Hiroyuki Hisai, Tamaki Sakurai, Yutaka Koshiba, Natsumi Yamauchi, Saki Natsumi, Etsu Miyazaki
Background: Previous meta-analyses show that prophylactic pancreatic stent (PPS) placement reduces the rate and severity of post-ERCP pancreatitis (PEP) in both high-risk and low-risk patients; however, PPS do not eliminate the risk completely. Early PPS dislodgement and occlusion may occur prematurely and contribute to more frequent or severe PEP. The aim of this study was to assess the safety and efficacy of rescue ERCP with pancreatic stent replacement against PEP following PPS placement.
Methods: Between January 2005 and December 2017, out of 3,991 ERCPs, PPS placement was performed in 344 patients at our institution. Among them, PEP occurred in 15 patients (4.36%). Out of these 15 patients, 9 patients (4 men, 5 women; mean age: 74 years, range, 54–82 years) who underwent rescue ERCP with pancreatic stent replacement were analyzed. The cause of PEP following PPS placement was stent dislodgement (n=6) and occlusion (n=3). Timing of stent dislodgment was assessed radiographically. The mean serum amylase level before initial ERCP was 79±41 (range, 26–159) IU/L. Rescue ERCP after PPS placement was performed within 24 h in five patients, 48 h in 3, and 5 days later in one. The stent used in the present study was a straight, double-barbed, 5F in diameter and 3 cm in length pancreatic stent. PEP was defined based on the consensus criteria.
Results: Indications for initial ERCP were biliary stricture (n=5) and choledocholithiasis (n=4). The median risk score for PEP was 0.5 (range, 0.5–3.0). Pancreatic stent replacement was technically successful in all patients. The median bedside index for severity of acute pancreatitis was 2 (range, 0–2) and median CT severity index was 4 (range, 2–6), respectively. The mean serum amylase levels of the next day after replacement (965±926 IU/L, range, 111–2,293) were significantly decreased compared with those before replacement (1,692±1,431 IU/L, range, 116–4,186; P=0.0382). Pancreatic pain was promptly reduced after the procedure in eight patients. Two patients developed severe PEP. There were no procedure-related deaths.
Conclusions: Rescue ERCP with pancreatic stent replacement seems to be an effective procedure for the management of PEP due to stent dislodgement and occlusion following PPS placement. Factors other than ductal obstruction may contribute to PEP in high-risk patients undergoing ERCP and PPS placement. Additional studies are necessary to fully evaluate pancreatic stent replacement for this indication.
