Pancreatic stenting prevents pancreatitis after biliary sphincterotomy in patients with sphincter of Oddi dysfunction: A prospective randomized trial

Most patients with sphincter of Oddi dysfunction (SOD) have pancreatic sphincter hypertension (PSH) with or without biliary SOD. Preliminary data have suggested that PSH may explain the increased risk of post-ERCP pancreatitis after endoscopic biliary sphincterotomy (EBS) in patients with SOD. Purpose: To determine if pancreatic stenting after EBS protects against post-ERCP pancreatitis in patients with PSH. Methods: In a prospective trial, 80 patients with PSH (mean basal pressure ≥ 40 mmHg) were randomized to either a pancreatic STENT (n=41) or NO STENT (n=39) after BBS. The duct was aspirated during pancreatic manometry to decrease hydrostatic pressure in all patients. Pancreatic stents were 5 or 7 FG, 2-3 cm long, and extracted usually 1-4 days after EBS. Results: Both groups were similar with regard to age, distal bile duct diameter, accessory papilla patency, Cambridge classification of pancreatic ductography, and biliary cumulation difficulty. Below is the incidence of post-ERCP pancreatitis (graded according to Gastrointest Endosc 1991;37:383-393). After Biliary Sphincterotomy n Pancreatitis Grade Pancreatic YES 41 1(2%) 1 Mild STENT NO 39 10(26%)* 5 Mild 5 Moderate * significantly different compared to STENT group (p=0.003) Another 19 eligible patients with PSH were not randomized but also underwent EBS without pancreatic stenting; 4 (21%) developed post-ERCP pancreatitis. Of 28 excluded patients with normal pancreatic manometry, only 2 (7%) developed pancreatitis after EBS. Summary: Stenting the pancreatic duct significantly reduced pancreatitis after EBS in SOD patients with PSH. Conclusions: Short-term pancreatic duct stenting should be strongly considered in patients with proven SOD undergoing EBS; pancreatic manometry can properly select the minority that will not benefit from stenting.