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Systematic pancreatic stenting after endoscopic snare papillectomy may reduce the risk of postinterventional pancreatitis

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Abstract

Background

Pancreatitis is the most feared complication of endoscopic papillectomy (EP). Prevention by pancreatic duct stenting following EP has been advocated but not proven by a randomized trial. The purpose of the present retrospective review is to compare a period of systematic stenting with the period before in which stents were placed selectively.

Methods

A total of 107 patients undergoing EP from February 1999 to December 2009 were retrospectively reviewed. After an initial period with selective stenting (dilated duct, previous pancreatitis) between 1999 and 2002 (n = 24, group 1), stents were placed routinely after EP unless pancreas divisum was diagnosed (2002–2009; n = 83, group 2) to reduce postpapillectomy acute pancreatitis (PAP). PAP rates defined by Consensus Criteria were compared in the two periods.

Results

Five patients in group 1 were selected to receive a pancreatic stent (21 %); in group 2 stenting was successful in 75 of 78 patients (success rate 96 %) without pancreas divisum (n = 5). Overall, PAP occurred in 11 % of patients. PAP rate was significantly reduced after introduction of systematic pancreatic stenting (5 vs 25 %; p = 0.01) and occurred less often in stented than in nonstented patients: (5 % (4/80) vs 27 % (6/22), p = 0.0019). PAP also occurred in one of five patients with pancreas divisum. Selective stenting of patients also was an independent risk factor for PAP (OR 13, p = 0.001) in a multivariate analysis.

Conclusions

Attempts at systematic stenting after EP pancreatic stenting appears to prevent PAP. Results should be corroborated by a randomized trial.

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References

  1. Scarpa A, Capelli P, Zamboni G et al (1993) Neoplasia of the ampulla of Vater. Ki-ras and p53 mutation. Am J Pathol 142:1163–1172

    PubMed  CAS  Google Scholar 

  2. Seifert E, Schulte F, Stolte M (1992) Adenoma and carcinoma of the duodenum and papilla of Vater: a clinicopathologic study. Am J Gastroenterol 87:37–42

    PubMed  CAS  Google Scholar 

  3. Yamaguchi K, Enjoji M, Kitamura K (1990) Endoscopic biopsy has limited accuracy in diagnosis of ampullary tumors. Gastrointest Endosc 36:588–592

    Article  PubMed  CAS  Google Scholar 

  4. Suzuki K, Kantou U, Murakami Y et al (1983) Two cases with ampullary cáncer who underwent endoscopic excision. Prog Dig Endosc 23:236–239

    Google Scholar 

  5. Binmoeller K, Boaventura S, Ramsperger K et al (1993) Endoscopic snare excision of benign adenomas of the papilla of Vater. Gastrointest Endosc 39:127–131

    Article  PubMed  CAS  Google Scholar 

  6. Martin JA, Haber GB, Korta PP et al (1997) Endoscopic snare ampullectomy for resection of benign ampullary neoplasms. Gastrointest Endosc 45:AB139

    Article  Google Scholar 

  7. Záradová Z, Dvorák M, Hajer J (2001) Endoscopic therapy of benign tumors of the papilla of Vater. Endoscopy 33:345–347

    Article  Google Scholar 

  8. Desilets D, Dy R, Ku P et al (2001) Endoscopic management of tumors of the major duodenal papilla: refined techniques to improve outcome and avoid complications. Gastrointes Endosc 54:202–208

    Article  CAS  Google Scholar 

  9. Norton I, Gostout CJ, Baron TH et al (2002) Safety and outcome of the endoscopic snare excision of the major duodenal papilla. Gastrointest Endosc 56:239–243

    Article  PubMed  Google Scholar 

  10. Napoléon B, Barthet M, Saurin JC et al (2003) Les risques de l’ampullectomie endoscopique sont-ils assez faibles pour en faire une alternative à la chirurgie: résultats d’une étude rétrospective multicentrique. Gastroenterol Clin Biol 27(HS1):AS0050

    Google Scholar 

  11. Cheng CL, Sherman S, Fogel E et al (2004) Endoscopic snare papillectomy for tumors of the duodenal papillae. Gastrointest Endosc 60:757–764

    Article  PubMed  Google Scholar 

  12. Catalano M, Linder J, Chak A et al (2004) Endoscopic management of adenoma of the major duodenal papilla. Gastrointest Endosc 59:225–232

    Article  PubMed  Google Scholar 

  13. Kahaleh M, Shami VM, Brock A et al (2004) Factors predictive of malignancy and endoscopic respectability in ampullary neoplasia. Am J Gastroenterol 99:2235–2239

    Article  Google Scholar 

  14. Bohnacker S, Seitz U, Nguyen D et al (2005) Endoscopic resection of benign tumors of the duodenal papilla without and with intraductal growth. Gastrointest Endosc 62:551–560

    Article  PubMed  Google Scholar 

  15. Harewood GC, Pochron NL, Gostout CJ (2005) Prospective, randomized, controlled trial of prophylactic pancreatic stent placement for endoscopic snare excision of the duodenal ampulla. Gastrointest Endosc 62:367–370

    Article  PubMed  Google Scholar 

  16. Katsinelos P, Paroutoglou G, Kounturas J et al (2006) Safety and long-term follow-up of endoscopic snare excision of ampullary adenomas. Surg Endosc 20:608–613

    Article  PubMed  CAS  Google Scholar 

  17. Irani S, Arai A, Ayub K et al (2009) Papillectomy for ampullary neoplasms: results of a single referral center over a 10-year period. Gastrointest Endosc 70:923–932

    Article  PubMed  Google Scholar 

  18. Boix J, Lorenzo-Zúñiga V, de Vega Moreno et al (2009) Endoscopic resection of ampullary tumors: 12-year review of 21 cases. Surg Endosc 23:45–49

    Article  PubMed  Google Scholar 

  19. Jung MK, Cho CM, Park SY et al (2009) Endoscopic resection of ampullary neoplasms: a single-center experience. Surg Endosc 23:2568–2574

    Article  PubMed  Google Scholar 

  20. Yamao T, Isomoto H, Kohno S et al (2010) Endoscopic snare papillectomy with biliary and pancreatic stent placement for tumors of the major duodenal papilla. Surg Endosc 24:119–124

    Article  PubMed  Google Scholar 

  21. Patel R, Davitte J, Varadarajulu S et al (2011) Endoscopic resection of ampullary adenomas: complications and outcomes. Dig Dis Sci 56:3235–3240

    Article  PubMed  Google Scholar 

  22. Jeanniard-Malet O, Caillol F, Pesenti C et al (2011) Short-term results of 42 endoscopic ampullectomies: a single-center experience. Scand J Gastroenterol 46:1014–1019

    Article  PubMed  Google Scholar 

  23. Hanaro M, Ryozawa S, Iwano H et al (2011) Clinical impact of endoscopic papillectomy for benign-malignant borderline of the major duodenal papilla. J Hepatobiliary Pancreat Sci 18:190–194

    Article  Google Scholar 

  24. Freeman ML, Overby C, Qi D (2004) Pancreatic insertion: consequences of failure and results of a modified technique to maximize success. Gastrointest Endosc 59:8–14

    Article  PubMed  Google Scholar 

  25. Sofuni A, Maguchi H, Itoi T et al (2007) Prophylaxis of post-endoscopic retrograde cholangiopancreatography pancreatitis by an endoscopic pancreatic spontaneous dislodgement stent. Clin Gastroenterol Hepatol 5:1339–1346

    Article  PubMed  Google Scholar 

  26. Singh P, Das A, Isenberg G et al (2004) Does prophylactic pancreatic stent placement reduce the risk of post-ERCP acute pancreatitis? A meta-analysis of controlled trials. Gastrointest Endosc 60:544–550

    Article  PubMed  Google Scholar 

  27. Andriulli A, Forlano R, Napolitano G et al (2007) Pancreatic duct stents in the prophylaxis of pancreatic damage after endoscopic retrograde cholangiopancreatography: a systematic analysis of benefits and associated risks. Digestion 75:156–163

    Article  PubMed  Google Scholar 

  28. Cotton PB, Lehmen G, Vennes J et al (1991) Endoscopic sphincterotomy complications and their management: an attempt at consensus. Gastrointest Endosc 37:383–393

    Article  PubMed  CAS  Google Scholar 

  29. Baillie J (2005) Endoscopic ampullectomy: does pancreatic stent placement make it safer? Gastrointest Endosc 62:371–373

    Article  PubMed  Google Scholar 

  30. Freeman ML, DiSario JA, Nelson DB et al (2001) Risk factors for post-ERCP pancreatitis: a prospective, multicenter study. Gastrointest Endosc 54:425–434

    Article  PubMed  CAS  Google Scholar 

  31. Sofuni A, Maguchi H, Mukai T et al (2011) Endoscopic pancreatic duct stents reduce the incidence of post-endoscopic retrograde cholangiopancreatography pancreatitis in high-risk patients. Clin Gastroenterol Hepatol 9:851–858

    Article  PubMed  Google Scholar 

  32. Kozarek RA, Ball TJ, Patterson DJ (1994) Endoscopic pancreatic duct sphincterotomy: indications, technique, and analysis of results. Gastrointest Endosc 40:592–598

    Article  PubMed  CAS  Google Scholar 

  33. Esber E, Sherman S, Earle D et al (1995) Complications of major papilla pancreatic sphincterotomy: a review of 236 patients. Gastrointest Endosc 43:405A

    Article  Google Scholar 

  34. Parsons WG, Howell DA, Qasseem T et al (1995) Pancreatic duct sphincterotomy without stenting. Gastrointest Endosc 41:427A

    Article  Google Scholar 

  35. Freeman ML, Nelson DB, Sherman S et al (1996) Complications of endoscopic biliary sphincterotomy. N Engl J Med 335:909–918

    Article  PubMed  CAS  Google Scholar 

  36. Loperfido S, Angelini G, Benedetti G et al (1998) Major early complications from diagnostic and therapeutic ERCP: a prospective multicenter study. Gastrointest Endosc 48:1–10

    Article  PubMed  CAS  Google Scholar 

  37. Masci E, Toti G, Mariani A et al (2001) Complications of diagnostic and therapeutic ERCP: a prospective multicenter study. Am J Gastroenterol 96:417–423

    Article  PubMed  CAS  Google Scholar 

  38. Meister T, Heinzow H, Heinecke A et al (2011) Post-ERCP pancreatitis in 2364 ERCP procedures: is intraductal ultrasonography another risk factor? Endoscopy 43:331–336

    Article  PubMed  CAS  Google Scholar 

  39. Choudhary A, Bechtold ML, Arif M et al (2011) Pancreatic stents for prophylaxis against post-ERCP pancreatitis: a meta-analysis and systematic review. Gastrointest Endosc 73:275–282

    Article  PubMed  Google Scholar 

  40. Freeman ML (2010) Pancreatic stents for prevention of post-ERCP pancreatitis: for every practice or for experts only? Gastrointest Endosc 71:940–944

    Article  PubMed  Google Scholar 

  41. Patel R, Varadarajulu S, Wilcox M (2012) Endoscopic ampulectomy. Techniques and outcomes. J Clin Gastroenterol 46:8–15

    Article  CAS  Google Scholar 

  42. Moon JH, Cha SW, Cho YD et al (2005) Wire-guided endoscopic snare papillectomy for tumors of the major duodenal papilla. Gastrointest Endosc 61:461–466

    Article  PubMed  Google Scholar 

  43. Keenan J, Mallery S, Freeman ML (2007) EUS rendezvous for pancreatic stent placement during endoscopy snare ampullectomy. Gastrointest Endosc 66:850–853

    Article  PubMed  Google Scholar 

  44. Carrara S, Arcidiacono PG, Diellou AM et al (2007) EUS-guided methylene blue injection into the pancreatic duct as a guide for pancreatic stenting after ampullectomy. Endoscopy 39:E151–E152

    Article  PubMed  Google Scholar 

  45. Park SH, De Bellis M, McHenry L et al (2003) Use of methylene blue to identify the minor papilla or its orifice in patients with pancreas divisum. Gastrointest Endosc 57:358–363

    Article  PubMed  Google Scholar 

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Disclosures

Drs. Bertrand Napoléon, M. Victoria Alvarez-Sanchez, Philippe Leclercq, François Mion, Jean Pialat, Rodica Gincul, Daniel Ribeiro, Marie Cambou, Christine Lefort, Mar Rodríguez, and Jean Yves Scoazec have no conflict of interest or financial ties to disclose.

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Authors and Affiliations

  1. Department of Gastroenterology, Hôpital Privé Jean Mermoz, 55 avenue Jean Mermoz, 69008, Lyon, France

    Bertrand Napoléon, M. Victoria Alvarez-Sanchez, Philippe Leclercq, Daniel Ribeiro, Marie Cambou, Christine Lefort & Mar Rodríguez-Girondo

  2. Department of Digestive Physiology, Hospices Civils de Lyon, Hôpital Edouard Herriot, Université Lyon-1, Lyon, France

    François Mion

  3. Office of Pathology, 41, Allée des Cyprès, Limonest, France

    Jean Pialat

  4. Department of Gastroenterology, Hospices Civils de Lyon, Hôpital Edouard Herriot, Lyon, France

    Rodica Gincul

  5. Department of Pathology, Hospices Civils de Lyon, Hôpital Edouard Herriot, Lyon, France

    Jean Yves Scoazec

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  1. Bertrand Napoléon
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  2. M. Victoria Alvarez-Sanchez
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Correspondence to Bertrand Napoléon.

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Napoléon, B., Alvarez-Sanchez, M.V., Leclercq, P. et al. Systematic pancreatic stenting after endoscopic snare papillectomy may reduce the risk of postinterventional pancreatitis. Surg Endosc 27, 3377–3387 (2013). https://doi.org/10.1007/s00464-013-2920-9

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  • DOI: https://doi.org/10.1007/s00464-013-2920-9

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