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Pancreas - Duct Stricture Dilation and Stent Exchange

abstract

This is a 52 year old with chronic pancreatitis and a persistent pancreatic head stricture after Extracorporeal Shock Wave Lithotripsy (ESWL), ERCP with pancreatic sphincterotomy and extraction of pancreatic stones and placement of pancreatic stents. Prior to this therapy, he had presented with intr...

actable pain requiring hospitalization. Since therapy, he had done well with minimal pain, return to work as an airport security agent, but required indwelling pancreatic stents as pain relapsed when the stents were removed. He is not a candidate for surgery because of portal vein thrombosis and portal hypertension noted on serial CT scans. Now you see three indwelling 5 French pancreatic stents. He has had these in for about 6 months and is beginning to have pain. We are going to change these stents and redilate the stricture. Because the stricture was hard to pass with a guidewire, we are cannulating beside the stents with an 025 hybrid Jagwire through a triple lumen Rapid exchange catheter (Boston Scientific) before removing the stents. Now we pass the wire to the tail tp maintain access, with a safety knuckle in the tail. The stents are removed one at a time with a rattooth forceps through the scope channel, while the wire remain in place. You can see the debris coming out of the duct. We cover these sorts of procedures with intravenous antibiotics. Now a pancreatogram is performed with a triple lumen cannula over the wire which has always remained in place. You can see the stricture between the arrows in the head of the pancreas, below a mildly dilated main pancreatic duct. Now a 6mm x 4cm hydrostatic Rapid Exchange dilating balloon (Boston Scientific) is positioned and inflated to 8 atmospheres. Then three 5F x 7cm single pigtail stents (Hobbs Medical) are placed, with internal flange to retain position. We use the Rapid Exchange dilating balloon as a push catheter, and the wire is withdrawn just enough to deploy the stent, then passed back into the duct for the next stent. We prefer multiple 5 French stents rather than a single large caliber stent because of better drainage of sidebranches between the stent lumens even after the stents occlude, The principle of treating a pancreatic stricture is much like that for benign biliary strictures, with as many stents as possible placed. However, long-term stricture response after stent removal is probably not as good as for biliary strictures because of surrounding pancreatic fibrosis.

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