Endoscopic pancreatic duct and biliary duct stenting in treatment of chronic pancreatitis with distal benign biliary stricture: a single-center experience

Ming-Wei Zheng, Ming-Fang Qin and Wang Cai

Tianjin, China

Original Article / Pancreas

Endoscopic pancreatic duct and biliary duct stenting in treatment of chronic pancreatitis with distal benign biliary stricture: a single-center experience

Ming-Wei Zheng, Ming-Fang Qin and Wang Cai

Tianjin, China

BACKGROUND:The development of endoscopic techniques such as endoscopic retrograde cholangiopancreatography (ERCP), endoscopic sphincterotomy (EST) and stenting are relatively new alternatives to surgery for the treatment of benign lesions in the biliary duct and pancreas. The objective of this study was to assess the value of stenting in the endoscopic pancreatic duct and biliary duct in the treatment of chronic pancreatitis with distal benign biliary stricture.

METHODS:Twenty-two patients diagnosed with chronic pancreatitis with distal benign biliary stricture underwent endoscopic treatment in our center, with ERCP, EST, endoscopic retrograde biliary drainage (ERBD) and endoscopic retrograde pancreatic drainage (ERPD) with stents. A numeric rating scale was used to assess pain intensity. The clinical data on endoscopic therapies and recovery of the patients were recorded and compared.

RESULTS:ERCPs were successfully performed in 21 patients and 1 (4.5%) failed because of pancreatic ductal variation. A total of 68 ERCPs were performed with 47 pancreatic duct stents and 39 biliary duct stents. The rate of complications was 13.2% (9/68). The abdominal pain score after endoscopic treatment was significantly reduced. The levels of bilirubin and alanine transaminase in all 21 patients were improved compared to those before endoscopic treatment.

CONCLUSION:Endoscopic stent drainage of the pancreatic duct and biliary duct for chronic pancreatitis with distal biliary benign stricture can be selected as a safe, effective and minimally invasive therapeutic method.

(Hepatobiliary Pancreat Dis Int 2011; 10: 539-543)

endoscopic; chronic pancreatitis; distal biliary stricture; plastic stent

Introduction

Chronic pancreatitis (CP) is a complex inflammatory disease of the pancreas which causes severe recurrent abdominal pain and pancreatic exocrine and endocrine insufficiency.[1]The pain from CP is usually difficult to control with medicine and meanwhile CP usually causes relevant complications in adjacent organs, which decreases the quality of life. Distal biliary benign stricture is one of the common complications in clinical practice. The objective of our study was to evaluate endoscopic treatment for CP with biliary benign stricture.

Methods

Between January 2004 and January 2010, 22 adult patients were admitted to our hospital for CP with distal benign biliary stricture. The diagnostic criteria were typical manifestations (abdominal pain, pancreatic exocrine insufficiency) and/or definite pathological findings, supporting imaging findings [endoscopic retrograde cholangiopancreatography (ERCP), magnetic resonance cholangiopancreatography (MRCP), computed tomography (CT)], and exclusion of pancreatic tumors. In the 22 patients, 15 were male and 7 female andtheir mean age was 54.3 (range 22-79) years. The mean body mass index (BMI) was 22.09±3.78 kg/m2. Among the 22 patients, 5 were admitted for acute abdominal pain with an amylase level higher than normal, and 16 for chronic pain in the upper abdomen; 1 was diagnosed on physical examination. Fifteen of the 22 patients had jaundice and an acute cholangiolitis attack occurred in one of them. Diarrhea was found in 6 patients. Thirteen patients had a history of bile duct disease, 2 had a history of severe acute pancreatitis and 10 had alcoholism. No definite etiological factors were found in the other 2 patients.

All of the 22 patients received liver function test and image examination, including B-ultrasonography (B-US), CT and MRCP to confirm the diagnosis of the disease while excluding malignant lesions.

Endoscopic procedures

All of the patients at first underwent ERCP under conscious sedation or general anesthesia to evaluate biliary and pancreatic anatomy. A distal benign biliary stricture was defined as distal narrowing of the common biliary duct with proximal dilatation and delayed evacuation of contrast into the duodenum. Diagnostic ERCP also can reveal the conditions of the pancreatic duct, including pancreatic ductal stones (PDS), pancreatic pseudocyst (PP) and pancreatic duct stricture. Endoscopic sphincterotomy (EST) and endoscopic pancreatic sphincterotomy (EPS) were performed first to solve the sphincter stricture. Then a hydrostatic balloon or dilation catheter was placed into the biliary or pancreatic duct beyond the stricture and dilation performed. The biliary duct was dilated first. The pressure of the balloon was usually 4560-6080 mmHg (6-8 atm) and maintained for 2 minutes. Or a biliary dilation catheter with a diameter of 5 to 10 Fr was used. The dilations were performed 2 or 3 times at intervals of 30 seconds. For pancreatic ductal dilation, the dilation catheters used were usually from 3 Fr to 7 Fr or more as needed. Endoscopic stone extraction was used to clear up biliary or pancreatic duct stones. Endoscopic retrograde pancreatic drainage (ERPD) and endoscopic retrograde biliary drainage (ERBD) were accomplished consecutively with 5-, 7-, 8.5- or 10-Fr plastic stents.

Postoperative period

The clinical data about operations and recovery of the 22 patients were recorded, including clinical symptom alleviation and complications. Postoperative pain was analyzed using a numeric rating scale to assess the pain intensity and required patients to rate their pain on a scale of 0 (no pain) to 10 (worst pain). The TBIL, DBIL and ALT were monitored 1 week and 3 months after endoscopic treatment. The patients were asked to recheck every 3 months.

Statistical analysis

The data of the patients before and after endoscopic treatment were compared. Continuous variables were compared using Student's t test. A P value less than 0.05 was considered statistically significant.

Results

ERCPs were performed successfully in 21 patients and one (4.5%) failed due to anatomical variation of the pancreatic duct. Pancreatic complications were found by ERCP in all 22 patients, 11 with PDS, 8 with pancreatic ductal stricture and 2 with PP. Referring to the biliary duct, ampullary stricture occurred in 7 patients and stricture in the distal common duct in 15. The mean length of biliary stricture was 3.2 (range 2-15) mm. Stones in the common duct were found in 4 patients.

Endoscopic stone extraction succeeded in 4 patients with stones in the common duct and 8 patients with PDS. In 3 patients with PDS, stones failed to be cleared up and they underwent stenting. Two patients with PP were cured by ERPD. Nine (13.2%) patients with complications occurred in 68 ERCPs: 5 with hyperamylasemia, 3 with mild acute pancreatitis and 1 with cholangitis, which were cured medically within 72 hours. No bleeding, perforation, infection or severe acute pancreatitis was found. After one week of first ERBD and ERPD, monitoring of liver functions indicated improved levels of bilirubin and ALT (Table 1).

The mean follow-up time was 28.4 (range 4-68) months. Sixty-eight ERCPs were performed for these 21 patients with an average of 3.2 ERCPs per patient. A total of 47 pancreatic duct stents and 39 biliary duct stents were inserted. Follow-up showed no recurrence of biliary duct stricture. The average duration of stenting was 11.3 months. Up to the end of follow-up, there were still 3 pancreatic duct stents and 2 biliary duct stents not removed. The pain score and BMI before and after endoscopic treatment were recorded and compared (Table 2).

Table 1. Bilirubin and ALT before and after ERCP (n=21)

Table 2. NRS and BMI before and after ERCP (n=21)

Discussion

Endoscopic treatments for bilio-pancreatic diseases are common in the clinic and to some degree have taken the place of traditional surgery. Many studies reported their experiences of single ERPD or single ERBD in the treatment of benign pancreatic duct or biliary duct stricture. But because of the special structure of the bilio-pancreatic ducts, pathological lesions usually involve the pancreatic duct and biliary duct simultaneously. So ERPD and ERBD can each play their therapeutic roles and cooperate with each other.

The principle of endoscopic bilio-pancreatic stenting, including ERPD and ERBD, is to alleviate outflow obstruction of the pancreatic and biliary ducts in order to decrease ductal hypertension, which is one of the main causes of symptoms, and improve liver function and pancreatic secretion. Because combined ERPD and ERBD can drain the pancreatic duct and biliary duct at the same time, it is applied in benign or malignant lesions, including inflammation and tumors, duodenal papilla, ampulla, and the head of the pancreas or distal common bile duct, which could result in simultaneous outflow obstruction of the bilio-pancreatic ducts. In our study, we applied bilio-pancreatic stenting in CP with distal benign biliary stricture.

CP, an ongoing inflammatory disease of the pancreas, has a relatively low incidence rate of about 5.4 per 100 000,[2]but the pain from CP usually fails to respond to medical treatment and seriously affects the quality of life.[3]Moreover, CP usually causes complications which have to be solved, such as PDS, PP and jaundice resulting from biliary duct stricture. Wang et al[4]reported that the incidence of CP combined with obstructive jaundice is about 13.4% in China. The biliary duct stricture caused by CP is usually located in the distal common duct which runs through the head of the pancreas. But it was noted that not all biliary duct strictures present with dominant jaundice but only elevate the levels of bilirubin and transaminase. If the biliary duct stricture is not treated at an early stage it can result in obstructive jaundice, biliary cirrhosis and acute cholangitis. So, though the management of CP with distal biliary duct stricture is a challenge to surgeons, it is necessary to take active measures for its treatment.

Traditionally, invasive therapy for CP with distal biliary duct stricture mainly depended on surgery. But relevant operations involving the biliary duct, pancreas and even intestinal tract are relatively complex with severe trauma and a high incidence of postoperative complications. For CP with distal benign biliary duct stricture, combined ERPD and ERBD is a relatively new, minimally invasive alternative to surgical methods.

EST is the first step and useful for sphincter stenosis which can result in outflow obstruction in the distal pancreatic duct and biliary duct. Ewald et al[5]reported 60 patients with duodenal ampulla stenosis who underwent EST and found abdominal pain was alleviated in 80%, with liver function and pancreatic exocrine function improved in a 3-year follow-up. For pancreatic sphincter stenosis, EPS has a direct therapeutic effect. Jakobs et al[6]reported EPS in 171 patients with CP and that the symptoms of abdominal pain in 97.7% of patients were alleviated. In our study, all of the 21 patients underwent EST and 18 underwent EPS, not only to relieve sphincter stenosis but also for stent insertion in the next step.

In ERPD, a pancreatic duct stent is inserted through the stricture to expand the lumen chronically. A patent stent can relieve abdominal pain from CP. The stricture can be expanded sufficiently to ,ensure a good flow long after the stent is removed. Two recent studies showed the effectiveness of ERPD for CP.[7,8]Vitale et al[9]also reported 89 patients with CP who underwent 407 ERPDs and 62 (82.7%) had the chronic pain alleviated with reduced use of analgesics. A study with a series of 1000 patients with CP treated by ERPD found a longterm success rate of endotherapy was 86% in this group and 65% patients had pain relief during a long-term follow-up.[10]

In addition, CP usually results in complications in the pancreas and adjacent organs. PDS and PP are common complications in CP. For PDS, whether stones are cleared up or not, ERPD is necessary to relieve pancreatic duct obstructive pain.[11]For PP communicating with the main duct of the pancreas, ERPD is definitely effective. Weckman et al[12]reported 79 patients with PP who underwent ERPD with a success rate of 86.1%.

In most series, the incidence of distal biliary duct stricture is about 10%, but it can be as high as 20% to 46% because of the inflammation causing the extrinsic compression in the low-grade intrapancreatic common duct. Complications such as cholangitis can occur inabout 10% of these patients and the average incidence of secondary biliary cirrhosis associated with these strictures is about 7.3%.[13]Numerous studies show that cholestasis can be effectively resolved by ERBD with plastic stent insertion and the technical success rate of ERBD is close to 100% with liver function recovered quickly. But the long-term results in some studies are discouraging.[14,15]However, Vitale et al[16]reported that 25 patients with stricture who underwent ERBD with stent insertion produced more promising results. All patients achieved relief of jaundice shortly after stenting. Stents were removed in 20 of the 25 patients after an average of 13 months (range 3-28) and none of these patients had a recurrence after a mean follow-up of 32 months. Kassab et al[17]reported 65 patients with iatrogenic bile duct stricture who underwent ERBD and 45 achieved satisfactory results without recurrence after a follow-up of 28 months. Catalano et al[18]reported that multiple biliary plastic stent placement to improve inflammatory stricture of the common duct is superior to a single stent. But in our study no multiple stents were inserted because we were afraid that multiple biliary duct stents would interfere with the drainage of the pancreatic duct. In addition, metal biliary duct stents were not used in our study since they become embedded in the wall of the biliary duct and difficult to recycle.[19]

The success rate of endoscopic stenting was 95.5% (21/22). After one week of first ERBD and ERPD, monitoring of liver functions indicated improved levels of bilirubin and ALT. Referring to endoscopic complications, hyperamylasemia and mild acute pancreatitis occur frequently. In our study, 9 (13.2%) complications occurred in 68 ERCPs (5 hyperamylasemia, 3 mild acute pancreatitis and 1 cholangitis), which were cured medically within 72 hours. No bleeding, perforation, infection or severe acute pancreatitis was found.

Clearly, it is more difficult to perform ERBD and ERPD in an endoscopic procedure than one alone. We usually performed ERPD first for the smaller diameter pancreatic duct stent which interfered little in the subsequent biliary duct stent insertion. But it should be noted that when ERPD is performed, guide wires should be kept in both the pancreatic duct and biliary duct simultaneously without migration. The diameters of stents depended on the degree of dilation of the pancreatic and biliary ducts. For mild and moderate dilation of the pancreatic duct, 5-7.0 Fr stents were usually selected, and for severe dilation, 8.5 Fr or larger diameters were selected. The diameter of a biliary duct stent was selected to be as large as possible to remain unobstructed as long as possible.

The duration of stent insertion is still controversial.[20]In our study, we asked patients to recheck every 3 months. If the stent blocked or the symptoms of acute pancreatitis occurred more than 3 times, a new stent was used instead. So the patients played an important role in the duration of stenting. A total of 47 pancreatic duct stents and 39 biliary duct stents were placed. In followup, no recurrence of biliary duct stricture was found. The average duration of stent placement was 11.3 months. The stents were finally removed when ERCP showed the contrast flowed into the duodenum within 3 minutes or an 8-10 mm balloon passed through the location of the stricture smoothly. In this condition, pain and jaundice were usually relieved gradually. So compared to the laboratory data, the relief of symptoms was also important for good results.

The mean follow-up time was 28.4 months (range 4-68) in our study. Sixty-eight ERCPs were performed for these 21 patients with an average of 3.2 ERCPs per patient. A total of 47 pancreatic duct stents and 39 biliary duct stents were inserted. During the follow-up, no recurrence of biliary duct stricture was found. The average duration of stenting was 11.3 months. Up to the end of the follow-up, 3 pancreatic duct stents and 2 biliary duct stents were not removed. There were no complications relevant to stent placement and removal. In the period of follow-up pain score was reduced and BMI was increased significantly after endoscopic treatment compared to those before treatment. But abdominal pain from CP was multifactorial, and one patient with PDS underwent surgical intervention because of unsatisfactory pain control.

In conclusion, although endoscopic stent drainage cannot prevent fibrosis of the pancreas, it is still useful to alleviate pancreatic pain and biliary ductal obstruction and improve the quality of life with less trauma. Endoscopic stent drainage of the biliary duct and pancreatic duct for CP with distal biliary benign stricture can be selected as a safe, effective and minimally invasive therapeutic method. But further follow-up and data collection are still needed.

Funding:None.

Ethical approval:Not needed.

Contributors:ZMW proposed the study. CW wrote the first draft. ZMW analyzed the data. All authors contributed to the design and interpretation of the study and to further drafts. ZMW is the guarantor.

Competing interest:No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.

1 Lankisch PG. Natural course of chronic pancreatitis.Pancreatology 2001;1:3-14.

2 Lin Y, Tamakoshi A, Matsuno S, Takeda K, Hayakawa T, Kitagawa M, et al. Nationwide epidemiological survey of chronic pancreatitis in Japan. J Gastroenterol 2000;35:136-141.

3 Garg PK, Tandon RK. Survey on chronic pancreatitis in the Asia-Pacific region. J Gastroenterol Hepatol 2004;19:998-1004.

4 Wang LW, Li ZS, Li SD, Chen F. A multi-center survey on chronic pancreatitis in China. Chin J Pancreatol 2007;7:1-5.

5 Ewald N, Marzeion AM, Bretzel RG, Kloer HU, Hardt PD. Endoscopic sphincterotomy in patients with stenosis of ampulla of Vater: three-year follow-up of exocrine pancreatic function and clinical symptoms. World J Gastroenterol 2007; 13:901-905.

6 Jakobs R, Benz C, Leonhardt A, Schilling D, Pereira-Lima JC, Riemann JF. Pancreatic endoscopic sphincterotomy in patients with chronic pancreatitis: a single-center experience in 171 consecutive patients. Endoscopy 2002;34:551-554.

7 Weber A, Schneider J, Neu B, Meining A, Born P, Schmid RM, et al. Endoscopic stent therapy for patients with chronic pancreatitis: results from a prospective follow-up study. Pancreas 2007;34:287-294.

8 Nguyen-Tang T, Dumonceau JM. Endoscopic treatment in chronic pancreatitis, timing, duration and type of intervention. Best Pract Res Clin Gastroenterol 2010;24:281-298.

9 Vitale GC, Cothron K, Vitale EA, Rangnekar N, Zavaleta CM, Larson GM, et al. Role of pancreatic duct stenting in the treatment of chronic pancreatitis. Surg Endosc 2004;18:1431-1434.

10 Rösch T, Daniel S, Scholz M, Huibregtse K, Smits M, Schneider T, et al. Endoscopic treatment of chronic pancreatitis: a multicenter study of 1000 patients with longterm follow-up. Endoscopy 2002;34:765-771.

11 Sasahira N, Tada M, Isayama H, Hirano K, Nakai Y, Yamamoto N, et al. Outcomes after clearance of pancreatic stones with or without pancreatic stenting. J Gastroenterol 2007;42:63-69.

12 Weckman L, Kylänpää ML, Puolakkainen P, Halttunen J. Endoscopic treatment of pancreatic pseudocysts. Surg Endosc 2006;20:603-607.

13 Abdallah AA, Krige JE, Bornman PC. Biliary tract obstruction in chronic pancreatitis. HPB (Oxford) 2007;9: 421-428.

14 Cahen DL, van Berkel AM, Oskam D, Rauws EA, Weverling GJ, Huibregtse K, et al. Long-term results of endoscopic drainage of common bile duct strictures in chronic pancreatitis. Eur J Gastroenterol Hepatol 2005;17:103-108.

15 Eickhoff A, Jakobs R, Leonhardt A, Eickhoff JC, Riemann JF. Endoscopic stenting for common bile duct stenoses in chronic pancreatitis: results and impact on long-term outcome. Eur J Gastroenterol Hepatol 2001;13:1161-1167.

16 Vitale GC, Reed DN Jr, Nguyen CT, Lawhon JC, Larson GM. Endoscopic treatment of distal bile duct stricture from chronic pancreatitis. Surg Endosc 2000;14:227-231.

17 Kassab C, Prat F, Liguory C, Meduri B, Ducot B, Fritsch J, et al. Endoscopic management of post-laparoscopic cholecystectomy biliary strictures. Long-term outcome in a multicenter study. Gastroenterol Clin Biol 2006;30:124-129.

18 Catalano MF, Linder JD, George S, Alcocer E, Geenen JE. Treatment of symptomatic distal common bile duct stenosis secondary to chronic pancreatitis: comparison of single vs. multiple simultaneous stents. Gastrointest Endosc 2004;60: 945-952.

19 Siriwardana HP, Siriwardena AK. Systematic appraisal of the role of metallic endobiliary stents in the treatment of benign bile duct stricture. Ann Surg 2005;242:10-19.

20 Morgan DE, Smith JK, Hawkins K, Wilcox CM. Endoscopic stent therapy in advanced chronic pancreatitis: relationships between ductal changes, clinical response, and stent patency. Am J Gastroenterol 2003;98:821-826.

Received January 25, 2011

Accepted after revision April 1, 2011

Author Affiliations: Department of Surgery, Tianjin Nankai Hospital, Tianjin 300100, China (Zheng MW, Qin MF and Cai W)

Ming-Wei Zheng, PhD, Department of Surgery, Tianjin Nankai Hospital, No. 122 San Wei Road, Nankai District, Tianjin 300100, China (Tel: 86-22-27435267; Fax: 86-22-27435266; Email: missyouxj@ 163.com)

© 2011, Hepatobiliary Pancreat Dis Int. All rights reserved.

10.1016/S1499-3872(11)60091-X