Prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis using pancreatic stents: A review of efficacy, diameter and length

Table 1 Randomized controlled trials of prophylactic pancreatic stent insertion for preventing post-endoscopic retrograde cholangiopancreatography pancreatitis

Author	Yr	Country	Sample number		Risk factors	PEP n (%)	Criteria for PEP
			Stent	No stent		Stent/no stent
Smithline et al[21]	1993	United States	43	50	Acinarization, pre-cutting, history of pancreatitis	Total 6 (14)/9 (18), P = 0.299; Mild 5 (12)/5 (10), P = NA; Moderate 1 (2)/2 (4) P = NA; Severe 0 (0)/2 (4), P = 0.264	Cotton
Tarnasky et al[22]	1998	United States	41	39	SOD	Total 1 (2)/10 (26), P = 0.003; Mild 0 (0)/5 (13), P = NA; Moderate 0 (0)/5 (13), P = NA; Severe 0 (0)/0 (0), P = NA	Cotton
Fazel et al[23]	2003	United States	38	36	Difficult cannulation SOD	Total 2 (5.3)/10 (28), P < 0.05; Mild 2 (5.3)/5 (14), P = NA; Moderate 0 (0)/2(6), P = NA; Severe 0 (0)/3 (8), P = NA	Cotton
Sofuni et al[24]	2007	Japan	98	103	IDUS, biopsy, EPBD, SOD, POCS, Duodenal diverticulum, acinarization, initial pancreato-graphy, difficulty of cannulation	Total 3 (3)/14 (13.6), P = 0.019; Mild 2 (2)/8 (7.8), P = 0.139; Moderate 1 (1)/6 (4.6), P = 0.156; Severe 0 (0)/0(0), P = NA	Cotton
Tsuchiya et al[25]	2007	Japan	32	32	EST, IDUS, EPBD, SOD, pancreatic duct cannulation	Total 1 (3.1)/4 (12.5), P > 0.05; Mild 1 (3.1)/2 (6.3), P = NA; Moderate 0 (0)/1 (3.1), P = NA; Severe 0 (0)/1 (3.1), P = NA	Cotton
Ito et al[26]	2010	Japan	35	35	History of pancreatitis, history of PEP, pancreatic duct opacification, EST, IDUS, EPBD, cytology of pancreatic juice, biopsy of pancreatic duct	Total 1 (2.9)/8 (23) (per-protocol) 0 (0)/9 (24), P = 0.0096; Mild 1 (2.9)/8 (23); Moderate and severe 0	Cotton
Sofuni et al[28]	2011	Japan	213	213	History of pancreatitis, SOD, pancreato-graphy, EST, precut sphincter-otomy, EPBD, CBD tissue sampling, pancreatic duct tissue sampling, biliary drainage without EST, ENBD without EST, IDUS, difficulty of cannulation, long procedural time	(Intention to treat) Total 20 (9.4)/31 (14.6), P = 0.076; Mild 16 (7.5)/22 (10.3), P = 0.24; Moderate 4 (1.9)/8 (3.8), P = 389; Severe 0 (0)/1 (0.5), P = 1.00; (Full analysis set) Total 16 (7.9)/31 (15.2), P = 0.021; Moderate 12 (5.9)/22 (10.8), P = 0.77; Mild 4 (1.97)/8 (3.92), P = 0.952; Severe 0 (0)/1 (0.5), P = 1.00	Cotton
Pan et al[27]	2011	China	20	20	History of pancreatitis, pancreatic duct cannulation, pancreato-graphy, difficult cannulation, hyperamyla-semia	Total 4 (20)/14 (70), P < 0.01; Mild, moderate, severe NA	Cotton
Kawaguchi et al[29]	2012	Japan	60	60	History of PEP, SOD, difficult cannulation, pre-cutting, pancreatic duct biopsy, IDUS of pancreatic duct	Total 1 (1.7)/8 (13.3), P = 0.032; Mild 1 (1.7)/8 (13.3), P = 0.032	Modified Cotton
Lee et al[30]	2012	Korea	50	51	Difficult biliary cannulation, pancreatic cannulation	Total 6 (12)/15 (29.4), P = 0.031; Mild 5 (10)/12 (23.5), P = NA; Moderate 1 (2)/2 (3.9), P = NA; Severe 0 (0)/1 (2), P = NA	Cotton
Yin et al[31]	2016	China	104	102	History of PEP, cannulation difficulty, periampullary diverticulum	Total 8 (7.7)/18 (17.7), P = 0.031, Mild, Moderate, severe NA	NA

RCT: Randomized controlled trial; PEP: Post-endoscopic retrograde cholangiopancreatography pancreatitis; SOD: Sphincter of Oddi dysfunction; IDUS: Intraductal ultrasonography; EPBD: Endoscopic papillary balloon dilation; POCS: Peroral cholangioscopy; EST: Endoscopic sphincterotomy; CBD: Common bile duct; ENBD: Endoscopic nasobiliary drainage; NA: Not available.

Table 2 Meta-analyses of prophylactic pancreatic stent insertion for preventing post-endoscopic retrograde cholangiopancreatography pancreatitis

Author	Yr	Number of included studies	Type of included studies	PEP rateStent/no stent	PS insertion for preventing PEP
Singh et al[33]	2004	5	Full text	n = 206/275	Recommended
			Abstract	Total 12/43, P = 0.001 Mild to moderate 12/36, P = 0.001; Severe 0/7, P = 0.15
Mazaki et al[34]	2010	8	Full text	n = 336/344	Recommended
			Abstract	Total 19/64, P < 0.001; Mild to moderate 19/55, P < 0.001; Severe 0/7, P < 0.04
Choudhary et al[35]	2011	8	Full text	n = 322/334	Recommended
			Abstract	Total 16/66, P < 0.00001
Mazaki et al[36]	2014	14	Full text	n = 751/781	Recommended
			Abstract	Total 49/133, P < 0.001; Mild to moderate 49/120, P < 0.001; Severe 0/13, P = 0.01
Shi et al[37]	2014	10	Full text	n = 561/584; Total 34/117, P < 0.001; Mild 24/70, P < 0.001; Moderate 6/24, P = 0.004; Severe 0/6, P = 0.077	Recommended
Fan et al[38]	2015	15	Full text	n = 1233/1277	Recommended
			Abstract	Total 49/133, P < 0.00001; Mild 49/120, P < 0.00001; Severe 0/13, P < 0.00001

PS: Pancreatic stent; PEP: Post-endoscopic retrograde cholangiopancreatography pancreatitis.

Table 3 Comparison of stent type

Author, yr	Stent type	n	Results
Flanged or unflanged
He et al[39], 2018	Internal unflanged 5-Fr 3 cm stent with a single pigtail on the duodenal side vs internal flanged 5-Fr 3 cm stent with a single pigtail on the duodenal side	138/138	Spontaneous migration was more frequent with the internal unflanged stent (migration at five days: 47.72% vs 15.67%, P < 0.001, migration at 14 d 84.21% vs 42.65%, P < 0.001)
Comparison of stent diameter
Rashdan et al[40], 2004	3-4-Fr, 3-8 cm without internal flange vs 5-6-Fr, NA, with internal flange	2447/493	The 3-4-Fr stent was more effective in preventing PEP than the 5-6-Fr stent (PEP rate: 3-4-Fr stent 8.7% (213/2447) vs 5-6Fr 11.0% (54/493), P = 0.0471)
Zolotarevsky et al[43], 2011	5-Fr 5 cm vs 3-Fr 6 cm	38/40	PEP rates did not differ. 5-Fr PS placement was easier [mean modified 5-point Likert scale[40,41]: 1.8 (5-Fr) vs 3.4 (3-Fr), P < 0.01)], faster [9.2 (5-Fr) vs 11.1 minutes (3-Fr), P = 0.355], and required fewer wires [1.5 (5-Fr) vs 1.9 (6-Fr), P = 0.002]
Pahk et al[44], 2011	4-Fr vs 5-Fr, both stents were 2 to 11 cm, unflanged	137/209	PEP rates did not differ. Spontaneous migration was more frequent with the 4-Fr stent [95.8% (115/137) vs 68.7% (134/209), P < 0.001 (by log-rank test)]
Olsson et al[45], 2016	≤ 5-Fr, ≤ 5 cm vs > 5-Fr, > 5 cm	241 (≤ 5-Fr)/135 (> 5-Fr)	The > 5-Fr, > 5 cm stent was more effective in preventing PEP (> 5-Fr, > 5 cm 1.4% vs ≤ 5-Fr, ≤ 5 cm 9.4%, P = 0.0252)
Comparison of stent length
Chahal et al[46], 2009	5-Fr 3 cm, unflanged vs 3-Fr 8 cm or longer, unflanged	116/133	Spontaneous migration was more frequent with the 5-Fr 3 cm stent (5-Fr 98% vs 3-Fr 88%, P = 0.0001). Failure of PS placement was observed more often in the longer 3-Fr stent group (5-Fr 0/116 vs 3-Fr 11/133, P = 0.0003). PEP rates did not differ
Fujisawa et al[47], 2016	5-Fr 3 cm vs 5-Fr 5 cm, both stents were unflanged and straight	98/102	The 5-Fr 3 cm stent was more efficient for preventing PEP (3 cm 2.0% vs 5 cm 8.8%, P = 0.035). The period until spontaneous dislodgement was significantly shorter for the 3 cm stent than for the 5 cm stent (3 cm 2 d vs 5 cm 4 d, P < 0.001)
Part of the pancreas in which the stent was inserted
Sugimoto et al[48], 2018	Pancreatic head vs pancreatic body or tail	131/16	After ERCP, the level of the pancreatic isozyme of serum amylase was higher in the head group than in the body/tail group [head group 138.5 (7.0-2086) IU/L vs body/tail group 78.5 (5.0-1266.5) IU/L, P < 0.03]

ERCP: Endoscopic retrograde cholangiopancreatography; PEP: Post-ERCP pancreatitis.