Pancreatic Stenting at Endoscopic Retrograde Cholangiopancreatography (ERCP) - Indications, Techniques, and Complications - UpToDate

6/2/24, 20:00 Pancreatic stenting at endoscopic retrograde cholangiopancreatography (ERCP): Indications, techniques, and complications - UpToDate
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Pancreatic stenting at endoscopic retrograde

cholangiopancreatography (ERCP): Indications,
techniques, and complications
AUTHORS: Marc F Catalano, MD, FACG, FACP, FASGE, AGAF, Vivek Kaul, MD, FACG, FASGE, AGAF
SECTION EDITOR: Douglas G Adler, MD, FACG, AGAF, FASGE
DEPUTY EDITOR: Kristen M Robson, MD, MBA, FACG
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Jan 2024.

This topic last updated: Nov 03, 2023.
INTRODUCTION
Endoscopic interventions such as pancreatic duct stenting have been increasingly used for
treating pancreatic disorders such as pancreatic duct obstruction and pancreatic duct leakage.
This topic will review issues related to endoscopic retrograde cholangiopancreatography (ERCP)-
guided pancreatic duct stenting including indications for therapeutic stenting, stent placement
and removal techniques, and complications.
The use of pancreatic stents to prevent post-ERCP pancreatitis is discussed separately. (See
"Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis".)
Endoscopic management of walled-off pancreatic fluid collections is discussed separately. (See

"Endoscopic interventions for walled-off pancreatic fluid collections".)
The use of biliary stents for treating malignant pancreaticobiliary obstruction is discussed
separately. (See "Endoscopic stenting for malignant biliary obstruction".)
The use of biliary stents for treating nonmalignant disease is discussed separately:
● Primary sclerosing cholangitis – (See "Primary sclerosing cholangitis in adults:

Management".)
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● Post-surgical biliary complications – (See "Liver transplantation in adults: Endoscopic

management of biliary adverse events" and "Endoscopic management of
postcholecystectomy biliary complications".)
INDICATIONS
Therapeutic stent placement
Pancreatic duct obstruction — Endoscopic therapy is indicated for patients with abdominal
pain due to pancreatic ductal obstruction, most commonly caused by pancreatic duct
stricture(s) and/or stone(s) [1]. Of note, endoscopic therapy alone is generally less feasible for
stones or strictures in the body of the pancreas and is impossible if the obstruction is in the tail
of the pancreas. The endoscopic interventions often involve a pancreatic sphincterotomy,
removal of pancreatic stones (if present), and placement of a transpapillary pancreatic duct
stent.
Chronic pancreatitis is often characterized by pain that may be related to increased pressure
within the pancreatic ductal system secondary to outflow obstruction of the main pancreatic
duct [2]. Pancreatic duct stenting has been associated with improvement in pain among
patients with chronic pancreatitis with downstream duct strictures resulting in upstream (ie,
closer to the tail of the pancreas) dilation [3,4]. The management of chronic pancreatitis is
discussed in more detail separately. (See "Chronic pancreatitis: Management".)
Some patients with pancreatic duct strictures also develop pancreatic duct stone formation
upstream from the stricture [4]. For patients with stones that cannot be completely cleared,
stent placement assists in drainage of pancreatic juices. Risk factors for incomplete stone
removal include >3 stones, stones in the pancreatic tail, stone size ≥10 mm, impacted stone(s),
and downstream pancreatic duct stricture [5].
Pancreatic duct leakage — ERCP-guided placement of a transpapillary pancreatic stent is

indicated for patients with pancreatic fistulas who are symptomatic or those with persistent or
enlarging fluid collections on abdominal imaging despite supportive care. Pancreatic ductal
disruptions may arise from acute or chronic pancreatitis, trauma, or surgical injury. Duct
disruptions lead to leakage of pancreatic fluid that may result in chronic pancreatic fistula
( table 1). Endoscopic therapy promotes internal drainage of pancreatic secretions, thereby
reducing flow through the fistula tract. Findings suggestive of a pancreatic duct disruption
include extravasation of contrast during injection of the pancreatic duct during ERCP, pancreatic
ascites, pancreatic fistula, or a fluid collection that communicates directly with the main
pancreatic duct [6]. (See "Endoscopic interventions for walled-off pancreatic fluid collections",
section on 'ERCP-guided transpapillary drainage'.)
The management of walled-off pancreatic fluid collections is discussed in more detail

separately. (See "Approach to walled-off pancreatic fluid collections in adults".)
Other interventions — Pancreatic stent placement is used in combination with extracorporeal

shock wave lithotripsy (ESWL) for patients without clearance of pancreatic stones after
fragmentation by ESWL [7]. (See "Extracorporeal shock wave lithotripsy for pancreatic stones".)
Stenting as a preventive strategy — Pancreatic duct stent placement has been used to
prevent pancreatitis in the following settings:
● Post ERCP-pancreatitis – The role of pancreatic stenting to prevent post-ERCP pancreatitis

is discussed separately. (See "Management of difficult biliary access during ERCP in
adults", section on 'Pancreatic stenting'.)
● Recurrent idiopathic acute pancreatitis – Prophylactic pancreatic duct stenting with or

without pancreatic sphincterotomy has been reported for patients with recurrent bouts of
idiopathic pancreatitis [8]. However, randomized trials are needed to clarify the role of this
intervention in such patients. (See "Etiology of acute pancreatitis".)
CONTRAINDICATIONS
ERCP-guided pancreatic duct stenting is typically contraindicated in the following patients:
● Patients who cannot tolerate sedation, monitored anesthesia care or general anesthesia
(see "Anesthesia for gastrointestinal endoscopy in adults")
● Patients with an untreated hemostatic disorder who are deemed to be at high risk for
bleeding by the advanced endoscopist (see "Gastrointestinal endoscopy in patients with
disorders of hemostasis")
● Patients who are hemodynamically unstable
● Patients with gastrointestinal (luminal) obstruction may undergo endoscopy, but the
examination may be limited to an area proximal to the level of obstruction (see "Enteral
stents for the palliation of malignant gastroduodenal obstruction")
PREPROCEDURE EVALUATION
The diagnosis of pancreatic duct obstruction or pancreatic duct leakage is often suspected
based on presenting symptoms (eg, abdominal pain, weight loss) and cross-sectional imaging
(computed tomography [CT] scan, magnetic resonance imaging [MRI] with magnetic resonance
cholangiopancreatography [MRCP]). Thus, most patients will have had imaging, thereby
mitigating the need for additional radiographic imaging before ERCP. Review of the
radiographic imaging prior to ERCP will help to define the biliary and pancreatic ductal
anatomy, exclude pancreas divisum, and identify pancreatic duct stones. (See "Chronic
pancreatitis: Clinical manifestations and diagnosis in adults".)
During a single endoscopic session, endoscopic ultrasound (EUS) is often performed prior to
ERCP because EUS may provide additional information such as defining pancreatic stone
location (ie, intraductal or parenchymal) and excluding occult tumors and common bile duct
stones.
STENT PLACEMENT
Patient preparation — The preprocedure preparation for patients undergoing ERCP with
pancreatic duct stent placement is similar to that described for patients undergoing ERCP for
other indications (see "Overview of endoscopic retrograde cholangiopancreatography (ERCP) in
adults", section on 'Patient preparation'):
● Adjusting medications – Most patients do not need to discontinue aspirin or nonsteroidal

anti-inflammatories when undergoing ERCP. Most patients who undergo ERCP with
pancreatic stent placement only (ie, without pancreatic or biliary sphincterotomy) typically
do not need to discontinue anticoagulant therapy. The management of antiplatelet and
anticoagulant therapy is typically individualized, managed in conjunction with the
prescribing specialist, and discussed separately. (See "Management of antiplatelet agents
in patients undergoing endoscopic procedures" and "Management of anticoagulants in
patients undergoing endoscopic procedures" and "Gastrointestinal endoscopy in patients
with disorders of hemostasis".)
● Antibiotic prophylaxis – Prophylactic antibiotics are generally not indicated for patients
undergoing ERCP with pancreatic duct stent placement in the absence of another
indication (eg, biliary obstruction, risk for incomplete drainage, pancreatic fistula)
( table 2). Thus, the use of antibiotic prophylaxis is individualized and based on patient-
and procedure-related risk factors for infection, in addition to endoscopist preference.
These issues are discussed separately. (See "Antibiotic prophylaxis for gastrointestinal
endoscopic procedures".)
● Anesthesia – The procedure is typically performed using monitored anesthesia care or

general anesthesia. Anesthetic management for endoscopic procedures including
preprocedure fasting is discussed separately. (See "Anesthesia for gastrointestinal
endoscopy in adults".)
Stents and other equipment
Types of stents — Pancreatic stents are available in varying lengths, diameters, and designs.
Newer stents may be brought to market, and availability varies by geographic area. Features of
pancreatic stents include [9,10]:
● Material – Most pancreatic stents are plastic stents composed of polyethylene materials.
● Size – Pancreatic stents are available in diameter sizes ranging from 3 to 10 French (Fr) and
in lengths ranging from 2 to 15 cm. Larger stents (10 Fr) are rarely used and are reserved
for patients with a markedly dilated, obstructed pancreatic duct (ie, duct diameter ≥4 mm)
that requires drainage.
● Design – Pancreatic stents are cylindrical in shape, and various designs are available.
Pancreatic stents may be either straight, curved, or single pigtail. Most stents have
features that help prevent internal migration (eg, distal flange, pigtail). Some stents have
both proximal and distal flaring to help anchor the stent. In addition, some stents have
radiopaque markers to improve visibility under fluoroscopy.
Some stents in development have features that mitigate the need for endoscopic stent removal
(eg, biodegradable stent) [11-13]. Other types of pancreatic stents are being studied such as
self-expandable stents (eg, removable, fully covered, metallic stents), but they are not used
routinely in clinical practice [14].
Stent selection is individualized and informed by the duct length to be traversed, diameter of
the duct lumen, indication for stenting (eg, obstruction, leakage), duct morphology (eg,
disruption), and endoscopist preference [15].
Guidewires — Guidewires are used to facilitate stent deployment. Guidewires vary in diameter
(eg, 0.018 inch, 0.021 inch, 0.025 inch, and 0.035 inch) and length, and may be hydrophilic,
straight, have a "J" tip, or a loop tip. Guidewires are available with various radiopaque markings
to aid in visualization and to minimize fluoroscopy time. Some guidewires are Teflon-coated,
which provides stability for stent placement and accessory exchanges. "Glidewire" and
"Roadrunner" are specialized wires that are used for patients with conditions resulting in
difficult cannulation (eg, papillary stenosis).
It is important to keep in mind that guidewire caliber needs to be compatible with the catheter
and stent size (eg, a 0.035 inch guidewire cannot be used to place a 3 Fr pancreatic stent or with
a 4 Fr cannulation catheter).
Dilators — Two types of dilators are commonly used: balloon dilators and passage dilator
catheters. Balloon dilators are inflation devices housed on a catheter, which are used to deliver
a specific radial pressure to a stenotic area. They are available in several diameters and lengths.
An inflation device is required to pressurize the balloon at a controlled rate.
Passage dilation catheters are available with a variety of tip sizes (ie, 3 to 11.5 Fr) or as
graduated dilating catheters. The size of the tip of the catheter limits the size of the guidewire
that can be used with it.
Stent deployment — Pancreatic duct stents are usually placed under endoscopic and
fluoroscopic guidance.
Pancreatic ductal obstruction — The technique for stent placement for patients with ductal
obstruction is summarized as follows [10]:
● Cannulate the ampulla and pancreatic duct.
● Place a guidewire across the location of the stricture and/or stone.
● Perform pancreatic sphincterotomy and stricture dilation, if needed ( image 1A-B). As an

example, patients with multiple or large pancreatic stones may require a combination of
pancreatic sphincterotomy, stricture dilation, and/or other stone removal methods in
addition to stent placement. Pancreatic sphincterotomy is used to facilitate access to the
main pancreatic duct and passage of endoscopic accessories used for stricture dilation
and stone removal. Patients being treated for a pancreatic leak or duct disruption may not
always require a pancreatic sphincterotomy.
● Advance the stent over the guidewire and deploy it. Because of the small diameter of most
pancreatic stents (eg, <10 Fr), they are usually deployed with only a guidewire and pushing
catheter. To avoid placing the stent completely within the pancreatic duct, we maintain
steady (but not increased) pressure on the pushing catheter, and we direct the endoscopy
assistant to maintain steady wire traction.
● After stent deployment, document the stent position by obtaining endoscopic and
fluoroscopic images.
Stent indwell time is individualized and is informed by the indication for stenting and
symptomatic response. However, most stents typically remain in place for four to eight weeks
prior to exchange or removal. (See 'Stent removal or replacement' below.)
Modifications to stent insertion technique can help minimize risks associated with pancreatic
stenting [16]:
● Avoid placing the upstream portion of the stent at or around the genu of the pancreas.
Transpapillary stents should either traverse the genu completely or remain entirely distal
to the genu. Stents that terminate near the genu may be more likely to cause ductal injury
or even perforation due to the sharp angulation at that site [17].
● Variations in pancreatic duct anatomy may inform the approach to stent placement. As an
example, wire cannulation of the pancreatic duct may be limited in patients with ansa
pancreatica, an anatomic variant consisting of a loop connecting the inferior branches of
the dorsal and ventral ducts [18]. For patients with such ductal anatomy, a shorter
transpapillary stent (eg, 2 to 3 cm in length) may be chosen because it reduces
manipulation of the pancreatic duct at the level of the ansa loop [19].
Endoscopic therapy with dilation and stenting for pancreatic duct strictures with or without
intraductal stones has been effective in reducing abdominal pain in 65 to 84 percent of patients
[3,20,21]. In a study including over 1000 patients with chronic pancreatitis with mean follow-up
of five years (range two to 12 years), pancreatic endotherapy for strictures, stones, or both was
associated with improvement in pain in 65 percent of patients [3].
Pancreatic duct leakage — For patients with pancreatic duct leakage, the technique for stent
placement is generally similar to placing a transpapillary stent for ductal obstruction. (See
'Pancreatic ductal obstruction' above.)
For patients with pancreatic duct leakage, stents are usually removed after four to six weeks
and are not replaced if the ductal disruption has resolved. (See 'Stent removal or replacement'
below.)
Bridging the region of the disruption with the stent is often accomplished, while nonbridging
transpapillary stent placement also promotes healing by reducing resistance to pancreatic juice
flow [22]. In a study of 43 patients with pancreatic duct disruption treated with pancreatic duct
stenting, 25 patients (58 percent) had resolution of the disruption [23]. Factors associated with
resolved ductal leakage after stenting included bridging of the ductal disruption and longer
duration of stenting (ie, six weeks).
Post-procedure care — Routine post-procedure care following ERCP is discussed separately.

(See "Overview of endoscopic retrograde cholangiopancreatography (ERCP) in adults".)
STENT REMOVAL OR REPLACEMENT
Timing — The duration of stenting is informed by the indications for stenting and the clinical
response to stenting (eg, symptomatic improvement). As an example, for patients with
pancreatic duct leakage, stents are usually removed after four to six weeks and are not replaced
if the ductal disruption has resolved. For patients who require stent replacement (also referred
to as stent exchange), stents are generally replaced every four to eight weeks until symptoms
are relieved. However, there is no clear consensus on the optimal time interval between stent
exchanges, and clinical practice is also guided by endoscopist preference. (See 'Stent
deployment' above.)
Factors contributing to the uncertainty regarding timing of stent removal and replacement are
the low reported rates of symptomatic stent occlusion and the risk, burden, and cost associated
with therapeutic ERCP. In a study examining outcomes after 146 pancreatic duct stent
placements in 115 patients, six percent of patients with occluded stents required hospitalization
for pancreatitis or increased pain [24]. The low rates of symptomatic stent occlusion may be
related to the observation that occluded stents may function as a "wick" around which
pancreatic juices continue to drain [25].
Technique — The technique for removing a stent from the pancreatic duct is summarized as
follows ( picture 1):
● Use a duodenoscope to visualize the ampulla and the intraluminal portion of the stent.
● Grasp the stent close to the tip, distal to the flaps (or flanges). Avoid excessive tightening
of the snare around the stent to prevent stent fracture. Alternatively, a biopsy forceps may
be used to grasp the stent for removal.
● Extract the stent smoothly from the duct by grasping the catheter at the accessory channel
and applying traction.
● After the stent is removed from the pancreatic duct, pull the snare and stent through the
duodenoscope. The removed stent is inspected to confirm that it is intact and without any
fracture.
Patients with conditions that require multiple stent exchanges (eg, stricture related to chronic
pancreatitis) may benefit from using varying stent lengths at subsequent exchanges, since most
stent-induced ductal changes occur at the upstream end of the stent within the pancreatic duct
[4]. Whenever possible, shorter stents are preferred over longer stents to limit the area of the
pancreatic duct that comes in contact with the foreign stent material, provided that the ductal
obstruction (or disruption) has been traversed. (See 'Stent-related morphologic changes' below.)
ADVERSE EVENTS
Adverse events associated with ERCP-guided pancreatic duct stent placement may be related to
the ERCP or to stent placement.
ERCP-related — Complications associated with ERCP may be due to the endoscopy itself (eg,
acute pancreatitis, perforation) or due to anesthesia (eg, hypotension). These complications are
discussed in more detail separately. (See "Overview of endoscopic retrograde
cholangiopancreatography (ERCP) in adults", section on 'Adverse events' and "Anesthesia for
gastrointestinal endoscopy in adults", section on 'Complications'.)
Stent-related — Pancreatic duct stent placement has been associated with a range of potential
complications. Some complications occur during or within several days of ERCP (ie, acute
complications), while other complications are delayed [19,26-29]:
● Acute complications include abdominal pain, ductal rupture related to catheter/balloon

dilation, gastrointestinal bleeding, intraprocedural inward stent migration, and post-ERCP
pancreatitis [30]. Prevention and management of post-ERCP pancreatitis is discussed
separately. (See "Post-endoscopic retrograde cholangiopancreatography (ERCP)
pancreatitis".)
● Nonacute or delayed complications include stent malfunction (migration, occlusion), stent-

related perforation, pancreatic ductal injury, and pancreatic stricture.
Stent-related morphologic changes — Pancreatic stents may induce morphologic changes

that resemble chronic pancreatitis:
● Prevalence – The reported rates of stent-induced changes (eg, pancreatic strictures, ductal
irregularities) have ranged from 18 to 80 percent [31-35]. Stent diameter size has been
linked to risk of ductal changes [31,35]. In a study including 2283 patients who underwent
ERCP and pancreatic stent placement, smaller diameter stents (3 to 4 Fr) were associated
with lower rates of ductal changes compared with larger stents (5 to 6 Fr [24 versus 80
percent]) [35].
● Location – The morphologic changes induced by pancreatic stenting may affect the
pancreatic parenchyma (eg, inflammatory response associated with the upstream end of
the stent) and/or the pancreatic duct (eg, dilation of side branches, narrowing, and ductal
irregularities) ( image 2A-B) [31,36].
● Detection – During ERCP that is performed to remove a therapeutic pancreatic stent, the
endoscopist may perform a pancreatogram to confirm resolution of the ductal pathology
and to evaluate for morphologic changes. (See 'Therapeutic stent placement' above.)
Stent-related ductal changes may also be detected on magnetic resonance

cholangiopancreatography (MRCP).
For patients with stent-induced changes such as ductal stricture, additional endoscopic therapy
such as stricture dilation and stenting may be performed.
Issues related to morphologic changes in a previously normal pancreas in the setting of

prophylactic stenting to prevent ERCP-related pancreatitis are discussed separately. (See "Post-
endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis".)
Stent occlusion — Most pancreatic duct stents occlude within 8 to 12 weeks after placement
[24,25,37,38]. In a study including 68 patients with pancreatic duct stents, 42 patients (62
percent) had complete stent occlusion at the time of stent removal and the median time to
occlusion was 35 days (95% CI, 30 to 40 days) [39]. Stents with >3 large side holes were less
likely to be occluded at the time of stent removal (hazard ratio [HR] 0.46, 95% CI 0.23-0.93).
Serious complications after stent blockage are uncommon, possibly due to drainage of
pancreatic juices alongside the occluded stent such that the stent acts as a wick [25]. However,
some patients develop abdominal pain or acute pancreatitis in the setting of stent occlusion
[27,33,37,40]. As a result, most advanced endoscopists perform stent exchanges electively
before occlusion is expected to occur. (See 'Stent removal or replacement' above.)
Occluded pancreatic stents can be treated endoscopically by removing the occluded stent and
replacing it with a new plastic stent.
The adherence of proteins to the inner surface of the stent seems to play a central role in stent
occlusion [34]. The occluding material (biofilm) consists of a protein matrix laden with calcium
carbonate crystals, mucopolysaccharides, and plant material [38].
Stent migration — Pancreatic duct stents may migrate in one of two directions:
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● Downstream stent migration (ie, outside the duct) rarely results in symptoms such as
worsening abdominal pain because the stent passes into the duodenum and is then
excreted [41]. In one report including 589 stent placements, the rate of downstream stent
migration was 8 percent [40].
● Upstream (or inward) stent migration (ie, into the duct) may lead to further complications
because of stent-induced ductal damage and technical challenges associated with stent
retrieval (small pancreatic duct diameter, bended duct course, presence of stricture)
[42,43]. In one report including 589 stent placements, upstream migration developed in 5
percent of patients [40].
However, most migrated pancreatic stents can be retrieved endoscopically ( image 3)

[42,44]. Surgical extraction is infrequently needed but has been performed for patients
with upstream migrated pancreatic stents in whom ERCP-guided retrieval attempts have
failed [45,46]. Pancreatoscopy may facilitate extraction of migrated pancreatic stents that
cannot be removed using retrieval techniques such as balloon catheter or grasping device
methods [47,48]. (See "Cholangioscopy and pancreatoscopy".)
The risk of upstream stent migration can be decreased by initial positioning the stent such
that it does not extend beyond the genu of the pancreas. In addition, modifications of
stent design have been studied to reduce the risk of internal migration. One possible
approach is eliminating internal stent flaring, which in one report, decreased risk of
upstream migration but increased the risk of downstream migration [35,40,49,50].
Other complications — Other complications related to pancreatic duct stenting include ductal
damage from the dilating catheter, cholangitis, and acute pancreatitis. While acute pancreatitis
is a known complication associated with ERCP, data have suggested that unsuccessful
pancreatic stent insertion was a risk factor for post-ERCP pancreatitis. In a study including 225
therapeutic ERCPs, failed stent insertion was associated with higher rates of acute pancreatitis
compared with successful stent placement (67 versus 14 percent) [19]. (See "Post-endoscopic
retrograde cholangiopancreatography (ERCP) pancreatitis".)
Evaluating for a suspected complication — For patients who had ERCP with pancreatic stent
placement and then developed symptoms such as new or worsening abdominal pain, our initial
evaluation for complications typically consists of laboratory testing (ie, liver biochemical tests,
amylase) and abdominal imaging (ie, plain film of the abdomen or computed tomography scan
if a walled-off pancreatic fluid collection is suspected). (See "Approach to walled-off pancreatic
fluid collections in adults", section on 'Clinical features'.)
SOCIETY GUIDELINE LINKS
Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Endoscopic retrograde
cholangiopancreatography (ERCP)".)
SUMMARY AND RECOMMENDATIONS
● Indications for therapeutic stent placement – Endoscopic retrograde

cholangiopancreatography (ERCP)-guided pancreatic duct stenting has been increasingly
used for treating pancreatic disorders such as pancreatic duct obstruction (often related to
pancreatic stricture and/or stones) and pancreatic duct leakage. (See 'Indications' above.)
● Preprocedure evaluation - Most patients will have had imaging prior to ERCP with
pancreatic duct stent placement, thereby mitigating the need for additional imaging prior
to the procedure. The diagnosis of pancreatic duct obstruction or pancreatic duct leakage
is often suspected based on presenting symptoms (eg, abdominal pain, weight loss) and
cross-sectional imaging (eg, computed tomography [CT] scan, magnetic resonance
imaging [MRI] with magnetic resonance cholangiopancreatography [MRCP]). (See
'Preprocedure evaluation' above.)
● Patient preparation - Antibiotic prophylaxis prior to ERCP-guided pancreatic stent

placement is generally not indicated in the absence of another indication (eg, biliary
obstruction, risk for incomplete drainage) ( table 2). Thus, the use of antibiotic
prophylaxis is individualized and based on patient- and procedure-related risk factors for
infection in addition to endoscopist preference. (See 'Patient preparation' above and
"Antibiotic prophylaxis for gastrointestinal endoscopic procedures".)
● Types of pancreatic stents - Pancreatic stents are available in varying lengths, diameters,
and designs and are primarily composed of polyethylene materials. Pancreatic stents are
cylindrical in shape, and most stents have features that help prevent internal migration
(eg, distal flange, pigtail). (See 'Types of stents' above.)
● Duration of pancreatic stent placement - The duration of stent placement is informed

by the indications for and clinical response to stenting (eg, symptomatic improvement)
(see 'Stent removal or replacement' above):
• For patients with pancreatic duct leakage, stents are usually removed after four to six
weeks and are not replaced if the duct disruption has resolved.
• For patients with pancreatic duct obstruction, stents are generally replaced every four
to eight weeks with the endpoint being resolution of symptoms.
● Adverse events - Adverse events reported with ERCP-guided pancreatic duct stent
placement may be related to the ERCP or to stent placement:
• Complications associated with ERCP may be due to the endoscopy itself (eg, acute
pancreatitis, perforation) or due to anesthesia (eg, hypotension). (See 'ERCP-related'
above.)
• Complications related to pancreatic stenting include stent dysfunction (eg, occlusion,

migration) and stent-related morphologic changes involving the pancreatic duct (eg,
stricture, irregularities) or parenchyma (eg, inflammatory change). (See 'Stent-related'
above.)
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22. ASGE Standards of Practice Committee, Chandrasekhara V, Chathadi KV, et al. The role of
endoscopy in benign pancreatic disease. Gastrointest Endosc 2015; 82:203.
23. Telford JJ, Farrell JJ, Saltzman JR, et al. Pancreatic stent placement for duct disruption.
Gastrointest Endosc 2002; 56:18.
24. Ikenberry SO, Sherman S, Hawes RH, et al. The occlusion rate of pancreatic stents.
25. Farnbacher MJ, Berner L, Raithel M, et al. Cleaning of occluded pancreatic duct
endoprostheses: a new indication for extracorporeal shock wave lithotripsy? Gastrointest
Endosc 2011; 74:527.
26. Ashby K, Lo SK. The role of pancreatic stenting in obstructive ductal disorders other than
pancreas divisum. Gastrointest Endosc 1995; 42:306.
27. Smits ME, Badiga SM, Rauws EA, et al. Long-term results of pancreatic stents in chronic
pancreatitis. Gastrointest Endosc 1995; 42:461.
28. Ponchon T, Bory RM, Hedelius F, et al. Endoscopic stenting for pain relief in chronic
pancreatitis: results of a standardized protocol. Gastrointest Endosc 1995; 42:452.
29. Cremer M, Devière J, Delhaye M, et al. Stenting in severe chronic pancreatitis: results of
medium-term follow-up in seventy-six patients. Endoscopy 1991; 23:171.
30. Geenen JE, Rolny P. Endoscopic therapy of acute and chronic pancreatitis. Gastrointest
Endosc 1991; 37:377.
31. Lawrence C, Cotton PB, Romagnuolo J, et al. Small prophylactic pancreatic duct stents: an
assessment of spontaneous passage and stent-induced ductal abnormalities. Endoscopy
2007; 39:1082.
32. Kozarek RA. Pancreatic stents can induce ductal changes consistent with chronic
pancreatitis. Gastrointest Endosc 1990; 36:93.
33. Morgan DE, Smith JK, Hawkins K, Wilcox CM. Endoscopic stent therapy in advanced chronic
pancreatitis: relationships between ductal changes, clinical response, and stent patency.
Am J Gastroenterol 2003; 98:821.
34. Smith MT, Sherman S, Ikenberry SO, et al. Alterations in pancreatic ductal morphology
following polyethylene pancreatic stent therapy. Gastrointest Endosc 1996; 44:268.
35. Rashdan A, Fogel EL, McHenry L Jr, et al. Improved stent characteristics for prophylaxis of
post-ERCP pancreatitis. Clin Gastroenterol Hepatol 2004; 2:322.
36. Bakman YG, Safdar K, Freeman ML. Significant clinical implications of prophylactic
pancreatic stent placement in previously normal pancreatic ducts. Endoscopy 2009;
41:1095.
37. Farnbacher MJ, Radespiel-Tröger M, König MD, et al. Pancreatic endoprostheses in chronic
pancreatitis: criteria to predict stent occlusion. Gastrointest Endosc 2006; 63:60.
38. Farnbacher MJ, Voll RE, Faissner R, et al. Composition of clogging material in pancreatic
endoprostheses. Gastrointest Endosc 2005; 61:862.
39. Buscaglia JM, DiMaio CJ, Pollack MJ, et al. Are large side holes associated with reduced rates
of pancreatic stent occlusion? Results of a prospective study. JOP 2009; 10:496.
40. Johanson JF, Schmalz MJ, Geenen JE. Incidence and risk factors for biliary and pancreatic
stent migration. Gastrointest Endosc 1992; 38:341.
41. Matsumoto K, Katanuma A, Maguchi H. Endoscopic removal technique of migrated
pancreatic plastic stents. J Hepatobiliary Pancreat Sci 2014; 21:E34.
42. Rana SS, Sharma R, Gupta R. Endoscopic retrieval of two proximally migrated plastic
pancreatic duct stents. JGH Open 2020; 4:97.
43. Lu Y, Jin Z, Wu JC, et al. Endoscopic retrieval technique of proximally migrated pancreatic
stents: a retrospective study in a tertiary centre. Gastroenterol Res Pract 2015;
2015:485980.
44. Lahoti S, Catalano MF, Geenen JE, Schmalz MJ. Endoscopic retrieval of proximally migrated
biliary and pancreatic stents: experience of a large referral center. Gastrointest Endosc
1998; 47:486.
45. Price LH, Brandabur JJ, Kozarek RA, et al. Good stents gone bad: endoscopic treatment of
proximally migrated pancreatic duct stents. Gastrointest Endosc 2009; 70:174.
46. Lucas DJ, Glaser JJ, Pearl JP. Laparoscopic distal pancreatectomy for retrieval of a proximally
migrated pancreatic stent. JSLS 2012; 16:169.
47. Kantsevoy SV, Frolova EA, Thuluvath PJ. Successful removal of the proximally migrated
pancreatic winged stent by using the SpyGlass visualization system. Gastrointest Endosc
2010; 72:454.
48. Rahimi A, Ejtehadi F. SpyGlass Pancreatoscopy and Successful Retrieval of a Proximally
Migrated Pancreatic Stent; Unusual Case and Technical Tips. Middle East J Dig Dis 2016;
8:232.
49. Johanson JF, Schmalz MJ, Geenen JE. Simple modification of a pancreatic duct stent to
prevent proximal migration. Gastrointest Endosc 1993; 39:62.
50. Ishihara T, Yamaguchi T, Seza K, et al. Efficacy of s-type stents for the treatment of the main
pancreatic duct stricture in patients with chronic pancreatitis. Scand J Gastroenterol 2006;
41:744.
Topic 2658 Version 20.0
GRAPHICS
Classification of pancreatic fistulas
1. External High output (>200 mL/day)
Low output (<200 mL/day)
Internal Pancreatic ascites, pleural effusion, communication with other viscera

or retroperitoneum or mediastinum
2. Based on underlying disease Acute pancreatitis

process
Chronic pancreatitis
Pancreatic cancer and other pancreatic neoplasms
Normal pancreas
3. Based on the immediate Postoperative (pancreatoduodenectomy, distal pancreatectomy,

predisposing cause surgery on organs adjacent to pancreas)
Percutaneous drainage of pancreatic fluid collections
Trauma
Courtesy of Dia T Simmons, MD, Santhi Swaroop Vege, MD, and Suresh T Chari, MD.
Graphic 66011 Version 2.0
Patients who require antibiotic prophylaxis for endoscopic procedures
Procedures that require

Patient group Comments*
prophylaxis
Specific patient groups
Patients with cirrhosis and All endoscopic procedures Patients with cirrhosis and acute
acute GI bleeding GI bleeding require antibiotics as
part of their routine treatment,
even if they are not undergoing
an endoscopic examination.
Cirrhosis with ascites Procedures that are high risk for Studies supporting using
infection or bacteremia ¶ prophylactic antibiotics in
patients with cirrhosis and ascite
are lacking. We believe it is
prudent to provide prophylaxis in
this group of patients, given the
risk of bacterial translocation.
Severe neutropenia (ANC <500 Procedures that are high risk for Studies supporting using
cells/mm 3 ) infection or bacteremia ¶ prophylactic antibiotics in
patients at increased risk for
Advanced hematologic
infection are lacking. We believe
malignancy
it is prudent to provide
prophylaxis in this group of
patients, given their increased
risk for infection.
Prophylaxis is not recommended

for patients who are
immunocompromised for other
reasons.
Synthetic vascular grafts Procedures that are high risk for When possible, elective
within six months of graft infection or bacteremia ¶ procedures should be performed
placement before a synthetic graft is placed
or delayed for six months
following graft placement. If a
procedure is necessary within six
months of graft placement, we
generally will give antibiotic
prophylaxis for high-risk
procedures.
Patients/conditions that
Procedure Comments*
require prophylaxis
For patients NOT falling into one of the above mentioned groups
Upper endoscopy
With or without biopsy, None

polypectomy,
esophageal stricture
dilation, endoscopic
sclerotherapy, or band
ligation of varices
With PEG/PEJ tube All patients The ASGE guidelines recommend

insertion pre-procedural screening for
MRSA in areas where MRSA is
endemic and attempting
decontamination before placing
the feeding tube.
Colonoscopy or flexible None Patients undergoing peritoneal

sigmoidoscopy, with or dialysis should have the
without biopsy or procedure done with the
polypectomy peritoneum empty. However, this
recommendation differs from
that of the ASGE, which
recommends antibiotic
prophylaxis for patients
undergoing peritoneal dialysis
prior to lower GI endoscopy, and
the ISPD, which recommends
antibiotic prophylaxis for patients
undergoing colonoscopy with
polypectomy.
ERCP Cholangitis Patients with cholangitis should

receive antibiotics as part of their
Biliary obstruction without
routine treatment. Additional
cholangitis if complete drainage
prophylaxis is not required.
is unlikely (eg, in patients with
malignant hilar carcinoma or If drainage is not successful,
primary sclerosing cholangitis) antibiotics should be started.
Once drainage has been
Biliary complications following
established, antibiotics can be
liver transplantation if drainage is
discontinued if there is no
unlikely
cholangitis.
EUS-FNA of cystic lesions Mediastinal cysts The ASGE recommends antibiotic

prophylaxis for all patients
undergoing EUS-FNA of cystic
lesions. However, we reserve it
for patients with mediastinal

cysts since they appear to be at
increased risk of infection. We do
not provide antibiotic prophylaxis
for EUS-FNA of pancreatic cysts
because there are insufficient
data to support their use in this
setting.
Antibiotics are typically continued

for three to five days after the
procedure.
EUS-FNA of solid lesions along None

the GI tract
Interventional EUS All patients

procedures Δ , natural orifice
transluminal endoscopic
surgery (NOTES)
NOTE: Refer to other table on antibiotic prophylaxis for endoscopic procedures for specific regimens.
GI: gastrointestinal; ANC: absolute neutrophil count; AHA: American Heart Association; ASGE: American
Society for Gastrointestinal Endoscopy; PEG: percutaneous endoscopic gastrostomy; PEJ: percutaneous
endoscopic jejunostomy; MRSA: methicillin-resistant Staphylococcus aureus; ISPD: the International
Society for Peritoneal Dialysis; ERCP: endoscopic retrograde cholangiopancreatography; EUS: endoscopic
ultrasound; FNA: fine-needle aspiration.
* The recommendations in this table are generally consistent with guidelines from the ASGE and AHA
except as noted here.
¶ Procedures that are high risk for bacteremia or infection include dilation of esophageal strictures,
endoscopic sclerotherapy, ERCP, EUS-FNA, and PEG/PEJ tube placement.
Δ Interventional EUS procedures include drainage of walled-off pancreatic necrosis, biliary drainage, and
fine-needle injection of cysts/tumors.
Recommendations summarized from:

1. ASGE Standards of Practice Committee, Khashab MA, Chithadi KV, et al. Antibiotic prophylaxis for GI endoscopy.
2. Otto CM, Nishimura RA, Bonow RO, et al. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart
Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice
Guidelines. Circulation 2021; 143:e72.
3. Nishimura RA, Carabello BA, Faxon DP, et al. ACC/AHA 2008 guideline update on valvular heart disease: focused update on
infective endocarditis: a report of the American College of Cardiology/American Heart Association Task Force on Practice
Guidelines: endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and
Interventions, and Society of Thoracic Surgeons. Circulation 2008; 118:887.
Balloon dilation of pancreatic duct stricture
This image shows a balloon that has been inflated within a stricture in the main pancreatic duct.
Courtesy of Marc Catalano, MD.
Residual pancreatic duct stricture following balloon dilation
Follow-up pancreatogram after balloon dilation of a pancreatic duct stricture shows an asymptomatic
short stricture.
Endoscopic removal of a pancreatic duct stent using a snare
This endoscopic image was taken during endoscopic retrograde cholangiopancreatography (ERCP). In
the second portion of the duodenum, a snare (arrow) was used to grasp the luminal portion of a plastic
pancreatic stent (arrowhead). The stent was removed from the pancreatic duct, and the snare and stent
were then pulled through the duodenoscope channel.
Courtesy of Vivek Kaul, MD, FACG, FASGE, AGAF.
Pancreatic duct stricture
Pancreatogram shows a dominant stricture (arrow) in the head of the pancreas following pancreatic duct
stenting.
Pancreatic parenchymal changes following pancreatic stent placement
Endoscopic ultrasound shows hypoechoic parenchymal changes (P) surrounding the proximal end of a
stricture following pancreatic duct stenting.
Proximal migration of a pancreatic stent
This pancreatogram demonstrates a pancreatic stent that has migrated into the pancreatic body. A mini-
snare has been advanced into the pancreatic duct and is opened beyond the stent to capture its proximal
end.
Contributor Disclosures
Marc F Catalano, MD, FACG, FACP, FASGE, AGAF No relevant financial relationship(s) with ineligible
companies to disclose. Vivek Kaul, MD, FACG, FASGE, AGAF Consultant/Advisory Boards: Ambu
[Endoscopy]; Castle Biosciences [Barretts esophagus]; Cook Medical [Endoscopy]; Motus GI [Endoscopy];
Steris Corp [Endoscopy]. All of the relevant financial relationships listed have been mitigated. Douglas G
Adler, MD, FACG, AGAF, FASGE Consultant/Advisory Boards: Abbvie [Endoscopy]; Boston Scientific
[Endoscopy]; Endorotor [Endoscopy]; Merit [Endoscopy]; Olympus [Endoscopy]. Speaker's Bureau: Abbvie
[Pancreatology, general GI]. All of the relevant financial relationships listed have been mitigated. Kristen
M Robson, MD, MBA, FACG No relevant financial relationship(s) with ineligible companies to disclose.
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must
conform to UpToDate standards of evidence.
Conflict of interest policy

Pancreatic Stenting at Endoscopic Retrograde Cholangiopancreatography (ERCP) - Indications, Techniques, and Complications - UpToDate

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6/2/24, 20:00 Pancreatic stenting at endoscopic retrograde cholangiopancreatography (ERCP): Indications, techniques, and complications - UpToDate

Official reprint from UpToDate®

Pancreatic stenting at endoscopic retrograde

Literature review current through: Jan 2024.

Endoscopic management of walled-off pancreatic fluid collections is discussed separately. (See

● Primary sclerosing cholangitis – (See "Primary sclerosing cholangitis in adults:

● Post-surgical biliary complications – (See "Liver transplantation in adults: Endoscopic

Therapeutic stent placement

Pancreatic duct leakage — ERCP-guided placement of a transpapillary pancreatic stent is

The management of walled-off pancreatic fluid collections is discussed in more detail

Other interventions — Pancreatic stent placement is used in combination with extracorporeal

● Post ERCP-pancreatitis – The role of pancreatic stenting to prevent post-ERCP pancreatitis

● Recurrent idiopathic acute pancreatitis – Prophylactic pancreatic duct stenting with or

ERCP-guided pancreatic duct stenting is typically contraindicated in the following patients:

● Patients who are hemodynamically unstable

● Adjusting medications – Most patients do not need to discontinue aspirin or nonsteroidal

● Anesthesia – The procedure is typically performed using monitored anesthesia care or

Stents and other equipment

● Cannulate the ampulla and pancreatic duct.

● Place a guidewire across the location of the stricture and/or stone.

● Perform pancreatic sphincterotomy and stricture dilation, if needed ( image 1A-B). As an

Post-procedure care — Routine post-procedure care following ERCP is discussed separately.

STENT REMOVAL OR REPLACEMENT

● Acute complications include abdominal pain, ductal rupture related to catheter/balloon

● Nonacute or delayed complications include stent malfunction (migration, occlusion), stent-

Stent-related morphologic changes — Pancreatic stents may induce morphologic changes

Stent-related ductal changes may also be detected on magnetic resonance

Issues related to morphologic changes in a previously normal pancreas in the setting of

However, most migrated pancreatic stents can be retrieved endoscopically ( image 3)

SOCIETY GUIDELINE LINKS

SUMMARY AND RECOMMENDATIONS

● Indications for therapeutic stent placement – Endoscopic retrograde

● Patient preparation - Antibiotic prophylaxis prior to ERCP-guided pancreatic stent

● Duration of pancreatic stent placement - The duration of stent placement is informed

• Complications related to pancreatic stenting include stent dysfunction (eg, occlusion,

Use of UpToDate is subject to the Terms of Use.

1. Nabi Z, Lakhtakia S. Endoscopic management of chronic pancreatitis. Dig Endosc 2021;

7. Dumonceau JM, Delhaye M, Tringali A, et al. Endoscopic treatment of chronic pancreatitis:

Endoscopy 2019; 51:179.

Topic 2658 Version 20.0

Classification of pancreatic fistulas

1. External High output (>200 mL/day)

Low output (<200 mL/day)

Internal Pancreatic ascites, pleural effusion, communication with other viscera

2. Based on underlying disease Acute pancreatitis

Pancreatic cancer and other pancreatic neoplasms

3. Based on the immediate Postoperative (pancreatoduodenectomy, distal pancreatectomy,

Percutaneous drainage of pancreatic fluid collections

Graphic 66011 Version 2.0

Patients who require antibiotic prophylaxis for endoscopic procedures

Procedures that require

Specific patient groups

Prophylaxis is not recommended

With or without biopsy, None

With PEG/PEJ tube All patients The ASGE guidelines recommend

Colonoscopy or flexible None Patients undergoing peritoneal

ERCP Cholangitis Patients with cholangitis should

EUS-FNA of cystic lesions Mediastinal cysts The ASGE recommends antibiotic

for patients with mediastinal

Antibiotics are typically continued

EUS-FNA of solid lesions along None

Interventional EUS All patients