Outcomes of Dilation of Recalcitrant Pancreatic Strictures Using a Wire-Guided Cystotome

Abstract

Background/aims: Pancreatic strictures in chronic pancreatitis are treated using endoscopic retrograde cholangiopancreatography (ERCP) with plastic stent placement. The management of recalcitrant strictures remains a challenge, with the use of a Soehendra stent retriever or a needle knife described in case reports. Here, we discuss our experience with dilation of dominant pancreatic strictures with a 6-Fr cystotome.

Methods: A retrospective review of an endoscopy database was performed to search for patients with pancreatic strictures recalcitrant to conventional methods of dilation in which a cystotome was used. Technical success was defined as the successful dilation of the stricture with plastic stent placement. Functional success was defined as substantial pain relief or resolution of pancreatic fistulae.

Results: Ten patients (mean age, 30.8 years) underwent dilation of a dominant pancreatic stricture secondary to chronic pancreatitis, with a 6-Fr cystotome. Seven patients presented with pain. Three patients had pancreatic fistulae (two had pancreatic ascites and one had a pancreaticopleural fistula). The median stricture length was 10 mm (range, 5-25 mm). The head of the pancreas was the most common location of the stricture (60%). Technical and functional success was achieved in all patients. One patient had self-limiting bleeding, whereas another patient developed mild post-ERCP pancreatitis.

Conclusion: The use of a 6-Fr cystotome (diathermy catheter) can be an alternative method for dilation of recalcitrant pancreatic strictures after the failure of conventional modalities.

Keywords: Dilation; Endoscopic retrograde cholangiopancreatography; Pancreatitis; Stents.

Fig. 1.

A 6-Fr monopolar cystotome used for dilation. The arrow points to the metal tip.

Fig. 2.

(A) Stricture at the neck of the pancreas (black arrow) with abnormal pancreaticobiliary ductal union Komi type IIA with a long common channel (red arrow), with the cystotome in the region of the head. (B) Cystotome passed across the stricture (arrow), with evident drainage of contrast. (C) Stent placed with complete drainage of contrast.

Fig. 3.

Stricture in region of the head (black arrow) with leak from the tail of the pancreas (red arrow) leading to a pancreaticopleural fistula.

Fig. 4.

Stricture in the proximal body of the pancreas (arrow) with a distally dilated pancreatic duct.

Fig. 5.

Algorithm proposal for dilation of dominant pancreatic strictures. ERCP, endoscopic retrograde cholangiopancreatography; MRCP, magnetic resonance cholangiopancreatography.