Outcome of Long-Term Transmural Stenting for Pancreatic-Fluid Collections

Endoscopic drainage of pancreatic-fluid collections (PFCs) can be accomplished by placing transpapillary or transmural (via the stomach or duodenum) stents. PFCs that are drained transmurally recur, usually in the first year after stent removal, in about 10% to 30% of patients. To determine whether long-term transmural stenting leads to a lower recurrence rate, investigators in Belgium conducted a randomized trial at a single center in 28 patients with acute or chronic pancreatitis. Eighteen patients who were not randomized (due to refusal to participate or major complications) also were followed prospectively.

Consecutive patients were enrolled if their PFCs were larger than 30 mm and resolved with transmural drainage and stent placement. PFCs included 6 acute pseudocysts, 15 chronic pseudocysts, 5 abscesses, and 2 organized liquefied necroses. Main pancreatic-duct rupture, identified by secretin-stimulated magnetic resonance cholangiopancreatography, was present in 14 patients. Stents either were left in place (Group A) or were retrieved within 2 weeks of PFC resolution (Group B). Therapy failure was defined as recurrence of symptomatic PFCs that required additional therapy.

All patients had successful endoscopic transmural drainage: via the stomach in 18 and via the duodenum in 10. Of the 17 patients with chronic pancreatitis, 10 underwent main pancreatic-duct drainage with major (9) or minor (1) sphincterotomy and pancreatic stent insertion to dilate strictures, if necessary (6). Patients were followed for a median of 14 months after drainage and 11.5 months after randomization. Five of 13 patients (38%) in Group B experienced PFC recurrences (because of main pancreatic-duct rupture in 4 and duct obstruction caused by pancreatic stones in 1) that required therapy at a median of 6 months after drainage. No patient in Group A experienced PFC recurrence (P=0.013). No severe complications related to keeping stents in place occurred. Among the nonrandomized patients, 13 had stents left in situ after PFC resolution; none had PFC recurrences during a median follow-up of 12 months. In a univariate analysis of all 46 patients, PFC recurrence was associated significantly with stent retrieval (P=0.002) and with short stenting period (P=0.05). In the subgroup of patients who underwent stent retrieval (all 13 Group B patients and 1 nonrandomized patient), PFC recurrence was associated with main pancreatic-duct rupture.