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Fan H, Li N, Zhang X, Xu W, Zhang W, Ding Y, Li L, Liu T, Xia S. A review on pancreatic duct stents: materials and emerging trends. Biomed Mater 2025; 20:032004. [PMID: 40209758 DOI: 10.1088/1748-605x/adcb7d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2024] [Accepted: 04/10/2025] [Indexed: 04/12/2025]
Abstract
Pancreatic duct strictures, which can arise from trauma, inflammation, or malignancy, often result in complications such as duct obstruction, pancreatic parenchymal hypertension, and ischemia. Endoscopic stenting is an effective therapeutic approach for managing these strictures. However, traditional plastic pancreatic duct stents fail to conform to the physiological curvature of the pancreas, while metal pancreatic duct stents with flared ends reduce migration but are associated with complications such as de novo strictures. Additionally, plastic and metal pancreatic duct stents require surgical removal. Whereas biodegradable pancreatic duct stents present a promising alternative due to their superior biocompatibility and ability to decompose into non-toxic materials, potentially eliminating the need for additional surgeries. Despite these advantages, biodegradable pancreatic duct stents remain in the experiment stage. This review assesses current materials of pancreatic duct stents, and emphasizes recent advancements in biodegradable options and emerging trends in clinical applications.
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Affiliation(s)
- Huijuan Fan
- Tianjin University of Traditional Chinese Medicine, Tianjin 301617, People's Republic of China
- Department of Gastroenterology, Characteristic Medical Center of the Chinese People's Armed Police Force, Tianjin Key Laboratory of Hepatopancreatic Fiberosis and Molecular Diagnosis & Treatment, Tianjin, 300162, People's Republic of China
| | - Nan Li
- Tianjin University of Traditional Chinese Medicine, Tianjin 301617, People's Republic of China
- Department of Gastroenterology, Characteristic Medical Center of the Chinese People's Armed Police Force, Tianjin Key Laboratory of Hepatopancreatic Fiberosis and Molecular Diagnosis & Treatment, Tianjin, 300162, People's Republic of China
| | - Xingguang Zhang
- Department of Gastroenterology, Characteristic Medical Center of the Chinese People's Armed Police Force, Tianjin Key Laboratory of Hepatopancreatic Fiberosis and Molecular Diagnosis & Treatment, Tianjin, 300162, People's Republic of China
| | - Wei Xu
- Department of Gastroenterology, Characteristic Medical Center of the Chinese People's Armed Police Force, Tianjin Key Laboratory of Hepatopancreatic Fiberosis and Molecular Diagnosis & Treatment, Tianjin, 300162, People's Republic of China
| | - Wencheng Zhang
- Department of Gastroenterology, Characteristic Medical Center of the Chinese People's Armed Police Force, Tianjin Key Laboratory of Hepatopancreatic Fiberosis and Molecular Diagnosis & Treatment, Tianjin, 300162, People's Republic of China
| | - Yangjuan Ding
- Tianjin University of Traditional Chinese Medicine, Tianjin 301617, People's Republic of China
- Department of Gastroenterology, Characteristic Medical Center of the Chinese People's Armed Police Force, Tianjin Key Laboratory of Hepatopancreatic Fiberosis and Molecular Diagnosis & Treatment, Tianjin, 300162, People's Republic of China
| | - Lingjian Li
- Tianjin University of Traditional Chinese Medicine, Tianjin 301617, People's Republic of China
- Department of Gastroenterology, Characteristic Medical Center of the Chinese People's Armed Police Force, Tianjin Key Laboratory of Hepatopancreatic Fiberosis and Molecular Diagnosis & Treatment, Tianjin, 300162, People's Republic of China
| | - Taotao Liu
- Department of Gastroenterology, Characteristic Medical Center of the Chinese People's Armed Police Force, Tianjin Key Laboratory of Hepatopancreatic Fiberosis and Molecular Diagnosis & Treatment, Tianjin, 300162, People's Republic of China
| | - Shihai Xia
- Department of Gastroenterology, Characteristic Medical Center of the Chinese People's Armed Police Force, Tianjin Key Laboratory of Hepatopancreatic Fiberosis and Molecular Diagnosis & Treatment, Tianjin, 300162, People's Republic of China
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Cai YL, Wang F, Zhang J, Liu M, Guo RX, Yang T, Li ZS, Hu LH. Incidence, risk factors and endoscopic retrieval of proximally migrated pancreatic stents: 25 years of experience in a high-volume center - a case controlled study. Int J Surg 2025; 111:3115-3119. [PMID: 39878160 DOI: 10.1097/js9.0000000000002273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2024] [Accepted: 12/13/2024] [Indexed: 01/31/2025]
Abstract
BACKGROUND AND AIM Proximal migration is one of the complications after pancreatic stenting. This study aims to determine the incidence, risk factors and endoscopic treatment of proximally migrated pancreatic stents. METHODS A retrospective search of all the endoscopic retrograde cholangiopancreatography (ERCP) records was conducted from 1997 to 2022 in our tertiary center. Proximal migration of the pancreatic stent was defined as when the stent shifted completely into the pancreatic duct and the distal end of the stent was no longer visible at the duodenal papilla. RESULTS A total of 9017 pancreatic duct stentings of 6083 patients were performed. The proximal migration rate was 0.2% (17/9017). Three predictive factors for proximal migration were identified: pancreatic duct stones (OR, 0.107), residual pancreatic duct stones (OR, 8.290) and straight-shape stent (OR, 4.725). After including 19 patients transferred from other hospitals, 46 ERCPs were performed to retrieve the proximally migrated stents in 36 patients. The success rate of endoscopic removal was 80.6% (29/36). 1 (2.8%) patient was referred to surgery, and 6 patients had new pancreatic stents placed for conservative treatment. 21.7% (10/46) cases developed post-ERCP pancreatitis and 2.2% (1/46) developed infection. CONCLUSIONS Proximal migration of pancreatic stents is less common, but deserves more attention. Endoscopy is efficient in retrieving proximally migrated stents. In patients with residual pancreatic duct stones and straight stent, the risk of proximal migration is significantly increased.
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Affiliation(s)
- Yi-Li Cai
- Department of Gastroenterology, Changhai Hospital, Naval Medical University, Shanghai, China
- Department of Gastroenterology, Naval Medical Center, Naval Medical University, Shanghai, China
| | - Fan Wang
- Department of Gastroenterology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Jie Zhang
- Department of Gastroenterology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Miao Liu
- Department of Gastroenterology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Rui-Xi Guo
- Department of Gastroenterology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Ting Yang
- Digestive Endoscopy Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Zhao-Shen Li
- Department of Gastroenterology, Changhai Hospital, Naval Medical University, Shanghai, China
- Digestive Endoscopy Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Liang-Hao Hu
- Department of Gastroenterology, Changhai Hospital, Naval Medical University, Shanghai, China
- Digestive Endoscopy Center, Changhai Hospital, Naval Medical University, Shanghai, China
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Adachi K, Yamauchi H, Kida M, Okuwaki K, Iwai T, Tadehara M, Uehara K, Nakatani S, Imaizumi H, Koizumi W. Stent-induced symptomatic pancreatic duct stricture after endoscopic prophylactic pancreatic duct stent placement for the normal pancreas. Pancreatology 2019; 19:665-671. [PMID: 31307882 DOI: 10.1016/j.pan.2019.06.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 06/06/2019] [Accepted: 06/29/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVES Stent-induced pancreatic duct stricture (SI-PDS) is a complication associated with pancreatic stent placement. However, symptomatic SI-PDS associated with prophylactic pancreatic duct stents has not been sufficiently investigated. METHODS We examined the incidence and characteristics of symptomatic SI-PDS in patients who underwent pancreatic duct stent placement to prevent post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) between April 2007 and March 2017. RESULTS We examined 124 patients with normal pancreases consisting of 75 men and 49 women with a median age of 67.5 years [interquartile range (IQR): 61-74 years]. The median main pancreatic duct (MPD) diameter was 3.3 mm (IQR: 2.6-4.1 mm). The median duration of stent placement was 7 days (IQR: 3-14 days). Spontaneous dislodgment stents were placed in 43.5% of cases (54/124). The diameter of the stent was 5 Fr in 93.5% of cases (116/124) and 7 Fr in 6.5% of cases (8/124). Symptomatic SI-PDS was observed in 2.4% (3/124) of patients overall: 6.5% of patients with an MPD diameter of <3 mm and 0% of patients with an MPD diameter of ≥3 mm. Univariate analysis revealed that an MPD diameter <3 mm was a significant factor for symptomatic SI-PDS (p = 0.048). All cases of symptomatic SI-PDS improved with endoscopic treatment. CONCLUSIONS Symptomatic SI-PDS occurred in 2.4% of patients who underwent prophylactic pancreatic duct stent placement for normal pancreases. Patients with an MPD diameter of <3 mm may be susceptible to symptomatic SI-PDS.
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Affiliation(s)
- Kai Adachi
- Department of Gastroenterology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami, Sagamihara, Kanagawa, 252-0375, Japan
| | - Hiroshi Yamauchi
- Department of Gastroenterology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami, Sagamihara, Kanagawa, 252-0375, Japan.
| | - Mitsuhiro Kida
- Department of Gastroenterology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami, Sagamihara, Kanagawa, 252-0375, Japan
| | - Kosuke Okuwaki
- Department of Gastroenterology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami, Sagamihara, Kanagawa, 252-0375, Japan
| | - Tomohisa Iwai
- Department of Gastroenterology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami, Sagamihara, Kanagawa, 252-0375, Japan
| | - Masayoshi Tadehara
- Department of Gastroenterology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami, Sagamihara, Kanagawa, 252-0375, Japan
| | - Kazuho Uehara
- Department of Gastroenterology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami, Sagamihara, Kanagawa, 252-0375, Japan
| | - Seigo Nakatani
- Department of Gastroenterology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami, Sagamihara, Kanagawa, 252-0375, Japan
| | - Hiroshi Imaizumi
- Department of Gastroenterology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami, Sagamihara, Kanagawa, 252-0375, Japan
| | - Wasaburo Koizumi
- Department of Gastroenterology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami, Sagamihara, Kanagawa, 252-0375, Japan
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Risk factors for migration, fracture, and dislocation of pancreatic stents. Gastroenterol Res Pract 2015; 2015:365457. [PMID: 25945085 PMCID: PMC4402177 DOI: 10.1155/2015/365457] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Accepted: 03/25/2015] [Indexed: 11/17/2022] Open
Abstract
Aim. To analyze the risk factors for pancreatic stent migration, dislocation, and fracture in chronic pancreatitis patients with pancreatic strictures. Materials and Methods. Endoscopic stent placements (total 386 times) were performed in 99 chronic pancreatitis patients with pancreatic duct stenosis at our institution between April 2006 and June 2014. We retrospectively examined the frequency of stent migration, dislocation, and fracture and analyzed the patient factors and stent factors. We also investigated the retrieval methods for migrated and fractured stents and their success rates. Results. The frequencies of stent migration, dislocation, and fracture were 1.5% (5/396), 0.8% (3/396), and 1.2% (4/396), respectively. No significant differences in the rates of migration, dislocation, or fracture were noted on the patient factors (etiology, cases undergoing endoscopic pancreatic sphincterotomy, location of pancreatic duct stenosis, existence of pancreatic stone, and approach from the main or minor papilla) and stent factors (duration of stent placement, numbers of stent placements, stent shape, diameter, and length). Stent retrieval was successful in all cases of migration. In cases of fractured stents, retrieval was successful in 2 of 4 cases. Conclusion. Stent migration, fracture, and dislocation are relatively rare, but possible complications. A good understanding of retrieval techniques is necessary.
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Rosenkranz L, Patel SN. Endoscopic retrograde cholangiopancreatography for stone burden in the bile and pancreatic ducts. Gastrointest Endosc Clin N Am 2012; 22:435-50. [PMID: 22748241 DOI: 10.1016/j.giec.2012.05.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Stones in biliary and pancreatic ducts are entities that plague hundreds of thousands of patients worldwide every year. Symptoms can be mild (pain) to life threatening (cholangitis, severe acute pancreatitis). In the last few decades, management of these stones has transitioned from exclusively surgical to now predominantly endoscopic techniques. This article reviews the evolution of endoscopic techniques used in the management of stones in the common bile duct and pancreatic duct.
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Affiliation(s)
- Laura Rosenkranz
- Department of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA.
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Case history of endoscopic stanting in complex treatment of chronic pancreatitis. КЛИНИЧЕСКАЯ ПРАКТИКА 2011. [DOI: 10.17816/clinpract83818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
The problem of chronic pancreatitis treatment is very relevant. It makes more questions than answers. In case of pancreatic duct stenosis with super stenosis dilatation the endoscopic stanting may be one of alternative methods in complex treatment of chronic pancreatitis. We describe the case history of using this technology.
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Abstract
Treatment of chronic pancreatitis has been exclusively surgical for a long time. Recently, endoscopic therapy has become widely used as a primary therapeutic option. Initially performed for drainage of pancreatic cysts and pseudocysts, endoscopic treatments were adapted to biliary and pancreatic ducts stenosis. Pancreatic sphincterotomy which allows access to pancreatic ducts was firstly reported. Secondly, endoscopic methods of stenting, dilatation, and stones extraction of the bile ducts were applied to pancreatic ducts. Nevertheless, new improvements were necessary: failures of pancreatic stone extraction justified the development of extra-corporeal shock wave lithotripsy; dilatation of pancreatic stenosis was improved by forage with a new device; moreover endosonography allowed guidance for celiac block, gastro-cystostomy, duodeno-cystostomy and pancreatico-gastrostomy. Although endoscopic treatments are more and more frequently accepted, indications are still debated.
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Shinozuka N, Okada K, Torii T, Hirooka E, Tabuchi S, Aikawa K, Tawara H, Ozawa S, Ogawa N, Miyazawa M, Takeda A, Otani Y, Koyama I. Endoscopic pancreatic duct drainage and stenting for acute pancreatitis and pancreatic cyst and abscess. ACTA ACUST UNITED AC 2007; 14:569-74. [PMID: 18040622 DOI: 10.1007/s00534-006-1203-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2006] [Accepted: 09/20/2006] [Indexed: 01/03/2023]
Abstract
BACKGROUND/PURPOSE Endoscopic drainage of pancreatic pseudocysts using transpapillary and transmural approaches has been reported. In this study, endoscopic nasopancreatic drainage (ENPD) and pancreatic stenting were performed in patients with pseudocyst and abscess associated with acute pancreatitis, and the usefulness and problems of the procedures were investigated. METHODS After endoscopic retrograde pancreatography was done, ENPD and/or pancreatic stenting were performed in 13 patients with pancreatitis and pseudocyst or abscess that communicated with the main pancreatic duct. RESULTS ENPD was performed in seven patients, and was effective in all five patients with cysts: the cysts disappeared or shrank. However, the condition in the two patients with abscess was unchanged, and percutaneous drainage was performed. Stenting was carried out in six patients, and the cyst disappeared or pancreatitis was improved in all six. The stent was removed from two patients, but no recurrence has been noted so far. CONCLUSIONS ENPD and stenting are effective therapeutic choices for acute and chronic pancreatitis and pseudocysts, and they are superior to percutaneous drainage to avoid pancreatic fistula, but they may not be effective for pancreatic abscess. Selection of therapeutic methods corresponding to individual cases is important.
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Affiliation(s)
- Nozomi Shinozuka
- Department of Surgery, Saitama Medical School, 38 Morohongo, Moroyama-machi, Iruma-gun, Saitama, 350-0495, Japan
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Freeman ML. Pancreatic stents for prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis. Clin Gastroenterol Hepatol 2007; 5:1354-65. [PMID: 17981248 DOI: 10.1016/j.cgh.2007.09.007] [Citation(s) in RCA: 130] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Placement of pancreatic stents is a relatively new and increasingly adopted approach to reduce the risk of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. Evidence for the efficacy of pancreatic stents in reducing post-ERCP pancreatitis continues to accumulate. Routine use of pancreatic stents in high-risk cases at advanced centers has changed the complexion of ERCP, reducing the incidence and severity of post-ERCP pancreatitis to a more acceptable level, and eliminating some of the fear factor surrounding previously prohibitively risky settings, such as treatment of sphincter of Oddi dysfunction (SOD). On the other hand, the adoption of prophylactic pancreatic stenting into some practices has been sporadic. Problems with pancreatic stent placement include technical difficulty with placement, need for follow-up evaluation to ensure passage or removal, and potential for inducing pancreatic ductal injury. There remain many challenges and unanswered questions which will be addressed in this review, including which patients are at risk for post-ERCP pancreatitis, how might pancreatic stents reduce risk, what is the evidence supporting efficacy of pancreatic stenting in reducing risk; and based on those data, which ERCPs are at sufficiently high risk to warrant a stent; at what point in an ERCP should a pancreatic stent be placed; how long pancreatic stents need to remain in place to be effective, the risk of inducing pancreatic duct injury by placement of a stent; the frequency and consequences of failure at attempted stent placement, and effectiveness of pancreatic stent placement in the hands of those with limited experience. Current recommendations for use of pancreatic stents and areas requiring further investigation are discussed.
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Affiliation(s)
- Martin L Freeman
- Minnesota Pancreas and Liver Center, Division of Gastroenterology, University of Minnesota, Hennepin County Medical Center, Minneapolis, Minnesota 55415, USA.
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Tsuchiya T, Itoi T, Sofuni A, Itokawa F, Kurihara T, Ishii K, Tsuji S, Kawai T, Moriyasu F. Temporary pancreatic stent to prevent post endoscopic retrograde cholangiopancreatography pancreatitis: a preliminary, single-center, randomized controlled trial. ACTA ACUST UNITED AC 2007; 14:302-7. [PMID: 17520207 DOI: 10.1007/s00534-006-1147-8] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2006] [Accepted: 06/27/2006] [Indexed: 12/12/2022]
Abstract
BACKGROUND Post endoscopic retrograde cholangiopancreatography (post-ERCP) pancreatitis is the most common complication of ERCP, which can occasionally become serious or fatal. This preliminary study was to prospectively evaluate the efficacy of a temporary unflanged pancreatic duct stent (PS) to prevent post-ERCP pancreatitis. METHODS A total of 64 patients were randomly divided into a control group, which did not undergo stenting, and a stent group. The stent used was a 5-Fr pigtail PS without an inner flange. RESULTS Placement of an unflanged PS was successful and without complications in all 32 patients. The rates of hyperamylasemia were 50.0% and 34.4% in the control and stent groups, respectively (P > 0.05), and the mean serum amylase levels were 456.2 and 257.9 IU/l, respectively (P = 0.035). The overall rates of post-ERCP pancreatitis diagnosed according to Cotton's criteria were 12.5% and 3.1% in the control and stent groups, respectively (P > 0.05). The severity of pancreatitis was severe in one patient, moderate in one, and mild in two in the control group, whereas in the stent group, the single case of pancreatitis was mild. CONCLUSIONS Placement of an unflanged 5-Fr PS may be useful in preventing post-ERCP pancreatitis.
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Affiliation(s)
- Takayoshi Tsuchiya
- Division of Gastroenterology, Department of Internal Medicine, Tokyo Medical University, 6-7-1 Nishishinjuku, Tokyo 160-0023, Japan
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Ishihara T, Yamaguchi T, Seza K, Tadenuma H, Saisho H. Efficacy of s-type stents for the treatment of the main pancreatic duct stricture in patients with chronic pancreatitis. Scand J Gastroenterol 2006; 41:744-50. [PMID: 16716976 DOI: 10.1080/00365520500383597] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Stents have been used to relieve pancreatic duct stricture and upstream dilatation. However, many of these stents are straight-type stents originally manufactured for biliary use. A plastic stent that was developed for use in the pancreatic duct was used in this study and its usefulness investigated. MATERIAL AND METHODS The stent (s-type stent: 10 Fr in diameter) has two alternate flexions and the shape resembles the tilde mark " approximately " in appearance. After obtaining informed consent, stents were placed in 20 patients with abdominal pain caused by chronic pancreatitis and stricture of the distal main pancreatic duct. The stents were removed according to the clinical manifestations and replaced with new ones if the stricture persisted. RESULTS In total, 33 stents were placed in 20 patients. Pain relief was attained in 19 patients (95%). The stricture improved after one stenting in 8 patients (40%). Owing to persistent stricture, the stenting was repeated in 11 patients. The 50% stent indwelling period was 369.0 days. No proximal or distal migration of the stent occurred and there were no serious complications. CONCLUSIONS In view of its long durability as a stent and no migration, the s-stent is safe and useful for the management of pancreatic ductal strictures in patients with chronic pancreatitis.
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Affiliation(s)
- Takeshi Ishihara
- Department of Medicine and Clinical Oncology, Graduate School of Medicine, Chiba University, Chiba, Japan.
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Farnbacher MJ, Mühldorfer S, Wehler M, Fischer B, Hahn EG, Schneider HT. Interventional endoscopic therapy in chronic pancreatitis including temporary stenting: a definitive treatment? Scand J Gastroenterol 2006; 41:111-7. [PMID: 16373284 DOI: 10.1080/00365520510024098] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE In the past 15 years there have been tremendous advances in endoscopic management of chronic pancreatitis (CP). However, the value of endoscopic pancreatic stenting is still debatable. MATERIAL AND METHODS In 98 patients suffering from symptomatic CP (84 M, 14 F, 49+/-12, age range 23-83 years) endotherapy including temporary stenting of the pancreatic duct was performed. After final stent removal, indicating the primary end-point of endotherapy, 96 patients were followed for 35+/-28 (8 days-111) months. All data were assessed retrospectively. RESULTS As well as other endoscopic procedures, a total of 358 prostheses were inserted in the pancreatic duct and left in place for 3+/-1 (1 day-11) months. Total stent treatment time was 10+/-10 (6 days-49) months. At 46+/-27 (4-111) months after limited endotherapy, 57 patients had no need for secondary intervention, two-thirds were even without further pain sensations. In 22 patients, surgical treatment and in 17 patients further endoscopic therapy became necessary, which was significantly correlated with continued alcohol consumption. CONCLUSIONS Temporary stent placement as a part of interventional endoscopic therapy in CP shows a high rate of technical and long-term clinical success, with no need for secondary treatment in a remarkable number of patients. Continued cessation of alcohol consumption supports the treatment benefit significantly.
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Affiliation(s)
- Michael J Farnbacher
- Medizinische Klinik I mit Poliklinik, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
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Fogel EL. Endoscopic evaluation and management of pancreatic duct strictures. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2004. [DOI: 10.1016/j.tgie.2004.03.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Inui K, Yoshino J, Okushima K, Miyoshi H, Nakamura Y. MERITS and DEMERITS OF METALLIC STENT FOR TREATMENT OF PANCREATIC DUCT STRICTURES IN PATIENTS WITH CHRONIC PANCREATITIS. Dig Endosc 2004. [DOI: 10.1111/j.1443-1661.2004.00384.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
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Affiliation(s)
- Martin L Freeman
- Division of Gastroenterology, Hennepin County Medical Center, University of Minnesota, MN 55415, USA
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Rashdan A, Fogel EL, McHenry L, Sherman S, Temkit M, Lehman GA. Improved stent characteristics for prophylaxis of post-ERCP pancreatitis. Clin Gastroenterol Hepatol 2004; 2:322-9. [PMID: 15067627 DOI: 10.1016/s1542-3565(04)00062-x] [Citation(s) in RCA: 117] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Pancreatic stenting is an effective method to prevent post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis in high-risk patients. This retrospective study evaluated the impact of modified stent characteristics on the rate of post-ERCP pancreatitis, spontaneous stent dislodgment, and stent-related sequelae. METHODS A total of 2283 patients underwent 2447 ERCPs over a 6-year period with placement of 3-4F diameter, unflanged pancreatic stents. The indication for stenting was pancreatitis prophylaxis predominantly in suspected sphincter of Oddi dysfunction (SOD), pancreas divisum therapy, and precut sphincterotomy. An abdominal radiograph was obtained 10-14 days later to assess spontaneous stent passage. Post-ERCP pancreatitis was defined according to established criteria. A total of 479 patients underwent repeat ERCPs after an initial ERCP with pancreatic stent placement. The prestenting pancreatogram was then compared with follow-up studies. RESULTS The pancreatitis rate with 3F, 4F, 5F, and 6F stents was 7.5%, 10.6%, 9.8%, and 14.6%, respectively (3F vs. 4F, 5F, 6F: P = 0.047). Spontaneous stent dislodgment was 86%, 73%, 67%, and 65%, respectively (3F vs. 4F, 5F, 6F: P < 0.0001). The frequency of ductal changes was 24% in patients with 3-4F stents compared with 80% with 5-6F stents. Ductal perforation from the stents occurred in 3 patients (0.1%). CONCLUSIONS Small diameter (3-4F), unflanged pancreatic stents are more effective than the traditionally used stents (5-6F) in preventing post-ERCP pancreatitis. Stent-induced ductal changes and the need for endoscopic removal are also significantly less with 3-4F stents. The 3F stent appears to be superior in all aspects studied. Additional studies are needed to define the ideal method to eliminate post-ERCP pancreatitis.
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Affiliation(s)
- Abdullah Rashdan
- Division of Gastroenterology/Hepatology, Indiana University Medical Center, Indianapolis, 46202, USA
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Abstract
Acute recurrent pancreatitis (ARP) results most commonly from alcohol abuse or gallstone disease. Initial evaluation fails to detect the cause of ARP in 10-30% of patients, and as a result the diagnosis of "idiopathic" ARP is given. In these patients, a more extensive evaluation including specialized labs, ERCP, endoscopic ultrasound, or magnetic resonance cholangiopancreatography typically leads to a diagnosis of microlithiasis, sphincter of Oddi dysfunction, or pancreas divisum. Less commonly, hereditary pancreatitis, cystic fibrosis, a choledochocele, annular pancreas, an anomalous pancreatobiliary junction, pancreatobiliary tumors, or chronic pancreatitis are diagnosed. Determining the etiology is important, as it helps to direct therapy, limits further unnecessary evaluation, and may improve a patient's long term prognosis.
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Affiliation(s)
- M J Levy
- The Mayo Clinic, Rochester, Minnesota 55905, USA
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18
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Abstract
It is hoped that, in this millennium, chronic pancreatitis will be diagnosed earlier in the course of the disease process. Improved axial imaging of the pancreatic duct and pancreatic parenchyma will diminish the need for other invasive tests. Surgical procedures are directed at pancreatic duct decompression or resection of the pancreas (head, body or tail) or, infrequently, total pancreatectomy. Pain relief in 75% to 90% is the general rule, with diabetes developing subsequently in as many as 33% of patients. Surgery for chronic pancreatitis is effective in correcting sequelae of pancreatic fibrosis. Endoscopic stenting of the pancreatic and bile duct is used more frequently today. Until their place is ascertained, careful performance of surgery will continue to be a mainstay of treatment.
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19
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Cope C, Tuite C, Burke DR, Long WB. Percutaneous management of chronic pancreatic duct strictures and external fistulas with long-term results. J Vasc Interv Radiol 2001; 12:104-10. [PMID: 11200342 DOI: 10.1016/s1051-0443(07)61411-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- C Cope
- Section of Vascular/Interventional Radiology, Hospital of the University of Pennsylvania, Philadelphia 19104, USA.
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20
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Heyries L, Desjeux A, Sahel J. Bile duct-duodenum and pancreatic-gastric fistulas: two exceptional complications of biliary and pancreatic stenting. Gastrointest Endosc 1999; 50:571-4. [PMID: 10502186 DOI: 10.1016/s0016-5107(99)70088-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- L Heyries
- Department of Gastroenterology and Hepatology, Sainte Marguerite Hospital, Marseille, France
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21
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Catalano MF. Endoscopic treatment of pancreatic duct strictures. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 1999. [DOI: 10.1016/s1096-2883(99)80005-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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22
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Jakobs R, Riemann JF. The role of endoscopy in acute recurrent and chronic pancreatitis and pancreatic cancer. Gastroenterol Clin North Am 1999; 28:783-800, xii. [PMID: 10503150 DOI: 10.1016/s0889-8553(05)70087-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/14/2023]
Abstract
Endoscopy plays an important role in the diagnosis and treatment of acute and chronic pancreatitis as well as pancreatic cancer. Sphincterotomy and stone removal in biliary pancreatitis, stone extraction and drainage in chronic pancreatitis, and stent implantation in pancreatic cancer are the predominant procedures. With endoscopy, minimal invasive techniques are at hand to solve urgent and long term problems.
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Affiliation(s)
- R Jakobs
- Department of Gastroenterology, Klinikum der Stadt Ludwigshafen gGmbH, Academic Teaching Hospital, University of Mainz, Germany
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23
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Baron TH, Dean LS, Morgan DE, Holt TL. Proximal migration of a pancreatic duct stent: endoscopic retrieval using interventional cardiology accessories. Gastrointest Endosc 1999; 50:124-5. [PMID: 10385741 DOI: 10.1016/s0016-5107(99)70363-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- T H Baron
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Alabama, Birmingham, Alabama, USA.
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24
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Affiliation(s)
- D L Carr-Locke
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA
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25
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Abstract
Abdominal pain, excruciating and recurrent, is the dominant feature of chronic pancreatitis that initially brings most of the patients to the physician's attention. The pathogenesis of pancreatic pain is often multifactorial and explains why not all patients respond to the same mode of therapy. Increased intraductal pressure as a result of ductal stricture and/or calculi is the most frequent cause for pain in the large majority of patients with large duct disease. Interstitial hypertension, ongoing pancreatic ischemia, neuronal inflammation, and extra pancreatic complications may be the sole or additional factors in the pathogenesis of pain. The management of pain is difficult and requires a team approach. Internist, gastroenterologist, radiologist, surgeon, and a psychiatrist may have to work together to achieve maximum success. Drug and alcohol dependency needs vigorous management by a psychiatrist. Supportive therapy with a low-fat diet and antioxidant supplementation are helpful. When analgesic therapy fails, surgery may have to be considered much before a narcotic dependency develops. If at all of use, oral pancreatic enzyme therapy is suitable only in a selected group of patients--women with idiopathic pancreatitis. Endoscopic papillotomy, stent placement, and stone removal, although becoming popular, are under trial only and appear to be suitable in those with obstructive disease mostly localized to the head of the pancreas without much proximal disease. A patient with a dilated duct system is a good candidate for Puestow's pancreatico-jejunal anastamosis, which appears to be the best surgical procedure. Those with small duct diseases are difficult to be managed. Resective procedures and celiac ganglion blocking are suggested but not of much help.
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Affiliation(s)
- C S Pitchumoni
- New York Medical College and Our Lady of Mercy Medical Center, Bronx 10466, USA
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26
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Reynaud D, Alric L, Escourrou J, Bonnet E, Duffaut M. [Endoscopic treatment of subcutaneous fat necrosis secondary to pancreatic-vascular fistula: apropos of a case]. Rev Med Interne 1998; 19:123-7. [PMID: 9775127 DOI: 10.1016/s0248-8663(97)83422-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
PATIENT AND METHOD We report the case of a 68-year-old man who presented a pancreatic tumor with a pancreato-vascular fistula and a Weber-Christian syndrome. Pancreatic enzymes levels at the admission were high: amylasemia 2,470 IU/L (N < 110) and lipasemia 11,700 IU/L (N < 220). The treatment consisted in total parenteral nutrition and somatostatin (100 micrograms x 3/day). Because we noted neither clinical nor biological improvement after 10 days of treatment, we performed an endoscopic retrograde pancreatography. During this examination, we put a 7 French diameter prosthesis through the Wirsung stenosis. RESULTS No problem arose after endoscopy: since the day after the endoscopy, pancreatic enzymes decreased by half and become normal in 4 days; arthralgias and cutaneous injuries, both caused by cytosteatonecrosis, disappeared respectively in 5 and 10 days. There is no evidence of subsequent recurrence after 3 months of follow-up. CONCLUSION Pancreatic endoscopic prosthesis can replace the surgical treatment of pancreato-vascular fistula with a good efficacy.
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Affiliation(s)
- D Reynaud
- Service de médecine interne, pavillon Dieulafoy, CHU Purpan, place du Docteur-Baylac, Toulouse, France
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27
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28
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Dean JW, Trerotola SO, Lehman GA. Combined percutaneous and endoscopic removal of a proximally migrated pancreatic stent. J Vasc Interv Radiol 1996; 7:935-8. [PMID: 8951763 DOI: 10.1016/s1051-0443(96)70873-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Affiliation(s)
- J W Dean
- Department of Radiology, Indiana University Medical Center, University Hospital, Indianapolis 46202-5253, USA
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29
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Sherman S, Hawes RH, Savides TJ, Gress FG, Ikenberry SO, Smith MT, Zaidi S, Lehman GA. Stent-induced pancreatic ductal and parenchymal changes: correlation of endoscopic ultrasound with ERCP. Gastrointest Endosc 1996; 44:276-82. [PMID: 8885346 DOI: 10.1016/s0016-5107(96)70164-5] [Citation(s) in RCA: 76] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Polyethylene pancreatic duct stents induce morphologic changes of the pancreatic duct in the majority of patients. This study was undertaken to determine if parenchymal abnormalities are present in patients undergoing short-term pancreatic duct stenting and to correlate these findings with the pancreatogram obtained at stent removal. METHODS Twenty-five patients underwent pancreatic duct stenting and had an endoscopic ultrasound evaluation of the pancreas at stent removal. The pancreatograms were evaluated at stent removal for ductal irregularity, narrowing, and side branch changes. Endoscopic ultrasound was used to assess for differences in the echo characteristics of the pancreatic parenchyma around the stent compared with the rest of the gland. RESULTS Of the 16 patients evaluated by ERCP at stent removal, 9 (56%) had 1 or more new ductographic changes. Endoscopic ultrasound identified parenchymal changes in the stented region in 17 of 25 patients (68%). Four patients who had parenchymal changes in the stented region on endoscopic ultrasound at stent removal had a follow-up study at a mean time of 16 months. Two patients had (new) changes suggestive of focal chronic pancreatitis in the stented region. CONCLUSION Short-term pancreatic duct stenting induced both ductal and parenchymal changes in more than 50% of patients. Chronic pancreatitis may be a consequence of pancreatic duct stenting.
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Affiliation(s)
- S Sherman
- Department of Medicine, Indiana University School of Medicine, Indiana University Medical Center, Indianapolis 46202-5000, USA
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30
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Cohen SA, Siegel JH, Kasmin FE. Complications of diagnostic and therapeutic ERCP. ABDOMINAL IMAGING 1996; 21:385-94. [PMID: 8832856 DOI: 10.1007/s002619900089] [Citation(s) in RCA: 78] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Complications associated with ERCP have been well defined, clinically recognized, and effectively managed conservatively. Few patients require surgery or prolonged hospitalization. The morbidity and mortality associated with ERCP and sphincterotomy have remained low, and, although the outcome of endoscopy is equivalent or better than surgical or radiologic techniques, the complications are less. Despite the general acceptance of ERCP, its therapeutic applications, its more universal performance, and the morbidity and mortality rates have remained the same or lower since its introduction a quarter of a century ago.
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Affiliation(s)
- S A Cohen
- Beth Israel Medical Center North Division, 170 East End Avenue at 87th Street, New York, NY 10128, USA
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31
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Smith MT, Sherman S, Ikenberry SO, Hawes RH, Lehman GA. Alterations in pancreatic ductal morphology following polyethylene pancreatic stent therapy. Gastrointest Endosc 1996; 44:268-75. [PMID: 8885345 DOI: 10.1016/s0016-5107(96)70163-3] [Citation(s) in RCA: 139] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Polyethylene stents placed in the main pancreatic duct induce morphologic alterations that may resemble chronic pancreatitis. METHODS We reviewed the sequential pancreatograms of stented patients who had long-term follow-up after stent removal. RESULTS Forty patients (66%) had a normal baseline pancreatogram, whereas 21 (34%) showed changes of chronic pancreatitis. In 49 of 61 patients (80.3%), one or more had new morphologic changes immediately after stent withdrawal graded as mild (69%), moderate (29%), or severe (2%). Changes included ductal irregularity (49%), narrowing (35.5%), and side branch change (15.5%). Sixteen of the 21 patients (76.1%) with an abnormal baseline pancreatogram had worsening of the baseline abnormality or additional changes while stented, whereas 33 of 40 (82.5%) with a normal baseline developed new morphologic changes. Correlation of stent-induced changes with stent size, length, patency at removal, and duration of stenting failed to show an association. Twenty-five patients with stent-induced changes had a follow-up pancreatogram at a mean of 192 days (10 to 740) after stent removal. There was complete resolution of the changes in 64%, partial resolution in 32%, and no improvement in 5%. CONCLUSION Morphologic changes induced by polyethylene pancreatic duct stents occurred in 80% of patients. More than one third of these changes did not resolve during the follow-up period. Because of concern over stent-induced fibrosis, the use of pancreatic stents should remain largely experimental.
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Affiliation(s)
- M T Smith
- Indiana University Medical Center, Division of Gastroenterology/Hepatology, Indianapolis 46202, USA
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32
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Tan CC, Hall RI, Pallan JP, Irons RP, Freeman JG. Trans-hepatic proximal migration of percutaneous-endoscopic biliary stent presenting as an abdominal wall abscess. Gastrointest Endosc 1996; 43:152-4. [PMID: 8635713 DOI: 10.1016/s0016-5107(06)80121-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- C C Tan
- Gastroenterology Unit, Derby City General Hospital, United Kingdom
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33
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Ponchon T, Bory RM, Hedelius F, Roubein LD, Paliard P, Napoleon B, Chavaillon A. Endoscopic stenting for pain relief in chronic pancreatitis: results of a standardized protocol. Gastrointest Endosc 1995; 42:452-6. [PMID: 8566637 DOI: 10.1016/s0016-5107(95)70049-8] [Citation(s) in RCA: 153] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Pancreatic endoscopic stenting aims to relieve abdominal pain due to chronic pancreatitis. Optimal treatment modalities and post-treatment effects have still to be determined. The object of this study was to investigate the results of a standardized protocol of endoscopic stenting. METHODS Twenty-three patients with abdominal pain due to chronic pancreatitis and stricture of the distal main pancreatic duct were treated according to the following protocol: after balloon dilation of the stenosis, a 10F stent was placed into the main pancreatic duct and then exchanged every 2 months, the total duration of drainage being 6 months. RESULTS Use of analgesics could be discontinued in 17 patients (74%) on termination of drainage, and in 12 patients (52%) 1 year later. These results were significantly associated with reduction of main pancreatic duct diameter and resolution of stricture, but were not influenced by abstinence from alcohol and pancreatic enzyme supplementation. CONCLUSIONS Pancreatic duct stenting results in short-term clinical improvement in patients with chronic pancreatitis and proximal main pancreatic duct stricture. Persistence of advantageous clinical results is to be expected in 50% of cases and when strictures have resolved.
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Affiliation(s)
- T Ponchon
- Department of Digestive Diseases, Hôpital E. Herriot, Lyon, France
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34
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Affiliation(s)
- S O Ikenberry
- Indiana University Medical Center, Indianapolis 46202
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35
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36
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Sherman S, Alvarez C, Robert M, Ashley SW, Reber HA, Lehman GA. Polyethylene pancreatic duct stent-induced changes in the normal dog pancreas. Gastrointest Endosc 1993; 39:658-64. [PMID: 8224688 DOI: 10.1016/s0016-5107(93)70218-7] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
This study was undertaken to evaluate the frequency, severity, and reversibility of stent-induced pancreatic ductal and parenchymal changes in the normal dog pancreas. Six adult mongrel dogs underwent duodenotomy and placement of 5F polyethylene pancreatic duct stents into the main pancreatic duct. After 8 weeks of stenting, the animals were randomly assigned to one of three groups: group I (n = 2), sacrifice; group II (n = 2), stent removal followed by sacrifice after an 8-week recovery period; group III (n = 2), the stent was exchanged and kept in place for an additional 8 weeks. In group III at 16 weeks the stent was removed, and the animals were allowed to recover for 8 weeks before sacrifice. Pancreatograms were obtained at each operation and were normal before stent placement. Gross and histologic evaluation was performed at the time of sacrifice. All stented animals developed radiographic, gross, and histologic abnormalities. Pancreatograms showed duct dilation in the stented region associated with a short stenosis at the mid to upstream segment of the stent. Group III animals had more advanced radiographic changes than group I and II animals. The radiographic findings were associated with gross evidence of fibrosis, which increased proportionately with the length of the stenting period. Group III animals developed moderate to severe pancreas atrophy. Histologic changes of obstructive pancreatitis were present in most experimental dogs. The results of this study suggest that pancreatic stenting may cause permanent damage in the normal dog pancreas. The cause of the damage appears to be related to stent occlusion, perhaps exacerbated by local stent-induced trauma.
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Affiliation(s)
- S Sherman
- Department of Surgery, UCLA School of Medicine
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37
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Johanson JF, Schmalz MJ, Geenen JE. Simple modification of a pancreatic duct stent to prevent proximal migration. Gastrointest Endosc 1993; 39:62-4. [PMID: 8454148 DOI: 10.1016/s0016-5107(93)70013-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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