Treatment of symptomatic distal common bile duct stenosis secondary to chronic pancreatitis: comparison of single vs. multiple simultaneous stents

Endoscopic therapy of benign biliary strictures

Benign biliary strictures are being increasingly treated with endoscopic techniques. The benign nature of the stricture should be first confirmed in order to ensure appropriate therapy. Surgery has been the traditional treatment, but there is increasing desire for minimally invasive endoscopic therapy. At present, endoscopy has become the first line approach for the therapy of post-liver transplant anastomotic strictures and distal (Bismuth Iand II) post-operative strictures. Strictures related to chronic pancreatitis have proven more difficult to treat, and endoscopic therapy is reserved for patients who are not surgical candidates. The preferred endoscopic approach is aggressive treatment with gradual dilation of the stricture and insertion of multiple plastic stents. The use of uncovered self expandable metal stents should be discouraged due to poor long-term results. Treatment with covered metal stents or bioabsorbable stents warrants further evaluation. This area of therapeutic endoscopy provides an ongoing opportunity for fresh research and innovation.

Advances in the endoscopic management of patients with pancreatic and biliary malignancies

Major advances in endoscopic techniques to diagnose and manage pancreatic biliary diseases have fundamentally changed the approach to these difficult clinical challenges. The diagnosis of benign and malignant pancreatic-biliary diseases is much more readily obtained through a combination of cross-sectional imaging and endoscopic procedures. Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) are the most important endoscopic tools for imaging and accessing the pancreatic biliary system. The review summarizes the major imaging methods for providing a diagnosis of bile duct malignancy, including ERCP, transhepatic cholangiography (THC), and magnetic resonance cholangiopancreatography (MRCP). High quality image examples of cholangiocarcinoma are provided. EUS has provided a new imaging modality for the detection of pancreatic and biliary malignancy. EUS is particularly sensitive for the detection of early pancreatic malignancy. Furthermore, EUS excels at the guidance of fine needle aspiration of pancreatic lesions. Diagnostic tissue acquisition for cholangiocarcinoma remains an important challenge. The endoscopic therapy for pancreatic-biliary malignancy involves the use of stenting which relieves the biliary obstruction commonly seen in these patients.

Biliary tract obstruction in chronic pancreatitis

Bile duct strictures are a common complication in patients with advanced chronic pancreatitis and have a variable clinical presentation ranging from an incidental finding to overt jaundice and cholangitis. The diagnosis is mostly made during investigations for abdominal pain but jaundice may be the initial clinical presentation. The jaundice is typically transient but may be recurrent with a small risk of secondary biliary cirrhosis in longstanding cases. The management of a bile duct stricture is conservative in patients in whom it is an incidental finding as the risk of secondary biliary cirrhosis is negligible. Initial conservative treatment is advised in patients who present with jaundice as most will resolve once the acute on chronic attack has subsided. A surgical biliary drainage is indicated when there is persistent jaundice for more than one month or if complicated by secondary gallstones or cholangitis. The biliary drainage procedure of choice is a choledocho-jejunostomy which may be combined with a pancreaticojejunostomy in patients who have associated pain. Since many patients with chronic pancreatitis have an inflammatory mass in the head of the pancreas, a Frey procedure is indicated but a resection should be performed when there is concern about a malignancy. Temporary endoscopic stenting is reserved for cholangitis while an expandable metal stent may be indicated in patients with severe co-morbid disease.

Updates in biliary endoscopy

PURPOSE OF REVIEW

Endoscopic retrograde cholangiopancreatography is a non-surgical approach to diseases of the pancreaticobiliary system that dates back to the late 1960s. Initially, endoscopic retrograde cholangiopancreatography was purely a diagnostic procedure. After the first report of endoscopic sphincterotomy in 1974, therapeutic uses were possible for diseases that previously required surgery. As therapeutic indications broaden, our understanding of complications has tempered the initial excitement. Non-invasive imaging in many circumstances has replaced the diagnostic utilization of endoscopic retrograde cholangiopancreatography which is now reserved primarily for therapeutic indications. This review is intended to address biliary therapeutics with an update on the recent directions of this field.

RECENT FINDINGS

Advancements in the endoscopic retrograde cholangiopancreatography medical literature in the last year have concentrated on the management of difficult common bile duct stones using electrohydraulic lithotripsy, chronic pancreatitis and pancreatic cancer-induced biliary strictures, postoperative bile leaks, the use of newer methods of biliary access and finally the use of ulinastatin for the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis.

SUMMARY

This is an update of the work in the field of biliary endoscopy over the last year. The goal of this review is to address specific management concerns in the field of biliary endoscopy from the literature published in 2005.

Endoscopic therapy for chronic pancreatitis: an evidence-based review

In the setting of chronic pancreatitis, pancreatic ductal obstruction, and ductal leak, pseudocyst formation and biliary obstruction present many challenges for endoscopists. Although chronic pancreatitis has a variety of clinical manifestations, most commonly patients present with intermittent or chronic abdominal pain. Recent studies suggest stenting of pancreatic ductal strictures has a significant impact on reducing chronic pain. The removal of ductal calculi, presumably from relieving obstruction, also improves abdominal pain. When the site of leak is bypassed, ductal leaks may be cured by endoscopic stenting. Multiple plastic bile duct stents to treat chronic pancreatitis-associated bile duct stricture can delay the need for surgery. Although these endoscopic techniques have been beneficial for many patients, further study is warranted to better define their role in chronic pancreatitis compared with well-established surgical techniques.

Endoscopic therapy for chronic pancreatitis

When endoscopic therapy is used for the treatment of patients with painful chronic pancreatitis, extracorporeal shock wave lithotripsy (ESWL) can be proposed as a first-line approach when obstructive ductal stone(s) induce upstream dilation of the main pancreatic duct. Stone fragmentation by ESWL is followed by endoscopic ductal drainage using pancreatic sphincterotomy, fragmented stone(s) extraction, and pancreatic stenting in case of ductal stricture. After completion of endoscopic pancreatic ductal drainage, long-term clinical benefit can be expected for two thirds of the patients. Best clinical results are associated with absence or cessation of smoking and with early treatment in the course of chronic pancreatitis, while alcohol abuse increases the risks of diabetes, steatorrhea and mortality. The complications of chronic pancreatitis are mainly the development of pseudocyst secondary to the downstream ductal obstruction, and biliary obstruction caused by fibrotic changes in the head of the pancreas. Successful endoscopic pseudocyst drainage is currently obtained in most patients, and carries a low complication rate. Biliary stenting is a safe and effective technique for the short-term treatment of symptomatic bile duct stricture due to chronic pancreatitis, but permanent resolution is obtained in only 25% of cases. In conclusion, endoscopic management is now considered to be the preferred interventional treatment of chronic pancreatitis, for patients selected on the basis of the anatomical changes caused by the disease. This treatment is generally safe, minimally invasive, often effective for years, does not prevent further surgery, and can be repeated.

Chronic pancreatitis

PURPOSE OF REVIEW

As in our previous reviews, we endeavor to review important new observations in chronic pancreatitis made in the past year. We included articles, including review articles, only if they contained new observations or readdressed old questions and provided new insights into old and new concepts.

RECENT FINDINGS

Important observations include the following: (1) Strong association between cystic fibrosis transmembrane regulator dysfunction/mutations and 'recurrent acute pancreatitis', particularly in patients with pancreas divisum (2) Pancreas divisum may be incidental finding in recurrent acute pancreatitis (3) Smoking increases risk of chronic pancreatitis (4) Coxsackie B virus may increase severity of alcoholic chronic pancreatitis (5) CD4+ T cells and an immune reaction against amylase may play a role in pathogenesis of autoimmune pancreatitis (6) 2-(18F)-Fluro-2-deoxy-D-glucose positron emission tomography might be useful to detect pancreatic cancer in chronic pancreatitis patients at risk for developing pancreatic cancer, but contrast-enhanced Doppler ultrasound or endosonography may be as sensitive and better than contrast enhanced computed tomography (7) Superiority of surgery vs endotherapy for long term pain relief and weight gain in painful chronic pancreatitis (8) Early treatment of pain and malabsorption may improve life quality (9) Antifibrogenesis and fibrolytic agents as potential therapies.

SUMMARY

Ongoing basic and clinical research this past year has further characterized genetic, molecular and clinical aspects of chronic pancreatitis. The advent of predictable and lasting treatments of chronic pancreatitis is most likely to appear on the wings of carefully conducted studies targeting genetic and molecular mechanisms of chronic pancreatitis, particularly pancreatic fibrogenesis.