Pancreatic stents in the management of chronic pancreatitis

Abstract

Background: Elevated pancreatic duct pressure is a potential source of pain in patients with chronic pancreatitis. Endoscopic pancreatic duct stenting is a minimally invasive way of reducing this pressure and may be a useful adjunct to surgery in these patients. Methods: We prospectively reviewed a series of nine symptomatic patients with obstructive chronic pancreatitis and relative contraindications to open surgery, who were managed by attempted endoscopic placement of a pancreatic stent. Results: Stents were successfully inserted endoscopically into the main or accessory duct in six patients and into a pseudocyst, transduodenally, in one patient. Of the two unsuccessful insertions, one proceeded to longitudinal pancreato-jejunostomy and in the other a stent was inserted at distal pancreatic cyst-jejunostomy. Median follow up was 21 months (range 14–43). In all eight cases with stent insertion there was rapid pain resolution, pain scores falling from 9/10 (8–10) to 2 (1–5) after 2 days (1–7). Associated symptoms of weight loss, nausea and vomiting settled in all eight cases. In one patient with a persistent pancreatic fistula, the fistula resolved. In the three with pseudocysts, the cysts resolved on computed tomography (CT) (one recurred). Five patients subsequently proceeded to stent removal after 6 months (5–23). In three of these, the stent was removed endoscopically, and replaced endoscopically in two cases, with pain resolution. Two patients underwent transduodenal pancreatic duct septectomy (one had stent change prior) and one proceeded to pseudocyst-gastrostomy, with pain resolution. The remaining three patients with stents in situ remain symptom-free. No patient suffered acute pancreatitis. Conclusions: In selected patients with obstructive chronic pancreatitis, insertion of a pancreatic stent is a safe procedure, which can lead to rapid symptomatic control over the intermediate period. A significant proportion will need further intervention.