Reducing post-endoscopic submucosal dissection pancreatitis in periampullary duodenal lesions: the role of prophylactic pancreatic duct stenting

Endoscopic submucosal dissection (ESD) has emerged as a transformative approach for managing superficial duodenal neoplasms, providing en bloc resection and precise histological assessment.1 However, ESD of the periampullary duodenum, particularly near the papilla of Vater, poses significant technical and clinical challenges.2 One of the most feared adverse events is post-ESD pancreatitis. This complication not only jeopardizes patient outcomes, but also limits the broader adoption of advanced endoscopic techniques in this anatomically complex region. Thus, mitigating the risk of pancreatitis is central to advancing the safety and efficacy of periampullary duodenal ESD.

The paper by Kobayashi et al.,3 addresses the clinically relevant and timely question: How best to reduce the risk of post-ESD pancreatitis in anatomically challenging regions? Given the potential severity of pancreatitis and its effects on patient outcomes, strategies to mitigate this complication should be carefully evaluated.

The pathogenesis of post-ESD pancreatitis in the periampullary duodenum is multifactorial.4 Manipulation and resection near the papilla of Vater can induce direct thermal or mechanical injury to the ampullary complex and surrounding tissues. Attempts to close mucosal defects, especially with clips or suturing devices, may inadvertently obstruct the pancreatic duct (PD) orifice, impede the outflow of pancreatic juice, and precipitate pancreatitis.5 Moreover, local edema and inflammation after ESD further exacerbate this risk by narrowing the ductal lumen and facilitating enzyme activation within the pancreatic parenchyma. These mechanisms underscore the unique vulnerability of the periampullary region and justify the development of targeted preventive strategies.6,7

Prophylactic PD stenting has gained popularity as a practical intervention to preempt post-ESD pancreatitis in high-risk anatomical settings.8,9 A transpapillary stent keeps the duct open, preventing obstruction due to mucosal closure, swelling, or accidental clip placement. Emerging data suggest that PD stenting is feasible and safe when performed by experienced endoscopists, with a low rate of stent-related complications. Complementary measures, including careful defect closure techniques, judicious use of thermal energy, and periprocedural pharmacological prophylaxis, may further augment protection against pancreatitis. However, the efficacy and safety of these interventions must be weighed against the procedural complexity and patient-specific risk factors.

The literature evaluating prophylactic PD stenting in periampullary duodenal ESD is marked by heterogeneity in study design, outcome measures, and reporting standards. Many published studies are retrospective, single-center, and limited by small sample sizes, which restricts the generalizability of their findings. Outcome definitions, particularly for post-ESD pancreatitis, differ, and procedural details such as stent type, timing, and removal protocols are inconsistently reported. Although several studies have demonstrated a reduction in the incidence of pancreatitis with PD stenting, the lack of adequately powered randomized controlled trials precludes definitive conclusions. Rigorous prospective studies with standardized endpoints are needed to clarify the intervention's true benefit-risk profile.

Incorporating prophylactic PD stenting into periampullary ESD protocols requires careful patient and lesion selection. Candidates most likely to benefit are those with lesions encroaching on or abutting the papilla, where the risk of ductal compromise is greatest. Proceduralists must be adept at selective cannulation and stent deployment, with contingency plans for complex anatomies or failed access. The decision to use a stent should also consider patient comorbidities, anticipated complexity of defect closure, and the risk of stent-related adverse events, such as migration or infection. Multidisciplinary discussions and individualized risk assessments are paramount for improving outcomes.10

Therefore, reducing the risk of post-ESD pancreatitis in the periampullary duodenum is essential for therapeutic endoscopy. Prophylactic PD stenting is a promising strategy; however, its routine adoption must be guided by robust evidence and adapted to procedural and patient-specific factors.

Prophylactic PD stent placement before ESD is a practical and physiologically grounded approach to reduce post-ESD pancreatitis in periampullary duodenal lesions. Drawing on the principles established for post-endoscopic retrograde cholangiopancreatography pancreatitis prevention and contemporary management strategies for duodenal ESD–related adverse events, this approach may help preserve PD patency and minimize papillary dysfunction.

Future research should prioritize multicenter, randomized studies with standardized outcome definitions and transparent reporting of procedural variables. Endoscopists must remain vigilant, balance innovation with safety, and embrace a multidisciplinary, evidence-driven approach to high-risk duodenal ESD. The pursuit of safer and more effective interventions will ultimately expand the therapeutic reach of endoscopic resection and improve patient care in this complex anatomical landscape.