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Benefit of Prophylactic Pancreatic Stent Placement During High-Risk ERCP: Technical Factors
abstract
This abstract is available on the publisher's site.
Access this abstract nowBACKGROUND
Prophylactic pancreatic stent placement (PSP) is effective for preventing pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP) in high-risk cases, but the optimal technical approach to this intervention remains uncertain.
METHODS
In this secondary analysis of 787 clinical trial participants who underwent successful stent placement, we studied the impact of: 1) whether pancreatic wire access was achieved for the sole purpose of PSP or naturally during the conduct of the case; 2) the amount of effort expended on PSP; 3) stent length; 4) stent diameter; and 5) guidewire caliber. We used logistic regression models to examine the adjusted association between each technical factor and post-ERCP pancreatitis (PEP).
RESULTS
Ninety-one of the 787 patients experienced PEP. There was no clear association between PEP and whether pancreatic wire access was achieved for the sole purpose of PSP (vs. occurring naturally; OR 0.82, 95%CI 0.37-1.84), whether substantial effort expended on stent placement (vs. non-substantial effort; OR 1.58, 95%CI 0.73-3.45), stent length (>5 cm vs. ≤5 cm; OR 1.01, 95%CI 0.63-1.61), stent diameter (≥5 Fr vs. <5 Fr; OR 1.13, 95%CI 0.65-1.96), or guidewire caliber (0.035 inch vs. 0.025 inch; 0.83, 95%CI 0.49-1.41).
CONCLUSIONS
The 5 modifiable technical factors studied in this secondary analysis of large-scale randomized trial data did not appear to have a strong impact on the benefit of prophylactic pancreatic stent placement in preventing PEP after high-risk ERCP. Within the limitations of post hoc subgroup analysis, these findings may have important implications in procedural decision-making and suggest that the benefit of PSP is robust to variations in technical approach.
Additional Info
Disclosure statements are available on the authors' profiles:
Technical factors associated with the benefit of prophylactic pancreatic stent placement during high-risk ERCP: a secondary analysis of the SVI trial dataset
Am. J. Gastroenterol 2024 Aug 27;[EPub Ahead of Print], BJ Elmunzer, J Zhang, GA Coté, SA Edmundowicz, S Wani, R Shah, JY Bang, S Varadarajulu, VK Singh, M Khashab, RS Kwon, JM Scheiman, FF Willingham, SA Keilin, GI Papachristou, A Chak, A Slivka, D Mullady, V Kushnir, J Buxbaum, R Keswani, TB Gardner, N Forbes, A Rastogi, A Ross, J Law, P Yachimski, YI Chen, A Barkun, ZL Smith, J Serrano, B Petersen, AY Wang, JR Saltzman, RL Spitzer, C Ordiah, C Spino, LD Foster, V Durkalski-MauldinFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
Elmunzer and a very large consortium of coinvestigators are to be congratulated for achieving the landmark stent versus indomethacin study of the effectiveness of pancreatic stenting for the prevention of post-ERCP pancreatitis, published previously. This study is particularly important as it was done in the era in which rectal NSAIDs have largely replaced pancreatic stenting as the cornerstone of prevention of this most common complication of ERCP, with an inadvertent rise in incidence and severity of post-ERCP pancreatitis. The authors were able to demonstrate that insertion of a protective pancreatic stent added significant additional benefit to rectal NSAIDs. Most importantly, this benefit was present by intention-to-treat in the entire group randomized to pancreatic stent placement, including the 20% with failed stent insertion.
In the current secondary analysis, the authors analyzed technical factors associated with the benefit of stent insertion. They found that no specific characteristics of the stent placement including diameter of guidewire, effort required for insertion, or characteristics of the stent were significant predictors of subsequent post-ERCP pancreatitis. While somewhat surprising, these data suggest that successful placement of a pancreatic duct stent mostly reverses the potentially injurious process of placement, as long as NSAIDs were also administered. One factor that could not be analyzed that would have been of great interest is whether premature dislodgement was associated with elevated risks of subsequent pancreatitis. Very few, if any, cases of severe post-ERCP pancreatitis are associated with a well-placed and retained stent, with delayed but severe pancreatitis occurring after rapid (<12–24 hour) dislodgement.
Although an important analysis, it would have been of great interest to analyze in detail the factors associated with failed pancreatic stent insertion, known to be potentially harmful and leading to reluctance of many endoscopists to utilize this long-proven prophylactic maneuver. The overall failure of stent insertion in this very large multicenter study was a surprisingly high 20%, suggesting that certain centers had even higher failure rates. It has been shown that by using very small caliber wires and stent lengths and configurations adapted to depth of wire insertion, approximately 100% success rates can be achieved in all intended patients without pancreas divisum, regardless of duct size and configuration such as ansa loop.
The important takeaway from this landmark study and its post hoc analysis are that all endoscopists performing ERCP should seek and achieve expertise in placement of prophylactic pancreatic stents. Exact type of stent may not be as important as previously thought, although factors involved in achieving success bear further investigation.