Percutaneous Placement of Metal Stents in the Main Pancreatic Duct

ABSTRACT

Catheterization of the pancreatic ducts is almost exclusively carried out by an endoscopic approach. Percutaneous pancreatic duct stenting is advocated as a last resort, when endoscopy has failed. The main indication for pancreatic duct stenting is a primary or intermediate treatment of pain, related to chronic pancreatitis and a therapeutic test prior to major surgery. A solitary or dominant ductal stricture, located in the head of the pancreas, represents the best indication. Other indications are intractable pain in pancreatic cancer, with dilated ducts or a postoperative anastomotic stenosis. A prerequisite for percutaneous puncture of the main pancreatic duct, with CT guidance, is a minimal diameter of 3 to 5 mm. The access route is predominantly anterior and transgastric. Stents with a diameter of 5 to 6 mm and a length of 2 to 4 cm are placed. Only a few case reports of the percutaneous stenting technique are available. The endoscopic literature reported an immediate pain relief in 94% and a long term benefit in 64% of the cases with chronic pancreatitis. The main drawback of placement of metal stents in the pancreatic duct is clogging, which is not significantly improved compared to the use of plastic stents.

KEYWORD

Pancreatic ducts - metal stents - endoscopy - percutaneous placement - interventional techniques

REFERENCES

• 1 Cremer M, Toussaint J, Dunham F. Endoscopic management of chronic pancreatitis.  Gastrointest Endosc . 1980;  26 65-71
• 2 Fuji T, Amano H, Aruma K. Pancreatic sphincterotomy and pancreatic endoprosthesis.  Endoscopy . 1985;  17 69-72
• 3 Cremer M, Sugai B, Delhaye M. Expandable pancreatic metal stents (Wallstent) for chronic pancreatitis: first world series.  Gastroenterology . 1990;  98 A215(Abst)
• 4 Haaga J R, Highman L M, Cooperman A V. Percutaneous CT-guided pancreatography and pseudocystography.  AJR Am J Roentgenol . 1979;  132 829-830
• 5 Gobien R P, Stanley J H, Anderson M C. Percutaneous drainage of pancreatic duct for treating acute pancreatitis.  AJR Am J Roentgenol . 1983;  141 795-796
• 6 Dondelinger R F, Kurdziel J C. Percutaneous placement of expandable metal stents in the main pancreatic duct.  Semin Intervent Radiol . 1991;  8 316-320
• 7 Kurdziel J C, Dondelinger R F, Barthelme G. Percutaneous transgastric internal drainage, endoscopy and stenting of the pancreatic duct: a new technique.  Eur J Radiol . 1991;  12 1-3
• 8 Kozarek R A, Patterson D J, Ball T J, Traverso L W. Endoscopic placement of pancreatic stents and drains in the management of pancreatitis.  Ann Surg . 1989;  209 261-266
• 9 Cremer M, Devière J, Delhaye M, Baize M, Vandermeeren A. Stenting in severe chronic pancreatitis: results of medium-term follow-up in seventy-six patients.  Endoscopy . 1991;  23 171-176
• 10 Schwarz M, Iseumaun R, Berger H G. Stenting in chronic pancreatitis-the mistakes and limitations.  Z Gastroenterol . 2000;  38 367-374
• 11 Eisendrath P, Devière J. Expandable metal stents for benign pancreatic duct obstruction.  Gastrointest Endosc Clin N Am . 1999;  9 547-554
• 12 Langier R, Renou C. Endoscopic ductal drainage may avoid resective surgery in chronic pancreatitis without large ductal dilatation.  Int J Pancreatol . 1998;  23 145-152
• 13 Hamalainen K P, Halme L, Tierala E. Endoscopically inserted stent as treatment for pancreatic ascites. A case report.  Acta Radiol . 1997;  38 550-552
• 14 Lambiase P, Serry J P, Taylor-Robinson S D. Resolution of panniculitis after placement of pancreatic duct stent in chronic pancreatitis.  Am J Gastroenterol . 1996;  91 1835-1837
• 15 Kozarek R A. Endoscopic therapy of complete and partial pancreatic duct disruptions.  Gastrointest Endosc Clin N Am . 1998;  8 39-53
• 16 Tham T C, Lichtenstein D R, Vandervoort J. Pancreatic duct stents for ``obstructive type'' pain in pancreatic malignancy.  Am J Gastroenterol . 2000;  95 956-960
• 17 Costamagna G, Alevras P, Palladino F. Endoscopic pancreatic stenting in pancreatic cancer.  Can J Gastroenterol . 1999;  13 481-487
• 18 Davidson B R, Agarwal A, Khan A. Use of plastic stents for the external drainage of the pancreatic duct at the time of pancreatico-duodenectomy.  Ann Surg . 1999;  230 451-452
• 19 Vaughan D, Imrie C, Kelleher J, Drumm B, Osborne H. Pancreatic duct stenting as a treatment for hereditary pancreatitis.  Pediatrics . 1999;  104 1129-1133
• 20 Elton E, Howell D A, Parsons W G, Qaseem T, Hanson B L. Endoscopic pancreatic sphincterotomy: indications, outcome and a safe stentless technique.  Gastrointest Endosc . 1998;  47 240-249
• 21 Mathieson J R, Cooperberg P L, Murray D J. Pancreatic duct obstruction treated with percutaneous antegrade insertion of a metal stent: report of two cases.  Radiology . 1992;  185 465-467
• 22 Shlansky-Goldberg R D, Soulen M, Rosato E F, Cope C. Percutaneous management of external pancreatic fistulas : the use of articulated and metal stents.  J Vasc Interv Radiol . 1995;  6 191-196
• 23 White T T, Keith R G. Long-term follow-up study of fifty patients with pancreatico-jejunostomy.  Surg Gynecol Obstet . 1973;  136 353-358
• 24 Binmoeller K F, Jue P, Seifert H. Endoscopic pancreatic stent drainage in chronic pancreatitis and a dominant stricture: long-term results.  Endoscopy . 1995;  27 638-644
• 25 Smits M E, Badiga S M, Rauws E A, Tytgat G N, Huibregtse K. Long-term results of pancreatic stents in chronic pancreatitis.  Gastrointest Endosc . 1995;  42 461-467
• 26 Ponchon T, Bory R M, Hedelins F. Endoscopic stenting for pain relief in chronic pancreatitis: results of a standardized protocol.  Gastrointest Endosc . 1995;  42 452-456
• 27 Renou C, Grandval P, Ville E, Lougier R. Endoscopic treatment of the main pancreatic duct: correlations among morphology, manometry, and clinical follow-up.  Int J Pancreatol . 2000;  27 143-149
• 28 Johanson J F, Schmalz M J, Geenen J E. Incidence and risk factors for biliary and pancreatic stent migration.  Gastrointest Endosc . 1992;  38 341-346
• 29 Lahoti S, Catalano M F, Geenen J E, Schmalz M J. Endoscopical retrieval of proximally migrated biliary and pancreatic stents: experience of a large referral center.  Gastrointest Endosc . 1998;  47 486-491
• 30 Sherman S, Hawes R H, Savides T J. Stent-induced pancreatic ductal and parenchymal changes: correlation of endoscopic ultrasound with ERCP.  Gastrointest Endosc . 1996;  44 276-282
• 31 Smith M T, Sherman S, Ikenberry S O, Hawes R H, Lehman G A. Alterations in pancreatic ductal morphology following polyethylene pancreatic stent therapy.  Gastrointest Endosc . 1996;  44 268-275