Observational Study
Copyright ©The Author(s) 2018. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Jan 21, 2018; 24(3): 408-414
Published online Jan 21, 2018. doi: 10.3748/wjg.v24.i3.408
Metal stents placement for refractory pancreatic duct stricture in children
In Sook Jeong, Sung Hee Lee, Seak Hee Oh, Do Hyun Park, Kyung Mo Kim
In Sook Jeong, Sung Hee Lee, Seak Hee Oh, Kyung Mo Kim, Department of Pediatrics, University of Ulsan College of Medicine, Asan Medical Center Children’s Hospital, Seoul 05505, South Korea
Do Hyun Park, Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, South Korea
Author contributions: Jeong IS, Lee SH, Oh SH and Kim KM contributed to the conception and design of the study; all authors contributed to the study implementation, data acquisition, and data analysis; Jeong IS wrote the manuscript; and all authors contributed to the editing, reviewing, and final approval of the manuscript.
Institutional review board statement: This study was reviewed and approved by the Ethics Committee of Asan Medical Center and University of Ulsan College of Medicine (2017-0210).
Informed consent statement: Patients were not required to provide informed consent for this study because the analysis used anonymous clinical data that were obtained after each patient had agreed to treatment with written consent.
Conflict-of-interest statement: None of the authors have any conflicts of interests to declare.
Data sharing statement: There are no additional data available in relation to this manuscript.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Kyung Mo Kim, MD, Professor, Department of Pediatrics, Asan Medical Center Children’s Hospital, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, South Korea. kmkim@amc.seoul.kr
Telephone: +82-2-30103380 Fax: +82-2-4733725
Received: November 10, 2017
Peer-review started: November 11, 2017
First decision: December 13, 2017
Revised: December 20, 2017
Accepted: December 26, 2017
Article in press: December 26, 2017
Published online: January 21, 2018
Processing time: 70 Days and 21 Hours
ARTICLE HIGHLIGHTS
Research background

Plastic stents (PSs) or metal stents have been widely used for the management of biliary and pancreatic duct strictures in endoscopic interventions. The fully covered self-expandable metal stent (FCSEMS) was designed to compensate for the defects of PSs and uncovered self-expandable metal stents (SEMSs). FCSEMSs have been widely used for the management of biliary and pancreatic duct strictures in adults. In general, studies on the application of stents in pediatric patients are lacking. This study reported our experience with using FCSEMS as part of the treatment for benign main pancreatic duct (MPD) strictures in pediatric patients with chronic pancreatitis (CP).

Research motivation

The major cause of CP in pediatric patients is hereditary pancreatitis rather than gallstones and alcoholism, unlike in adults. Pediatric patients experience mental and physical repetitive pain from complications of MPD stricture during their long life. Stenting is an important indication in pediatric ERCP. In a previous study, the use of FCSEMSs in the management of MPD stricture showed efficacy and safety at 6-mo intervals in adults. We report that our short-term outcomes in children are similar to the results obtained for adults, in terms of the improvement of strictures and the safety of the procedure.

Research objectives

This study evaluated the feasibility, safety, and therapeutic effect of FCSEMSs for the management of benign MPD strictures in pediatric patients with CP.

Research methods

This was a retrospective study of data collected through medical chart reviews between December 2014 and June 2017 at Asan Medical Center Children’s Hospital in Seoul, Korea. Eight patients with CP and benign dominant MPD stricture refractory to PS placement were enrolled. A dominant stricture was defined when the contrast medium on the endoscopic retrograde pancreatography film was not washed out and the upstream MPD dilation was ≥ 6 mm in diameter. Feasibility was evaluated based on technical success, migration, and patency. Technical success was determined in accordance with the success of stent placement and removal. Stricture improvement was evaluated by measuring the diameter of the stricture and the upstream dilation of the MPD. Safety was evaluated based on the occurrence of adverse events at 3 d and 14-21 d after FCSEMS placement. The Wilcoxon signed-rank test was used to compare changes in the diameter of the pancreatic duct between pre- and post-FCSEMS measurements. The IBM SPSS Statistics ver. 23.0 software was used for statistical analysis, and the stenting duration and patency are expressed as median values and ranges.

Research results

In all 8 patients, the placement of the 6-mm FCSEMS with dual flaps was technically successful. The median indwelling time of stenting was 6 mo (range, 3-10 mo). Stent embedding and occlusion did not develop. The patency of the stent lumen in the 8 patients with an FCSEMS had been maintained upon assessment at the time of stent removal. No stent migrations, adverse events, and mortalities were observed. After the removal of the stone and insertion of the stent, the pain disappeared and statistically significant improvements in stricture and upstream dilation were observed. The mean stricture diameter was 1.1 ± 0.3 cm before stenting and 2.8 ± 0.9 cm after stenting (P < 0.05). The diameter of the upstream dilatation showed improvement from 8.4 ± 2.5 cm to 6.3 ± 1.6 cm after stenting (P < 0.05). A future study with a larger sample size could clarify the usefulness of FCSEMS in children with benign MPD dilatation.

Research conclusions

This is the first study to investigate the efficacy and safety of the placement of the 6-mm FCSEMS with dual flaps in children. Despite the technical success and satisfactory clinical outcomes in these 8 children, the present study had certain limitations, including its retrospective design, relatively small sample size, and short follow-up period. In this study, we report our experience with using FCSEMS as part of the management of benign MPD strictures in pediatric patients with CP, providing valuable information about useful treatment for such patients. FCSEMS placement is an effective and safe management strategy for MPD strictures in pediatric patients with CP.

Research perspectives

We report the first case series of the use of FCSEMSs in the pediatric population with CP and MPD strictures refractory to PS placement. Despite the small sample size and lack of long-term follow-up, this preliminary study presents evidence of the feasibility of using FCSEMS even in children, with technical and functional success. A future long-term investigation with a greater number of patients is warranted.