Can endoscopic palliation of large neoplasm increase the risk of pancreatitis after endoscopic retrograde cholangiopancreatography

Recently, a patient presented with severe acute pancreatitis after biliary self-expandable metallic stent (SEMS) placement for palliation of an unresectable pancreatic cancer. This case induced us to consider the risk of acute pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP). The use of biliary SEMS represents the best therapeutic option for the treatment of neoplastic obstructive jaundice because it has a lower mortality and morbidity than surgery. It does not pose as a risk factor for inducing postERCP acute pancreatitis (PEAP) or other complications but increases only the risk of cholangitis [1]. However, SEMS is considered to be the first therapeutic palliation procedure for patients with unresectable pancreatic cancer. It offers better results than surgical palliation in terms of lower procedure-related complications and improves life quality [2, 3] Moreover, studies have shown the feasibility of simultaneous SEMS positioning for treating combined biliary and duodenal obstructions [4, 5]. We thought the PEAP in our case may have been attributable either to obstruction of the Wirsung caused by SEMS positioning or to direct damage due to the stent expansion, although no evidence for this exists in the literature. However, the causes more likely were a prolonged manipulation of the papilla due to a difficult cannulation or an excessive main pancreatic duct opacification. In a recent study, Cotton et al. [6] showed that the cited maneuvers can increase fatal post-ERCP complications. Although Schutz and Abbott [7] state that only technical success depend on the ERCP degree of difficulty and that complications do not, Cotton et al. [6] think that complicated procedures (grade 3 of the modified Madhotra classification [8]) pose higher risk for the development of complications because the approach to the papilla can be extremely complex. We think that large neoplasms (diameter, [4 cm) modifying the common bile duct (CBD) anatomy (kinking, coiling, stretching) also should be considered as a factor increasing the complexity of ERCP and thus the possibility of procedure-related pancreatitis. However, but at this writing, no author considers this to be a risk factor. To simplify the CBD cannulation, Ito et al. [9] recently have suggested inserting a pancreatic guidewire to achieve a selective biliary cannulation. This still needs a randomized study. Several authors have stated that the use of pancreatic stents probably is the best way to prevent PEAP [10–16]. Different series have shown that the use of this device reduces the incidence of PEAP from a range of 11.1% to 66.7% for patients with no stent to a range of 5% to 14.4% for patients with a stent. When the main pancreatic duct cannulation is obtained first, as often happens if the neoplastic lesion does not involve the duct, the clinician should place a pancreatic stent at once before proceeding to the CBD. The use of small-caliber (maximum, 5 Fr) short (2–3 cm) stents [17] and elimination of flaps before insertion [18] allow a spontaneous migration in 2 to 3 weeks without the need for endoscopic removal. Pancreatic stent positioning G. Fanello (&) M. Benedetti G. Martino M. Marengo R. L. Meniconi F. Papini P. Chirletti Department of Surgery, ‘‘F. Durante’’–General Surgery Unit, ‘‘Sapienza’’ University of Rome, Policlinico Umberto I, Viale del Policlinico, 155, 00161 Rome, Italy e-mail: gianfranco.fanello@uniroma1.it