholecystitis 3.1 %; necrosis 0.4 %; pancreatic stent migration 4.9 % and occlusion 7.9 %; perforation 0.8 %; pseudocysts 3.0 %; and retroperitoneal perforation 1.2 %.

Conclusions: The meta-analysis shows that pancreatic stent placement after ERCP reduces the risk of PEP.

References

• 1 Cotton P B, Garrow D A, Gallagher J. et al . Risk factors for complications after ERCP: a multivariate analysis of 11,497 procedures over 12 years.  Gastrointest Endosc. 2009;  70 80-88
• 2 Loperfido S, Angelini G, Benedetti G. et al . Major early complications from diagnostic and therapeutic ERCP: a prospective multicenter study.  Gastrointest Endosc. 1998;  48 1-10
• 3 Masci E, Toti G, Mariani A. et al . Complications of diagnostic and therapeutic ERCP: a prospective multicenter study.  Am J Gastroenterol. 2001;  96 417-423
• 4 Mehta S N, Pavone E, Barkun J S. et al . Predictors of post-ERCP complications in patients with suspected choledocholithiasis.  Endoscopy. 1998;  30 457-463
• 5 Vandervoort J, Soetikno R M, Tham T C. et al . Risk factors for complications after performance of ERCP.  Gastrointest Endosc. 2002;  56 652-656
• 6 Fogel E L, Eversman D, Jamidar P. et al . Sphincter of Oddi dysfunction: pancreaticobiliary sphincterotomy with pancreatic stent placement has a lower rate of pancreatitis than biliary sphincterotomy alone.  Endoscopy. 2002;  34 280-285
• 7 Pezzilli R, Romboli E, Campana D. et al . Mechanisms involved in the onset of post-ERCP pancreatitis.  JOP. 2002;  3 162-168
• 8 Freeman M L, Guda N M. Prevention of post-ERCP pancreatitis: a comprehensive review.  Gastrointest Endosc. 2004;  59 845-864
• 9 Bai Y, Gao J, Zhang W. et al . Meta-analysis: allopurinol in the prevention of postendoscopic retrograde cholangiopancreatography pancreatitis.  Aliment Pharmacol Ther. 2008;  28 557-564
• 10 Zheng M, Bai J, Yuan B. et al . Meta-analysis of prophylactic corticosteroid use in post-ERCP pancreatitis.  BMC Gastroenterol. 2008;  8 6
• 11 Andriulli A, Leandro G, Federici T. et al . Prophylactic administration of somatostatin or gabexate does not prevent pancreatitis after ERCP: an updated meta-analysis.  Gastrointest Endosc. 2007;  65 624-632
• 12 Choi C W, Kang D H, Kim G H. et al . Nafamostat mesylate in the prevention of post-ERCP pancreatitis and risk factors for post-ERCP pancreatitis.  Gastrointest Endosc. 2009;  69 e11-18
• 13 Zhang Y, Chen Q B, Gao Z Y. et al . Meta-analysis: octreotide prevents post-ERCP pancreatitis, but only at sufficient doses.  Aliment Pharmacol Ther. 2009;  29 1155-1164
• 14 Rudin D, Kiss A, Wetz R V. et al . Somatostatin and gabexate for post-endoscopic retrograde cholangiopancreatography pancreatitis prevention: meta-analysis of randomized placebo-controlled studies.  J Gastroenterol Hepatol. 2007;  22 977-983
• 15 Elmunzer B J, Waljee A K, Elta G H. et al . A meta-analysis of rectal NSAIDs in the prevention of post-ERCP pancreatitis.  Gut. 2008;  57 1262-1267
• 16 Fazel A, Quadri A, Catalano M F. et al . Does a pancreatic duct stent prevent post-ERCP pancreatitis? A prospective randomized study.  Gastrointest Endosc. 2003;  57 291-294
• 17 Harewood G C, Pochron N L, Gostout C J. Prospective, randomized, controlled study of prophylactic pancreatic stent placement for endoscopic snare excision of the duodenal ampulla.  Gastrointest Endosc. 2005;  62 367-370
• 18 Patel R, Tarnasky P R, Hennessy W S. et al . Does stenting after pancreatic sphincterotomy reduce post-ERCP pancreatitis in patients with prior biliary sphincterotomy? Preliminary results of a prospective randomized study [abstract].  Gastrointest Endosc. 1999;  49 AB80
• 19 Sherman S, Blaut U, Watkins J L. et al . Does prophylactic administration of corticosteroid reduce the risk and severity of post-ERCP pancreatitis: a randomized, prospective, multicenter study [abstract].  Gastrointest Endosc. 1996;  43 413
• 20 Smithline A, Silverman W, Rogers D. et al . Effect of prophylactic main pancreatic duct stenting on the incidence of biliary endoscopic sphincterotomy-induced pancreatitis in high-risk patients.  Gastrointest Endosc. 1993;  39 652-657
• 21 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
• 22 Tarnasky P R, Palesch Y Y, Cunningham J T. et al . Pancreatic stenting prevents pancreatitis after biliary sphincterotomy in patients with sphincter of Oddi dysfunction.  Gastroenterology. 1998;  115 1518-1524
• 23 Tsuchiya T, Itoi T, Sofuni A. et al . Temporary pancreatic stent to prevent post endoscopic retrograde cholangiopancreatography pancreatitis: a preliminary, single-center, randomized controlled study.  J Hepatobiliary Pancreat Surg. 2007;  14 302-307
• 24 Andriulli A, Forlano R, Napolitano G. et al . Pancreatic duct stents in the prophylaxis of pancreatic damage after endoscopic retrograde cholangiopancreatography: a systematic analysis of benefits and associated risks.  Digestion. 2007;  75 156-163
• 25 Masci E, Mariani A, Curioni S. et al . Risk factors for pancreatitis following endoscopic retrograde cholangiopancreatography: a meta-analysis.  Endoscopy. 2003;  35 830-834
• 26 Singh P, Das A, Isenberg G. et al . Does prophylactic pancreatic stent placement reduce the risk of post-ERCP acute pancreatitis? A meta-analysis of controlled studies.  Gastrointest Endosc. 2004;  60 544-550
• 27 Cotton P B, Lehman G, Vennes J. et al . Endoscopic sphincterotomy complications and their management: an attempt at consensus.  Gastrointest Endosc. 1991;  37 383-393
• 28 Mazaki T, Ebisawa K. Enteral versus parenteral nutrition after gastrointestinal surgery: a systematic review and meta-analysis of randomized controlled studies in the English literature.  J Gastrointest Surg. 2008;  12 739-755
• 29 Egger M, Davey S mith, Altman D G, eds. Systematic reviews in health care: meta-analysis in context. 2nd edn. London; BMJ Books 2001
• 30 Sutton A J. Methods for meta-analysis in medical research. West Sussex; John Wiley & Sons Ltd 2002
• 31 DerSimonian R, Laird N. Meta-analysis in clinical studies.  Controlled Clin Trials. 1986;  7 177-188
• 32 Higgins J P, Thompson S G, Deeks J J. et al . Measuring inconsistency in meta-analyses.  BMJ. 2003;  327 557-560
• 33 Ioannidis J P, Trikalinos T A. The appropriateness of asymmetry tests for publication bias in meta-analyses: a large survey.  CMAJ. 2007;  176 1091-1096
• 34 Cremer M, Deviere 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
• 35 Rossos P G, Kortan P, Haber G B. Complications associated with pancreatic duct stenting.  Gastrointest Endosc. 1992;  38 252
• 36 Johanson J F, Schmalz M J, Geenen J E. Simple modification of a pancreatic duct stent to prevent proximal migration.  Gastrointest Endosc. 1993;  39 62-64
• 37 Cohen S A, Kasmin F E, Siegel J H. Alterations of pancreatic stents.  Gastrointest Endosc. 1994;  40 256-257
• 38 Ashby K, Lo S K. The role of pancreatic stenting in obstructive ductal disorders other than pancreas divisum.  Gastrointest Endosc. 1995;  42 306-311
• 39 Esber E, Sherman S, Earle D. et al . Complications of minor papilla endoscopic pancreatic sphincterotomy. A review of 236 patients.  Gastrointest Endosc. 1996;  43 405
• 40 Soltani S, Lo S K. How safe is endoscopic pancreatic sphincterotomy?.  Gastrointest Endosc. 1996;  43 413
• 41 Aizawa T, Ueno N. Stent placement in the pancreatic duct prevents pancreatitis after endoscopic sphincter dilation for removal of bile duct stones.  Gastrointest Endosc. 2001;  54 209-213
• 42 Fogel E L, Eversman D, Jamidar P. et al . Sphincter of Oddi dysfunction: pancreaticobiliary sphincterotomy with pancreatic stent placement has a lower rate of pancreatitis than biliary sphincterotomy alone.  Endoscopy. 2002;  34 280-285
• 43 Catalano M F, Linder J D, Chak A. et al . Endoscopic management of adenoma of the major duodenal papilla.  Gastrointest Endosc. 2004;  59 225-232
• 44 Freeman M L, 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
• 45 Rashdan A, Fogel E L, McHenry L. et al . Improved stent characteristics for prophylaxis of post-ERCP pancreatitis.  Clin Gastroenterol Hepatol. 2004;  2 322-329
• 46 Ito K, Fujita N, Noda Y. et al . Efficacy and safety of prophylactic pancreatic duct stent (Pit-stent) placement in patients at high-risk of post-ERCP pancreatitis.  Gut. 2005;  54 Suppl VII A149-0
• 47 Fejes R, Kurucsai G, Szekely A. et al . Feasibility and safety of emergency ERCP and small-caliber pancreatic stenting as a bridging procedure in patients with acute biliary pancreatitis but difficult sphincterotomy.  Surg Endosc. 2010;  24 1878-1885
• 48 Chahal P, Tarnasky P R, Petersen B T. et al . Short 5Fr vs long 3Fr pancreatic stents in patients at risk for post-endoscopic retrograde cholangiopancreatography pancreatitis.  Clin Gastroenterol Hepatol. 2009;  7 834-839
• 49 Das A, Singh P, Sivak M V. et al . Pancreatic-stent placement for prevention of post-ERCP pancreatitis: a cost-effectiveness analysis.  Gastrointest Endosc. 2007;  65 960-968
• 50 Freeman M L. Pancreatic stents for prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis.  Clin Gastroenterol Hepatol. 2007;  5 1354-1365
• 51 Cennamo V, Fuccio L, Zagari R M. et al . Can a wire-guided cannulation technique increase bile duct cannulation rate and prevent post-ERCP pancreatitis? A meta-analysis of randomized controlled studies.  Am J Gastroenterol. 2009;  104 2343-2350
• 52 Cheung J, Tsoi K K, Quan W L. et al . Guidewire versus conventional contrast cannulation of the common bile duct for the prevention of post-ERCP pancreatitis: a systematic review and meta-analysis.  Gastrointest Endosc. 2009;  70 1211-1219
• 53 Shao L M, Chen Q Y, Chen M Y. et al . Can wire-guided cannulation reduce the risk of post-endoscopic retrograde cholangiopancreatography pancreatitis? A meta-analysis of randomized controlled trials.  J Gastroenterol Hepatol. 2009;  24 1710-1715
• 54 Moher D, Pham B, Jones A. et al . Does quality of reports of randomised studies affect estimates of intervention efficacy reported in meta-analyses?.  Lancet. 1998;  352 609-613
• 55 Jüni P, Witschi A, Bloch R. et al . The hazards of scoring the quality of clinical studies for meta-analysis.  JAMA. 1999;  282 1054-1060
• 56 Schulz K F, Chalmers I, Hayes R J. et al . Empirical evidence of bias. Dimensions of methodological quality associated with estimates of treatment effects in controlled studies.  JAMA. 1995;  273 408-412
• 57 Bakmen Y G, Safdar K, Freeman M L. Significant clinical implication of prophylactic pancreatic stent placement in previously normal pancreatic ducts.  Endoscopy. 2009;  41 1095-1098
• 58 Price L H, Brandabur J J, Kozarek R A. et al . Good stents gone bad: endoscopic treatment of proximally migrated pancreatic duct stents.  Gastrointest Endosc. 2009;  70 174-179