Retrospective Study
Copyright ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Nov 28, 2020; 26(44): 7036-7045
Published online Nov 28, 2020. doi: 10.3748/wjg.v26.i44.7036
Endoscopic pancreaticobiliary drainage with overlength stents to prevent delayed perforation after endoscopic papillectomy: A pilot study
Liang Wu, Fang Liu, Nan Zhang, Xiao-Peng Wang, Wen Li
Liang Wu, International Center for Diagnosis and Treatment of Liver Diseases, The Fifth Medical Center of Chinese PLA General Hospital, Beijing 100039, China
Fang Liu, Nan Zhang, Wen Li, Department of Gastroenterology and Hepatology, The First Medical Center of Chinese PLA General Hospital, Beijing 100853, China
Xiao-Peng Wang, Department of Gastroenterology and Hepatology, Chinese PLA 305 Hospital, Beijing 100017, China
Author contributions: Li W designed the study, mainly performed endoscopic papillectomy, placed overlength stents, and revised the manuscript; Wu L and Liu F assisted in the endoscopic operation, analyzed the data and drafted the manuscript; Wu L and Liu F contributed equally to this work; Zhang N was involved in the preparation of resected specimens, immunohistochemical analysis and interpretation of pathological results; Wang XP assessed study details and revised the manuscript; and all authors read and approved the final version of the manuscript.
Institutional review board statement: This study was reviewed and approved by the Ethics Committee of the Chinese PLA General Hospital.
Informed consent statement: All study participants, or their legal guardian, provided informed written consent prior to study enrollment and were aware of the option of surgical treatment.
Conflict-of-interest statement: The authors have no financial relationships to disclose.
Data sharing statement: No additional data are available.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Wen Li, DPhil, DSc, Chief Doctor, Executive Vice President, Professor, Department of Gastroenterology and Hepatology, The First Medical Center of Chinese PLA General Hospital, No. 28 Fuxing Road, Haidian Distict, Beijing 100853, Beijing, China.
Received: August 20, 2020
Peer-review started: August 20, 2020
First decision: September 12, 2020
Revised: September 24, 2020
Accepted: October 13, 2020
Article in press: October 13, 2020
Published online: November 28, 2020
Research background

Endoscopic papillectomy (EP) is rapidly replacing traditional surgical resection and is a less invasive procedure for the treatment of duodenal papillary tumors in selected patients. With the expansion of indications, concerns regarding EP include not only technical difficulties, but also the risk of complications, especially delayed duodenal perforation. Delayed perforation after EP is a rare but fatal complication. Exposure of the artificial ulcer to bile and pancreatic juice is considered to be one of the causes of delayed perforation after EP. To drain bile and pancreatic juice away from the wound may help to prevent delayed perforation.

Research motivation

Although the application of an endoscopic nasobiliary drainage (ENBD) tube can achieve external drainage of bile, it is generally unable to drain pancreatic juice at the same time and may cause stress due to nasopharyngeal discomfort; while the conventional plastic biliary and pancreatic stents cannot drain bile and pancreatic juice a distance due to their limited length. These drainage methods cannot avoid erosion of the artificial ulcer by bile and/or pancreatic juice after EP. Therefore, we modified the ENBD tubes into overlength biliary and pancreatic stents to drain bile and pancreatic juice to the proximal jejunum.

Research objectives

The present study aimed to evaluate the feasibility and safety of placing overlength biliary and pancreatic stents after EP.

Research methods

This is a single-center, retrospective study. Five patients with exposure or injury of the muscularis propria after EP were included. A 7-Fr overlength biliary stent and a 7-Fr overlength pancreatic stent, modified by an ENBD tube, were placed in the common bile duct and pancreatic duct, respectively, and the bile and pancreatic juice were drained to the proximal jejunum.

Research results

EP and overlength stents placement were technically feasible in all five patients, with an average operative time of 63.0 ± 5.6 min. Of the five lesions (median size 20 mm, range 15-35 mm), en bloc excision and curative resection was achieved in four. The final histopathological diagnoses of the endoscopic specimens were one tubular adenoma with high-grade dysplasia (HGD), one tubulovillous adenoma with low-grade dysplasia, one hamartomatous polyp with HGD, one poorly differentiated adenocarcinoma and one atypical juvenile polyposis with tubulovillous adenoma, HGD and field cancerization invading the muscularis mucosae and submucosa. There were no stent-related complications, but one papillectomy-related complication (mild acute pancreatitis) occurred without any episodes of bleeding, perforation, cholangitis or late-onset duct stenosis.

Research conclusions

For patients with exposure or injury of muscularis propria after EP, the placement of overlength biliary and pancreatic stents is a feasible and useful technique to prevent delayed perforation.

Research perspectives

Overlength biliary and pancreatic stents placement after EP is a feasible, useful and safe technique to prevent papillectomy-related complications, especially delayed perforation, in selected patients by experienced endoscopists. However, due to the unique physiology and intricate anatomy of the duodenum, it is often difficult and time-consuming to place the distal ends of overlength stents into the jejunum. In view of the limited number of patients and the short-term follow-up, a further larger prospective study with long-term follow-up is needed to confirm our results.