Endoscopic treatment in chronic pancreatitis, timing, duration and type of intervention

Endoscopic interventions in pancreatic strictures and stones-A structured approach

Chronic pancreatitis (CP) is an irreversible disease of varied etiology characterized by destruction of pancreatic tissue and loss of both exocrine and endocrine function. Pain is the dominant and most common presenting symptom. The common cause for pain in CP is ductal hypertension due to obstruction of the flow of pancreatic juice in the main pancreatic duct either due to stones or stricture or a combination of both. With advances in technology and techniques, endoscopic retrograde cholangiography (ERCP) and stenting should be the first line of therapy for strictures of the main pancreatic duct (MPD). Small calculi in the MPD can be extracted by ERCP and balloon trawl. Extracorporeal shockwave lithotripsy (ESWL) remains the standard of care for large pancreatic calculi and aims to fragment the stones 3 mm or less that can easily be extracted by a subsequent ERCP. Single operator pancreatoscopy with intraductal lithotripsy is a technique in evolution and can be tried when ESWL is not available or is unsuccessful in producing stone fragmentation.

Endoscopic Retrograde Cholangiopancreatography for Management of Chronic Pancreatitis

Management of symptomatic chronic pancreatitis (CP) has shifted its approach from surgical procedures to minimally invasive endoscopic procedures. Increased experience and advanced technology have led to the use of endoscopic retrograde cholangiopancreatography (ERCP) as a therapeutic tool to provide pain relief and treat CP complications including pancreatic stones, strictures, and distal biliary strictures, pseudocysts, and pancreatic duct fistulas. In this article the authors will discuss the use of ERCP for the management of CP, its complications, recent advancements, and techniques from the most up to date literature available.

Evolution of Pancreatic Endotherapy

In the last half century, endotherapy for pancreatic diseases has changed considerably. Although endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) were introduced initially as diagnostic tools, they quickly evolved into therapeutic tools for preventing and managing complications of pancreatitis. More recently, therapeutic endoscopy has shown potential in palliation and cure of pancreatic neoplasms. This article discusses the changing landscape of pancreatic endotherapy as therapeutic ERCP and EUS were introduced and because they have evolved to treat different diseases.

Management of Pancreatic Duct Stones: Extracorporeal Approach

Stone clearance with extracorporeal shock wave lithotripsy is a safe and effective procedure for large pancreatic calculi not extractable by the standard endoscopic retrograde cholangiopancreatography techniques. In properly selected patients, this minimally invasive approach should be offered as the first line of therapy instead of surgery. Complete stone clearance can be achieved in three-fourths with long-term pain relief in two-thirds of patients. Re-intervention is required in less than half of the patients. Future studies should compare the extracorporeal approach with intraductal lithotripsy using the pancreatoscope.

Clinical Profile, Etiology and Role of Endotherapy in Chronic Calcific Pancreatitis: An Experience from North India

Background: In recent years, we have witnessed an evolving landscape in the management of chronic pancreatitis (CP). Endoscopy plays a pivotal role in CP management. Because the management of CP is problematic, we aimed to review and evaluate the role of endoscopy in the management of CP. Methods: This study was carried out in patients with painful chronic calcific pancreatitis who were admitted to the Department of Gastroenterology at the Sher-I-Kashmir Institute of Medical Sciences (SKIMS), Srinagar. This was an observational prospective study. We included 67 patients with painful chronic calcific pancreatitis and pancreatic duct abnormalities (stones, strictures, or ductal variations) in our study. These patients had to access exocrine and endocrine status before any therapeutic measures. All the patients underwent endoscopic retrograde cholangiopancreatography (ERCP) as a therapeutic measure. After ERCP, the patients were followed up for 2 years to assess improvement in pain (visual analog scale score reduction), endocrine status (HBA1C reduction), or exocrine status (Fecal elastase reduction). Results: 67 patients were included in the study. Among them males were 32 (47.8%), females were 35(52.5%) and the age distribution studied were as in the age group of 15-30 years, patients were 23 (34.3%), in 30-45 years, there was 20 (29.9%), in age group of 45-60 year, patients were 20 (29.9%), and in the age group of 60-75 years, the patients were 4 (6%). Etiology was sought in all patients; alcohol-related CP was seen in three patients (4.5%), genetic in 11 (16.4%), IgG4 in one (1.5%), pancreatic divisum in 6 (9.0%), hyperparathyroidism in on1e (1.5%), and idiopathic in 45 (67.2%). All patients underwent ERCP for their symptoms to reduce ductal pressure, which is postulated as one of the hypotheses for pain in CP. Pancreatic duct (PD) clearance was attempted in all patients (complete in 42 [62.7%], partial in 17 [25.4%], and failed in 8 [11.9%]). These patients were followed for a period of two years after endotherapy, and the important predictors for pain reduction were single PD stones, disease in the head and body, and non-stricturing disease. Conclusion: Endotherapy offers a high rate of success in selected patients, clearance being better in distal disease and CP without PD strictures, suggesting early disease usually gets cleared very easily.

AGA Clinical Practice Update on the Endoscopic Approach to Recurrent Acute and Chronic Pancreatitis: Expert Review

DESCRIPTION

The purpose of this American Gastroenterological Association (AGA) Clinical Practice Update Expert Review is to provide practical, evidence-based guidance to clinicians regarding the role of endoscopy for recurrent acute and chronic pancreatitis.

METHODS

This expert review was commissioned and approved by the AGA Institute Clinical Practice Updates Committee and the AGA Governing Board to provide guidance on a topic of clinical importance to the AGA membership, underwent internal peer review by the Clinical Practice Updates Committee (CPUC), and external peer review through standard procedures of Gastroenterology. This review is framed around the 8 best practice advice points agreed upon by the authors, based on the results of randomized controlled trials, observational studies, systematic reviews and meta-analyses, as well expert consensus in this field. Best Practice Advice Statements BEST PRACTICE ADVICE 1: After an unrevealing initial evaluation, endoscopic ultrasound is the preferred diagnostic test for unexplained acute and recurrent pancreatitis. Magnetic resonance imaging with contrast and cholangiopancreatography is a reasonable complementary or alternative test to endoscopic ultrasound, based on local expertise and availability. BEST PRACTICE ADVICE 2: The role of endoscopic retrograde cholangiopancreatography (ERCP) for reducing the frequency of acute pancreatitis episodes in patients with pancreas divisum is controversial, but minor papilla endotherapy may be considered, particularly for those with objective signs of outflow obstruction, such as a dilated dorsal pancreatic duct and/or santorinicele. There is no role for ERCP to treat pain alone in patients with pancreas divisum. BEST PRACTICE ADVICE 3: The role of ERCP for reducing the frequency of pancreatitis episodes in patients with unexplained recurrent acute pancreatitis and standard pancreatic ductal anatomy is controversial and should only be considered after a comprehensive discussion of the uncertain benefits and potentially severe procedure-related adverse events. When pursued, ERCP with biliary sphincterotomy alone may be preferable to dual sphincterotomy. BEST PRACTICE ADVICE 4: Surgical intervention should be considered over endoscopic therapy for long-term treatment of patients with painful obstructive chronic pancreatitis. Endoscopic intervention is a reasonable alternative to surgery for suboptimal operative candidates or those who favor a less invasive approach, assuming they are clearly informed that the best practice advice primarily favors surgery. BEST PRACTICE ADVICE 5: When ERCP is pursued, small (≤5mm) main pancreatic duct stones can be treated with pancreatography and conventional stone extraction maneuvers. For larger stones, extracorporeal shockwave lithotripsy and/or pancreatoscopy with intraductal lithotripsy may be required. BEST PRACTICE ADVICE 6: When ERCP is pursued, prolonged stent therapy (6-12 months) is effective for treating symptoms and remodeling main pancreatic duct strictures. The preferred approach is to place and sequentially add multiple plastic stents in parallel (upsizing); emerging evidence suggests that fully covered self-expanding metal stents may have a role for this indication, but additional research is necessary. BEST PRACTICE ADVICE 7: ERCP with stent insertion is the preferred treatment for benign biliary stricture due to chronic pancreatitis. FCSEMS placement is favored over multiple plastic stents whenever feasible, given similar efficacy but significantly reduced need for stent exchange procedures during the treatment course. BEST PRACTICE ADVICE 8: Celiac plexus block should not be routinely performed for the management of pain due to chronic pancreatitis. The decision to proceed with celiac plexus block in selected patients with debilitating pain in whom other therapeutic measures have failed can be considered on a case-by-case basis, but only after discussion of the unclear outcomes of this intervention and its procedural risks.

Endoscopic Management of Complications in Chronic Pancreatitis

PURPOSE OF REVIEW

Management of complications in patients with chronic pancreatitis is often suboptimal. This review discusses detailed endoscopic approaches for managing complications in CP.

LITERATURE FINDINGS

CP is characterized by progressive and irreversible destruction of pancreatic parenchyma and ductal system resulting in fibrosis, scarring, and loss of glandular function. Abdominal pain remains is the most common symptom of the disease and the main aim of medical, endoscopic, and surgical therapy is to help relieve symptoms, prevent disease progression, and manage complications related to CP. In fact, advances in our understanding of CP have improved medical care and quality of life in these patients. With significant sequela, morbidity and a progressive nature, a thorough understanding of the pathophysiology, natural course, diagnostic approaches, and optimal management strategies for this disease is warranted. The existing modalities and new innovations in this field are safe, effective, and likely to have a positive impact on management of complication in CP whenever used in the right context.

Pain relief in chronic pancreatitis: endoscopic or surgical treatment? a systematic review with meta-analysis

BACKGROUND AND AIMS

Pain is one of the consequences of chronic pancreatitis (CP) that has the greatest impact on the quality of life of patients. Endoscopic and surgical interventions, by producing a decrease in intraductal pancreatic pressure, can provide pain relief. This is the first systematic review that includes only randomized clinical trials (RTCs) comparing outcomes in the short-term (less than 2 years) and long-term (more than 2 years) between these two types of interventions.

MATERIAL AND METHODS

A comprehensive search of multiple electronic databases to identify RTCs comparing short and long-term pain relief, procedural complications, and days of hospitalization between endoscopic and surgical interventions was performed following the PRISMA guidelines.

RESULTS

Three RCTs evaluating a total of 199 patients (99 in the endoscopy group and 100 in the surgery group) were included in this study. Surgical interventions provided complete pain relief, with statistical difference, in the long-term (16,4% vs 35.7%; RD 0.19; 95% CI 0.03-0.35; p = 0.02; I2 = 0%), without significant difference in short-term (17.5% vs 31.2%; RD 0.14; 95% CI -0.01-0.28; p = 0.07; I2 = 0%) when compared to endoscopy. There was no statistical difference in short-term (17.5% vs 28.1%; RD 0.11; 95% CI -0.04-0.25; p = 0.15; I2 = 0%) and long-term (34% vs 41.1%; RD 0.07; 95% CI -0.10-0.24; p = 0.42; I2 0%) in partial relief of pain between both interventions. In the short-term, both complications (34.9% vs 29.7%; RD 0.05; 95% CI -0.10-0.21; p = 0.50; I2 = 48%) and days of hospitalization (MD -1.02; 95% CI -2.61-0.58; p = 0.21; I2 = 0%) showed no significant differences.

CONCLUSION

Surgical interventions showed superior results when compared to endoscopy in terms of complete long-term pain relief. The number of complications and length of hospitalization in both groups were similar.

Success of extracorporeal shock wave lithotripsy and ERCP in symptomatic pancreatic duct stones: a systematic review and meta-analysis

Background and study aims  Pain is the most frequent and dominant symptom of chronic pancreatitis. Currently, these patients are treated using a step-up approach, including analgesics and lifestyle adjustments, endoscopic, and eventually surgical treatment. Extracorporeal shock wave lithotripsy (ESWL) is indicated after failure of the first step in patients with symptomatic intraductal stones larger than 5 mm in the head or body of the pancreas. To assess the complete ductal clearance rate and pain relief after ESWL in patients with symptomatic chronic pancreatitis with pancreatic duct stones, a systematic review and meta-analysis was performed. Patients and methods  A systematic literature search from January 2000 to December 2018 was performed in PubMed, the Cochrane Library, and EMBASE for studies on ductal clearance rate of ESWL in patients with symptomatic chronic pancreatitis with pancreatic duct stones. Results  After screening 486 studies, 22 studies with 3868 patients with chronic pancreatitis undergoing ESWL for pancreatic duct stones were included. The pooled proportion of patients with complete ductal clearance was 69.8 % (95 % CI 63.8-75.5). The pooled proportion of complete absence of pain during follow-up was 64.2 % (95 % CI 57.5-70.6). Complete stone fragmentation was 86.3 % (95 % CI 76.0-94.0). Post-procedural pancreatitis and cholangitis occurred in 4.0 % (95 % CI 2.5-5.8) and 0.5 % (95 % CI 0.2-0.9), respectively. Conclusion  Treatment with ESWL results in complete ductal clearance rate in a majority of patients, resulting in absence of pain during follow up in over half of patients with symptomatic chronic pancreatitis caused by obstructing pancreatic duct stones.

Chronic pancreatitis: an overview of diagnosis and management

INTRODUCTION

Chronic pancreatitis entails a heavy burden on the healthcare system because of its often protracted evolution, requiring complex diagnostic and therapeutic procedures.

AREAS COVERED

This review focuses on novel imaging and endoscopic diagnostic and therapeutic interventions that have changed the management of patients with chronic pancreatitis. We have conducted an extensive search of original papers and guidelines, in order to provide a comprehensive and up to date review of available evidence in these areas of interest.

EXPERT OPINION

The traditional challenges in managing chronic pancreatitis patients stemmed from the limitations of diagnostic modalities, which could not correctly identify patients in an early stage of the disease, as well as from the scarcity of therapeutic options available. Advances in imaging of CT-scan, MRI, and EUS have opened the way for early diagnosis and staging. This has allowed more aggressive and tailored therapeutic modalities, particularly in endoscopic therapy and minimally invasive surgical interventions. Although high-quality data from large RCTs is still scarce, evidence-based algorithms for diagnosis and therapy are now changing the way we address this chronic disease. In the near future, we can expect a tailored approach based on patient and disease-related predictive factors, relying on a vast armamentarium of endoscopic and surgical solutions.

Endoscopic and surgical treatment options for chronic pancreatitis: an imaging perspective

Chronic pancreatitis is a chronic fibro-inflammatory syndrome characterized by chronic pancreatic inflammation leading to fibrosis and scarring. Patients with this multifactorial debilitating illness often require endoscopic or surgical intervention for treatment. Radiologists play a crucial role in pre-therapeutic workup as well as post-treatment imaging of chronic pancreatitis. This review summarizes the most common surgical and endoscopic treatment options that are currently available for chronic pancreatitis, including the implications on imaging.

Drainage procedure for pancreatolithiasis: re-examination of the pancreatic duct diameter standard

Purpose

Pancreatic duct decompression relieves pancreatic duct stone (PDS)-associated abdominal pain, though a consensus indication for the drainage procedure of the main pancreatic duct (MPD) is lacking. Moreover, major prognostic factors for postsurgical long-term pain relief and recurrence are largely unknown.

Methods

The clinical outcomes of 65 consecutive PDS patients undergoing surgery from 2008–2012 with 3+ years of follow-up were assessed.

Results

At postsurgical follow-up (median, 4.5 years; range, 3–7 years; procedure: Partington, n = 32; Frey, n = 27; pancreatoduodenectomy, n = 3; distal pancreatectomy, n = 3), the early complication and complete stone clearance rates were 29.2% and 97%, respectively. Long-term, complete and partial pain relief were 93.9%, 83.1%, and 10.8%, respectively. The risk of pancreatic fistula was higher in the <8 mm group than in the >8 mm group (P < 0.05), and 80% of the pancreatic fistula cases occurred in the <8 mm group. A shorter pain duration (P = 0.007), smaller MPD diameter (P = 0.04), and lower Izbicki pain score (P < 0.001) predicted long-term pain relief. Pain recurrence after initial remission occurred in 5 patients and was only related to pain duration (P = 0.02). Stone recurrence and pancreatic exocrine functional and endocrine functional deterioration occurred in 2, 5, and 11 patients, respectively.

Conclusion

Surgery provides excellent stone clearance, long-term pain relief, and acceptable postoperative morbidity. Using 8 mm as the criterion for drainage surgery can minimize the postoperative pancreatic fistula risk. Individualized and timely surgical treatment may improve the effect of surgery.

Chronic Pancreatitis—Update on Pathophysiology and Therapeutic Approaches

Chronic pancreatitis is an inflammatory condition characterized by structural change within the pancreas, that leads to progressive and irreversible loss of functioning pancreatic parenchyma, exocrine/endocrine dysfunction and an increased risk of pancreatic ductal adenocarcinoma. Whilst hallmarks of advanced disease are readily identifiable on routine clinical imaging, concordance between structural changes within the pancreas and symptoms is poor, such that early diagnosis can be challenging. Traditionally, chronic pancreatitis has been managed with a ‘step-up’ approach of measures including analgesia, therapeutic endoscopy and surgery (in a select minority of patients). Accumulating evidence is emerging to challenge this approach: early surgical intervention may offer the opportunity to interrupt the disease process before irreversible sequelae become established. This article provides an overview of the pathophysiology underlying chronic pancreatitis together with a review of the current evidence to support established and novel therapeutic approaches to the disease.

Management of Pancreatic Duct Stones

PURPOSE OF REVIEW

Pancreatic duct stones are sequela of chronic pancreatitis. They can cause pancreatic duct obstruction which is the most important cause of pain in chronic pancreatitis. Stone resolution has shown to improve pain. The goal of this review is to highlight recent endoscopic and surgical advancements in treatment of pancreatic duct stones.

RECENT FINDINGS

Stone fragmentation by extracorporeal shock wave lithotripsy has become first line and the mainstay of treatment for majority of patients with pancreatic duct stones. Introduction of digital video pancreatoscopy in the last few years with the capability of guided lithotripsy has provided a robust therapeutic option where extracorporeal shock wave lithotripsy is unsuccessful or unavailable. Historically, surgery has been considered a more reliable and durable option when feasible. However, it had not been compared with more effective endoscopic therapy. Lithotripsy (extracorporeal and pancreatoscopy guided) is evolving as a strong treatment modality for pancreatic stones.

ESWL for large pancreatic calculi: Report of over 5000 patients

INTRODUCTION

The primary aim of this study was to evaluate efficacy, safety and short-term pain relief after ESWL for large pancreatic calculi in over 5000 patients at a single center.

METHODS

This is a retrospective analysis of prospectively collected data. Patients with painful calculi >5 mm, located in the head, neck and body region in the MPD, who were not amenable for extraction by the standard procedure of endoscopic pancreatic sphincterotomy were subjected to ESWL using a third generation dual focus lithotripter. Patients were followed up at 6 months for outcome evaluation.

RESULTS

A total of 5124 patients (66% males) were subjected to ESWL. Majority of stones (79.2%) were radiopaque. Single calculi were seen in 3851 (75.1%).The majority of stones were located in head region of MPD in 2824 (55.1%) patients. 4386 (85.5%) patients required 3 or less sessions for fragmentation and complete stone clearance was achieved in 3722 (72.6%). EPS was performed in 5022 (98%) while PD stenting was required in 3536 (69%) patients. Of the 4280 patients followed up for 6 months, 3529 (82.6%) patients were pain free. Another 512 (11.9%) patients had significant reduction in VAS score. In 229 (5.3%) there was no decrease in pain intensity. Minor and self-limiting complications were reported in 1153 (22.5%).

DISCUSSION

Our study confirms the safety and efficacy and short-term pain relief of ESWL for large calculi in the MPD. In properly selected patients, this should be offered as the first line of therapy for all large MPD calculi not amenable to the standard techniques of stone extraction.

Electrohydraulic Lithotripsy for Pancreatic Duct Stones Under Digital Single-Operator Pancreatoscopy (with Video)

BACKGROUND

Recently, a digital single-operator cholangiopancreatoscope (DSOC) has become available. This system allows the performance of electrohydraulic lithotripsy (EHL) even within the main pancreatic duct (MPD). However, there are only few reports of EHL for MPD stones using SPY-DS.

AIMS

The aim of this study was to evaluate the technical feasibility and efficacy of EHL for MPD stones under DSOC guidance.

METHODS

Between October 2016 and August 2017, patients with MPD stones were retrospectively enrolled in this study. The presence of MPD stones was diagnosed by endoscopic ultrasound and MRCP. The patients' baseline characteristics and those of the stones, including their size, number, and site in the MPD, number of EHL procedures, and adverse events, were reviewed.

RESULTS

A total of 21 patients were retrospectively enrolled. The etiologies of chronic pancreatitis were idiopathic (n = 4) and alcohol induced (n = 17). The pancreatic stone was variously located in the head (n = 6), body (n = 11), tail (n = 1), head and body (n = 2), and body and tail (n = 1) of the pancreas. Median pancreatic stone size was 12 mm, and the mean number of ERCP sessions was 1.29 (range 1-3). EHL was successfully performed in 15 patients (85.7%, 18/21), and the rate of complete stone clearance was 88.2% (18/21). Severe adverse events were not seen in any of the patients, although one patient developed mild acute pancreatitis.

CONCLUSIONS

In conclusion, although additional case reports and prospective studies are needed, EHL under DSOC may be an option to treat MPD stones.

Endoscopic and Conservative Management of Chronic Pancreatitis and Its Complications

Chronic pancreatitis is a progressive inflammatory disease of the pancreas potentially giving rise to several complications. For this reason, patients need long-term care and treatment by medical, interventional, and sometimes surgical measures. This article reviews current state-of-the-art strategies and guidelines for treating chronic pancreatitis with conventional and endoscopic measures.

Diagnostic and therapeutic recommendations for chronic pancreatitis. Recommendations of the Working Group of the Polish Society of Gastroenterology and the Polish Pancreas Club

This article describes the latest diagnostic and therapeutic recommendations in chronic pancreatitis, developed by the Working Group of the Polish Society of Gastroenterology and the Polish Pancreas Club. The recommendations refer to the diagnosis of chronic pancreatitis, autoimmune pancreatitis, conservative management, treatment of pain, and exocrine and endocrine pancreatic insufficiency, treatment of chronic pancreatitis by endoscopic and surgical methods, and oncological surveillance of chronic pancreatitis. This paper refers to the Polish recommendations published in 2011, which have been updated and supplemented. All recommendations were voted by experts of the Polish Society of Gastroenterology and the Polish Pancreas Club, who evaluated them each time on a five-degree scale, where I meant full acceptance, II – acceptance with some reservation, III – acceptance with serious reservation, IV – rejection with some reservation and V – full rejection. The results of the voting, together with a brief commentary, have been included with each recommendation put to the vote. In addition, the expert group assessed the value of clinical studies on which the statements are based, on a scale where A means high (based on meta-analyses and randomised clinical trials), B means medium (based on clinical trials and observational studies), and C means low (based mainly on expert opinion).

Management of Pancreatic Calculi: An Update

Pancreatolithiasis, or pancreatic calculi (PC), is a sequel of chronic pancreatitis (CP) and may occur in the main ducts, side branches or parenchyma. Calculi are the end result, irrespective of the etiology of CP. PC contains an inner nidus surrounded by successive layers of calcium carbonate. These calculi obstruct the pancreatic ducts and produce ductal hypertension, which leads to pain, the cardinal feature of CP. Both endoscopic therapy and surgery aim to clear these calculi and decrease ductal hypertension. In small PC, endoscopic retrograde cholangiopancreatography (ERCP) followed by sphincterotomy and extraction is the treatment of choice. Large calculi require fragmentation by extracorporeal shock wave lithotripsy (ESWL) prior to their extraction or spontaneous expulsion. In properly selected cases, ESWL followed by ERCP is the standard of care for the management of large PC. Long-term outcomes following ESWL have demonstrated good pain relief in approximately 60% of patients. However, ESWL has limitations. Per oral pancreatoscopy and intraductal lithotripsy represent techniques in evolution, and in current practice their use is limited to centers with considerable expertise. Surgery should be offered to all patients with extensive PC, associated multiple ductal strictures or following failed endotherapy.

Endoscopic Therapies for Chronic Pancreatitis

Chronic pancreatitis is a fibroinflammatory disease of the pancreas leading to varying degrees of endocrine and exocrine dysfunction. Treatment options are generally designed to control the pain of chronic pancreatitis, and endoscopic therapy is one of the main treatment modalities. Herein, we describe the endoscopic management of pancreatic duct calculi and strictures, entrapment of the intrapancreatic bile duct, celiac plexus interventions, and drainage of pancreatic pseudocysts.

Long-term results after endoscopic drainage of pancreatic pseudocysts: A single-center experience

BACKGROUND

Pancreatic pseudocysts (PPC) are collections of fluid encapsulated within a well-defined inflammatory wall that develop during pancreatic inflammation. Internal drainage represents the standard of care in lesions that persist and lead to symptoms and complications. Only limited data are available on long-term results and recurrence of PPC after drainage procedures. Thus, the aim of the present study was to analyse the long-term outcome after endoscopic drainage of PPC.

MATERIAL AND METHODS

Patient data were retrospectively collected by review of clinical records of the University Medical Center Mannheim. We assessed the clinical short-term outcome (results in the first 30 days after initial drainage procedure), medium-term outcome (results 6 months after initial drainage procedure) and long-term outcome (results after stent removal). We performed statistical analysis to identify possible risk factors for recurrence of PPC.

RESULTS

We identified 51 patients with initially successful endoscopic drainage of the PPC (n = 51/53, 96%). Among this cohort, 43 patients were available for assessment of medium-term results. In 82.9% of these 43 patients the drainage could be removed after successful treatment of the PPC. Thirty patients were available for long term follow-up with a mean observation period of 42.2 months (SD 32.8 months). Among these patients, seven (n = 7/30, 23.3%) had recurrent PPC. Approximately half of the recurrent cysts arose in different anatomical regions and most patients with recurrence had chronic pancreatitis.

CONCLUSION

Endoscopic drainage represents an effective treatment for PPC. Approximately one quarter of the patients developed recurrent PPC. Half of recurrent PPC developed in different pancreatic regions than the initial PPC.

Chronic pancreatitis: Multicentre prospective data collection and analysis by the Hungarian Pancreatic Study Group

Introduction

Chronic pancreatitis is an inflammatory disease associated with structural and functional damage to the pancreas, causing pain, maldigestion and weight loss and thus worsening the quality of life.

Aims and methods

Our aim was to find correlations from a multicentre database representing the epidemiological traits, diagnosis and treatment of the disease in Hungary. The Hungarian Pancreatic Study Group collected data prospectively from 2012 to 2014 on patients suffering from chronic pancreatitis. Statistical analysis was performed on different questions.

Results

Data on 229 patients (74% male and 26% female) were uploaded from 14 centres. Daily alcohol consumption was present in the aetiology of 56% of the patients. 66% of the patients were previously treated for acute exacerbation. One third of the patients had had previous endoscopic or surgical interventions. Pain was present in 69% of the cases, endocrine insufficiency in 33%, diarrhoea in 13% and weight loss in 39%. Diagnosis was confirmed with US (80%), CT scan (52%), MRI-MRCP (6%), ERCP (39%), and EUS (7,4%). A functional test was carried out in 5% of the patients. In 31% of the cases, an endoscopic intervention was performed with the need for re-intervention in 5%. Further elective surgical intervention was necessitated in 44% of endoscopies. 20% of the registered patients were primarily treated with surgery. The biliary complication rate for surgery was significantly smaller (2%) than endoscopy (27%); however, pancreatic complications were higher in the patients treated with surgery. Patients who smoked regularly needed significantly more surgical intervention following endoscopy (66.7% vs. 26.9%, p = 0.002) than non-smokers, and the ratio of surgical intervention alone was also significantly higher (27.3% vs. 10.8%, p = 0.004). The ratio of surgery in patients who smoked and drank was significantly higher (30.09% vs. 12.5%, p = 0.012) than in abstinent and non-smoking patients, similarly to the need for further surgical intervention after endoscopic treatment (71.43% vs. 27.78%, p = 0.004).

Conclusions

According to the data analysed, the epidemiological data and the aetiological factors in our cohort differ little from European trends. The study highlighted the overuse of ERCP as a diagnostic modality and the low ratio of use of endoscopic ultrasonography. The results proved that alcohol consumption and smoking represent risk factors for the increased need for surgical intervention. Chronic pancreatitis should be treated by multidisciplinary consensus grounded in evidence-based medicine.

Complications and management of forgotten long-term biliary stents

AIM

To evaluate complications and management outcomes of retained long-term plastic biliary stents.

METHODS

Endoscopic plastic biliary stent placement was performed in 802 patients at Yeungnam University Hospital between January 2000 and December 2014. Follow-up loss with a subsequently forgotten stent for more than 12 mo occurred in 38 patients. We retrospectively examined the cause of biliary stent insertion, status of stents, complications associated with biliary stents and management outcomes of long-term plastic biliary stents. Continuous variables were analyzed using the t test. Observed frequencies in subsets of the study population were compared using Fisher’s exact test and χ² tests. Statistical significance was defined as P < 0.05 (two-tailed).

RESULTS

Mean age of patients was 73.7 ± 12 years and male-to-female ratio was 2.2:1. Indications of plastic biliary stent insertion were bile duct stones (63.2%, 24/38) and benign bile duct stricture (52.6%, 20/38). Mean duration of retained plastic stent was 22.6 ± 12.2 mo, and in 10 cases (26.3%), stents were retained for more than 24 mo. Common bile duct (CBD) stones or sludge were found in most cases (92.1%, 35/38). The most common complication was acute cholangitis (94.7%, 36/38). Stent removal by endoscopic approach was successfully performed in 92.1% (35/38) of the cases. In 3 cases, an additional plastic stent was inserted alongside the previous stent due to failure of the stent removal. Endoscopic removal of bile duct stones was successful in 73.7% (28/38) of the cases. When patients were divided into two groups by duration of stent placement (12 to 24 mo vs over 24 mo), there were no differences in the development of cholangitis, presence of biliary stones, and success rate of endoscopic removal of stones and biliary stents.

CONCLUSION

The most common complication of retained long-term plastic biliary stents was acute cholangitis associated with CBD stones. Endoscopic management was successfully performed in most cases.

Ameliorating effect of antioxidants and pregabalin combination in pain recurrence after ductal clearance in chronic pancreatitis: Results of a randomized, double blind, placebo-controlled trial

BACKGROUND AND AIM

The aim of this study was to evaluate the effect of antioxidant-pregabalin combination on pain recurrence in patients with chronic calcific pancreatitis.

METHODS

In this randomized, double-blind, placebo-controlled trial, chronic calcific pancreatitis patients with pain recurrence following pancreatic ductal clearance of stones received either antioxidant-pregabalin combination or matching placebo for 2 months followed by open-label antioxidants for the next 4 months in both groups. Compliance, daily pain, and adverse events were recorded weekly and at the end of study by a coordinator blinded to treatment status. Primary outcome was pain improvement (visual analog scale and Izbicki score); secondary outcomes were as follows: complete pain resolution, painful days, and adverse events. Number needed-to-treat was calculated.

RESULTS

We randomized 42 and 45 patients (mean age 29.3 years) to treatment and placebo arms, respectively. Baseline characteristics, including pain scores, were similar for both groups. No patients received high-potency narcotic. At 2 months, a significant improvement in the treatment arm was observed in percent reduction of visual analog scale (-50 [-80.0; -32.1] vs -29.5 [-64.5; 0]; P = 0.01), Izbicki score (14.5 [0; 21.3] vs 30.0 [11.8; 41.3]; P = 0.001), complete pain resolution (20 [47.6%] vs 12 [26.7%]; P = 0.04), and number of painful days (10.0 [2.0; 16.0] vs 18.0 [7.0; 34.0]; P = 0.01). Needed-to-treat was 4.8. Pain reduction persisted at 6 months in the original treatment group (20.0 [15.0; 28.0] vs 36.0 [20.0; 50.0]; P = 0.006). A total of 33 patients in the treatment arm experienced mild to moderate self-limiting nausea/vomiting and drowsiness, respectively and did not require any change in study protocol.

CONCLUSION

Antioxidant-pregabalin combination results in significant relief in pain recurrence after ductal clearance in narcotic naïve patients with chronic calcific pancreatitis.

Chronic Pancreatitis: A Review

This is to incorporate the recent trends in chronic pancreatitis. Extensive literature search was done from Pubmed and Ovid SP. Full text articles and abstracts related to chronic pancreatitis were reviewed and the article was prepared. Chronic pancreatitis is evolving fast on its etiology and treatment areas. The main etiological factors are pointing towards genetic, alcohol, and smoking. Autoimmune has also been added as a cause. Endoscopic ultra sound (EUS) becoming the standard diagnostic procedure. Surgery is becoming the treatment of choice for pain and mechanical complications and not the endotherapy in the long-term follow-up. The numbers of surgeries are getting narrowed down. The two etiological groups of chronic pancreatitis namely alcohol + smoking and genetic getting clearer, where the later group present at an early age. Endoscopic ultrasound and imaging with secretin is diagnostic of chronic pancreatitis before the structural changes. Endotherapy is found to be inferior to surgery in long-term pain relief. Diagnostic criteria for autoimmune pancreatitis are established. Pancreaticogenic diabetes (Type3c) and its problem associated with fat malabsorption are being understood.

The Role of Endoscopic Retrograde Cholangiopancreatography in Management of Pancreatic Diseases

Endoscopic retrograde cholangiopancreatography is an effective platform for a variety of therapies in the management of benign and malignant disease of the pancreas. Over the last 50 years, endotherapy has evolved into the first-line therapy in the majority of acute and chronic inflammatory diseases of the pancreas. As this field advances, it is important that gastroenterologists maintain an adequate knowledge of procedure indication, maintain sufficient procedure volume to handle complex pancreatic endotherapy, and understand alternate approaches to pancreatic diseases including medical management, therapy guided by endoscopic ultrasonography, and surgical options.

Surgery remains the best option for the management of pain in patients with chronic pancreatitis: A systematic review and meta-analysis

Controversy related to endoscopic or surgical management of pain in patients with chronic pancreatitis remains. Despite improvement in endoscopic treatments, surgery remains the best option for pain management in these patients.

Endoscopic ultrasonography-guided drainage for patients with symptomatic obstruction and enlargement of the pancreatic duct

AIM: To evaluate the use of translumenal pancreatography with placement of endoscopic ultrasonography (EUS)-guided drainage of the pancreatic duct.

METHODS: This study enrolled all consecutive patients between June 2002 and April 2014 who underwent EUS-guided pancreatography and subsequent placement of a drain and had symptomatic retention of fluid in the pancreatic duct after one or more previous unsuccessful attempts at endoscopic retrograde cannulation of the pancreatic duct. In all, 94 patients underwent 111 interventions with one of three different approaches: (1) EUS-endoscopic retrograde drainage with a rendezvous technique; (2) EUS-guided drainage of the pancreatic duct; and (3) EUS-guided, internal, antegrade drainage of the pancreatic duct.

RESULTS: The mean duration of the interventions was 21 min (range, 15-69 min). Mean patient age was 54 years (range, 28-87 years); the M:F sex ratio was 60:34. The technical success rate was 100%, achieving puncture of the pancreatic duct including pancreatography in 94/94 patients. In patients requiring drainage, initial placement of a drain was successful in 47/83 patients (56.6%). Of these, 26 patients underwent transgastric/transbulbar positioning of a stent for retrograde drainage; plastic prostheses were used in 11 and metal stents in 12. A ring drain (antegrade internal drainage) was placed in three of these 26 patients because of anastomotic stenosis after a previous surgical intervention. The remaining 21 patients with successful drain placement had transpapillary drains using the rendezvous technique; the majority (n = 19) received plastic prostheses, and only two received metal stents (covered self-expanding metal stents). The median follow-up time in the 21 patients with transpapillary drainage was 28 mo (range, 1-79 mo), while that of the 26 patients with successful transgastric/transduodenal drainage was 9.5 mo (range, 1-82 mo). Clinical success, as indicated by reduced or absence of further pain after the EUS-guided intervention was achieved in 68/83 patients (81.9%), including several who improved without drainage, but with manipulation of the access route.

CONCLUSION: EUS-guided drainage of the pancreatic duct is a safe, feasible alternative to endoscopic retrograde drainage when the papilla cannot be reached endoscopically or catheterized.

Current status of endotherapy for chronic pancreatitis

Chronic pancreatitis is associated with varied morphological complications, including intraductal stones, main pancreatic ductal strictures, distal biliary strictures and pseudocysts. Endoscopic therapy provides a less invasive alternative to surgery. In addition, extracorporeal shockwave lithotripsy improves the success rate of endoscopic clearance of intraductal stones. However, recent data from randomised trials have shown better long-term outcomes with surgical drainage for obstructive pancreatic ductal disease. In patients with distal biliary strictures, stent insertion leads to good immediate drainage, but after stent removal, recurrent narrowing is common. Endoscopic drainage of pancreatic pseudocysts has excellent outcome and should be accompanied by pancreatic ductal stenting when a ductal communication is evident. In those who remain symptomatic, endoscopic ultrasonography-guided coeliac plexus block may provide effective but short-term pain relief. In this review, we present the current evidence for the role of endotherapy in the management of patients with chronic pancreatitis.

Pancreatic Endotherapy for Chronic Pancreatitis

Extracorporeal shock wave lithotripsy is recommended as the first-line therapy for large (>5-mm) obstructive pancreatic ductal stones. Dominant pancreatic duct strictures should be initially managed with a wide-bore single plastic stent with 3 monthly exchanges for a year, even in asymptomatic patients. Recent studies have evaluated multiple plastic and self-expanding covered metal stents for refractory pancreatic ductal stricture. Pancreatic pseudocysts should be treated endoscopically with or without endoscopic ultrasound guidance.

Laparoscopic frey procedure for chronic pancreatitis

BACKGROUND

Chronic pancreatitis can be relentless, resulting in debilitating pain and endocrine and exocrine insufficiency. Medical interventions are used initially but when these fail, surgical therapy is often indicated. Surgical options include resection, drainage, and hybrid procedures. Hybrid procedures, such as the Frey procedure are associated with improved outcomes in select patients. These advantages are even greater when the Frey is performed laparoscopically.

METHODS

A patient with chronic pancreatitis was referred to our clinic. Preoperative imaging revealed a dilated main pancreatic duct with multiple large pancreatic duct stones. She subsequently underwent a laparoscopic Frey procedure.

RESULTS

The patient did very well with no pancreatic leak, wound infection, or delayed gastric emptying. She was discharged home on postoperative day 6, symptom free with no narcotic requirement.

CONCLUSIONS

For patients in whom the laparoscopic Frey procedure is possible, it can be used to treat chronic pancreatitis with the benefits of a minimally invasive approach.

Temporary placement of a fully covered self-expandable metal stent in the pancreatic duct for aiding extraction of large pancreatic duct stones: preliminary data

BACKGROUND AND AIM OF STUDY

Endoscopic clearance of large stones in the pancreatic duct (PD) is very difficult, even in patients undergoing stone fragmentation by extracorporeal shock wave lithotripsy. Placement of fully covered self-expandable metal stents (FCSEMSs) has not yet been reported to aid extraction of large PD stones. This aim of this study is to evaluate the technical success and safety of temporary placement of a FCSEMS in the PD to aid extraction of large PD stones.

PATIENTS AND METHODS

Here, we report a pilot study and retrospective case series. Eight patients with chronic pancreatitis and large stones in the PD received endoscopic treatment. Eight symptomatic patients with more than three PD stones of large diameter (≥10 mm) were selected for FCSEMS placement and participation in this study. The patients' PD stones were located in the head, neck, and/or body of the pancreas and could not be cleared using a balloon catheter and basket. After placement of a FCSEMS (10 mm diameter) in the PD between 1 and 5 months (mean duration: 71 days), standard endoscopic maneuvers led to clearance of large PD stones. Technical success was defined as successful stent placement and the ability to achieve PD clearance in two endoscopic sessions. Complications were assessed according to consensus criteria.

RESULTS

FCSEMSs were placed successfully in all patients and PD stones were all cleared easily from the dilated PD using the retrieval balloon and basket. There were no significant complications such as acute pancreatitis, hemorrhage, migration, or stent incarceration. At the 6-month follow-up, no residual stones were observed on pancreatography, and all patients were doing well, without any symptom recurrence.

CONCLUSION

Temporary placement of an FSCEMS in the PD is a minimally invasive and feasible approach for aiding extraction of large PD stones.

Endoscopic therapy for chronic pancreatitis

PURPOSE OF REVIEW

To summarize recent data on techniques, efficacy and complications of endoscopic management of chronic pancreatitis.

RECENT FINDINGS

Extracorporeal shock wave lithotripsy with or without endoscopic retrograde cholangiopancreatography is the first-line treatment for large painful obstructive pancreatic duct calculi. Use of preextracorporeal shock wave lithotripsy secretin could result in better stone clearance. The first-line treatment for dominant pancreatic duct strictures is placement of a single 10-Fr polyethylene stent with planned exchanges every 3 months until 1 year. Other endoscopic approaches that have shown good efficacy include placement of simultaneous multiple plastic stents and fully covered self-expanding metallic stents. Endoscopic options to treat chronic pancreatitis-associated benign biliary strictures include single and simultaneous multiple plastic stenting and fully covered self-expanding metallic stents. The European Society of Gastrointestinal Endoscopy recommends multiple plastic stenting for such strictures, although fully covered self-expanding metallic stents should be currently used under research settings. Endoscopic ultrasonography-guided cholangiopancreatography and pancreatobiliary drainage is an evolving option for chronic pancreatitis-related ductal obstruction after failed endoscopic retrograde cholangiopancreatography. Recent data have supported the safety and efficacy of endotherapy for chronic pancreatitis in children.

SUMMARY

Endotherapy is the first line of management in chronic pancreatitis with symptomatic pancreatobiliary ductal obstruction. Further studies are required in certain key areas such as use of fully covered self-expanding metallic stents for pancreatic ductal and biliary strictures and endoscopic ultrasonography-guided pancreatobiliary drainage after failed endoscopic retrograde cholangiopancreatography.

Efficacy of pancreatic stenting prior to extracorporeal shock wave lithotripsy for pancreatic stones

BACKGROUND

Extracorporeal shock wave lithotripsy is the first-line therapy for large pancreatic duct stones; however, it requires a long duration of therapy.

AIMS

To clarify the effect of pancreatic stenting prior to extracorporeal shock wave lithotripsy on shortening the duration of therapy and reducing complications.

METHODS

We retrospectively compared 45 patients who underwent pancreatic stenting prior to extracorporeal shock wave lithotripsy (stenting group) and 35 patients who did not undergo stenting prior to extracorporeal shock wave lithotripsy (non-stenting group) with regard to the cumulative number of shock waves required for stone fragmentation (stone size <3mm) and the rate of complications.

RESULTS

The stenting group was associated with a significantly lower cumulative number of shock waves in univariate analysis (log-rank, p=0.046) and multivariate Cox proportional hazard analysis (hazard ratio, 1.88; 95% confidence interval, 1.13-3.14; p=0.015) than the non-stenting group. The frequency of pancreatitis tends to be lower in the stenting group than the non-stenting group (2.2% [1/45] vs 11.4% [4/35]; p=0.162).

CONCLUSIONS

Pancreatic stenting prior to extracorporeal shock wave lithotripsy reduced the cumulative number of shock waves required for pancreatic stone fragmentation, and could be useful to shorten the duration of therapy.

Treatment options in painful chronic pancreatitis: a systematic review

BACKGROUND

Longlasting and unbearable pain is the most common and striking symptom of chronic pancreatitis. Accordingly, pain relief and improvement in patients' quality of life are the primary goals in the treatment of this disease. This systematic review aims to summarize the available data on treatment options.

METHODS

A systematic search of MEDLINE/PubMed and the Cochrane Library was performed according to the PRISMA statement for reporting systematic reviews and meta-analysis. The search was limited to randomized controlled trials and meta-analyses. Reference lists were then hand-searched for additional relevant titles. The results obtained were examined individually by two independent investigators for further selection and data extraction.

RESULTS

A total of 416 abstracts were reviewed, of which 367 were excluded because they were obviously irrelevant or represented overlapping studies. Consequently, 49 full-text articles were systematically reviewed.

CONCLUSIONS

First-line medical options include the provision of pain medication, adjunctive agents and pancreatic enzymes, and abstinence from alcohol and tobacco. If medical treatment fails, endoscopic treatment offers pain relief in the majority of patients in the short term. However, current data suggest that surgical treatment seems to be superior to endoscopic intervention because it is significantly more effective and, especially, lasts longer.

Endoscopic treatment of pancreatic calculi

Chronic pancreatitis is a progressive inflammatory disease that destroys pancreatic parenchyma and alters ductal stricture, leading to ductal destruction and abdominal pain. Pancreatic duct stones (PDSs) are a common complication of chronic pancreatitis that requires treatment to relieve abdominal pain and improve pancreas function. Endoscopic therapy, extracorporeal shock wave lithotripsy (ESWL), and surgery are treatment modalities of PDSs, although lingering controversies have hindered a consensus recommendation. Many comparative studies have reported that surgery is the superior treatment because of reduced duration and frequency of hospitalization, cost, pain relief, and reintervention, while endoscopic therapy is effective and less invasive but cannot be used in all patients. Surgery is the treatment of choice when endoscopic therapy has failed, malignancy is suspected, or duodenal stricture is present. However, in patients with the appropriate indications or at high-risk for surgery, endoscopic therapy in combination with ESWL can be considered a first-line treatment. We expect that the development of advanced endoscopic techniques and equipment will expand the role of endoscopic treatment in PDS removal.

Endoscopic management of complications of chronic pancreatitis

Pseudocysts and biliary obstructions will affect approximately one third of patients with chronic pancreatitis (CP). For CP-related, uncomplicated, pancreatic pseudocysts (PPC), endoscopy is the first-choice therapeutic option. Recent advances have focused on endosonography-guided PPC transmural drainage, which tends to replace the conventional, duodenoscope-based coma immediately approach. Ancillary material is being tested to facilitate the endosonography-guided procedure. In this review, the most adequate techniques depending on PPC characteristics are presented along with supporting evidence. For CP-related biliary obstructions, endoscopy and surgery are valid therapeutic options. Patient co-morbidities (e.g., portal cavernoma) and expected patient compliance to repeat endoscopic procedures are important factors when selecting the most adapted option. Malignancy should be reasonably ruled out before embarking on the endoscopic treatment of presumed CP-related biliary strictures. In endoscopy, the gold standard technique consists of placing simultaneous, multiple, side-by-side, plastic stents for a one-year period. Fully covered self-expandable metal stents are challenging this method and have provided 50% mid-term success.

Endotherapy in chronic pancreatitis

Chronic pancreatitis (CP) is a progressive disease with irreversible changes in the pancreas. Patients commonly present with pain and with exocrine or endocrine insufficiency. All therapeutic efforts in CP are directed towards relief of pain as well as the management of associated complications. Endoscopic therapy offers many advantages in patients with CP who present with ductal calculi, strictures, ductal leaks, pseudocyst or associated biliary strictures. Endotherapy offers a high rate of success with low morbidity in properly selected patients. The procedure can be repeated and failed endotherapy is not a hindrance to subsequent surgery. Endoscopic pancreatic sphincterotomy is helpful in patients with CP with minimal ductal changes while minor papilla sphincterotomy provides relief in patients with pancreas divisum and chronic pancreatitis. Extracorporeal shock wave lithotripsy is the standard of care in patients with large pancreatic ductal calculi. Long term follow up has shown pain relief in over 60% of patients. A transpapillary stent placed across the disruption provides relief in over 90% of patients with ductal leaks. Pancreatic ductal strictures are managed by single large bore stents. Multiple stents are placed for refractory strictures. CP associated benign biliary strictures (BBS) are best treated with multiple plastic stents, as the response to a single plastic stent is poor. Covered self expanding metal stents are increasingly being used in the management of BBS though further long term studies are needed. Pseudocysts are best drained endoscopically with a success rate of 80%-95% at most centers. Endosonography (EUS) has added to the therapeutic armamentarium in the management of patients with CP. Drainage of pseudcysts, cannulation of inaccessible pancreatic ducts and celiac ganglion block in patients with intractable pain are all performed using EUS. Endotherapy should be offered as the first line of therapy in properly selected patients with CP who have failed to respond to medical therapy and require intervention.

Endoscopic therapy for chronic pancreatitis

Endoscopic therapy is recommended as the first-line therapy for painful chronic pancreatitis with an obstacle on the main pancreatic duct (MPD). The clinical response should be evaluated at 6 to 8 weeks. Calcified stones that obstruct the MPD are first treated by extracorporeal shockwave lithotripsy; dominant MPD strictures are optimally treated with a single, large, plastic stent that should be exchanged within 1 year even in asymptomatic patients. Pancreatic pseudocysts for which therapy is indicated and are within endoscopic reach should be treated by endoscopy.

Pancreatic and biliary stents

Biliary and pancreatic stents are used in a variety of benign and malignant conditions including strictures and leaks and in the prevention of post-ERCP pancreatitis.Both plastic and metal stents are safe, effective, and easy to use. SEMSs have traditionally been used for inoperable malignant disease. Covered SEMSs are now being evaluated for use in benign disease. Increasing the duration of patency of both plastic and metal stents remains an important area for future research.

Endoscopic therapy in chronic pancreatitis

Chronic pancreatitis (CP) is a debilitating disease that can result in chronic abdominal pain, malnutrition, and other related complications. The main aims of treatment are to control symptoms, prevent disease progression, and correct any complications. A multidisciplinary approach involving medical, endoscopic, and surgical therapy is important. Endoscopic therapy plays a specific role in carefully selected patients as primary interventional therapy when medical measures fail or in patients who are not suitable for surgery. Endoscopic therapy is also used as a bridge to surgery or as a means to assess the potential response to pancreatic surgery. This review addresses the role of endoscopic therapy in relief of obstruction of the pancreatic duct (PD) and bile du ct, closure of PD leaks, and drainage of pseudocysts in CP. The role of endoscopic ultrasound-guided celiac plexus block for pain in chronic pancreatitis is also discussed.

Long-term outcomes of endoscopic vs surgical drainage of the pancreatic duct in patients with chronic pancreatitis

BACKGROUND & AIMS

A randomized trial that compared endoscopic and surgical drainage of the pancreatic duct in patients with advanced chronic pancreatitis reported a significant benefit of surgery after a 2-year follow-up period. We evaluated the long-term outcome of these patients after 5 years.

METHODS

Between 2000 and 2004, 39 symptomatic patients were randomly assigned to groups that underwent endoscopic drainage or operative pancreaticojejunostomy. In 2009, information was collected regarding pain, quality of life, morbidity, mortality, length of hospital stay, number of procedures undergone, changes in pancreatic function, and costs. Analysis was performed according to an intention-to-treat principle.

RESULTS

During the 79-month follow-up period, one patient was lost and 7 died from unrelated causes. Of the patients treated by endoscopy, 68% required additional drainage compared with 5% in the surgery group (P = .001). Hospital stay and costs were comparable, but overall, patients assigned to endoscopy underwent more procedures (median, 12 vs 4; P = .001). Moreover, 47% of the patients in the endoscopy group eventually underwent surgery. Although the mean difference in Izbicki pain scores was no longer significant (39 vs 22; P = .12), surgery was still superior in terms of pain relief (80% vs 38%; P = .042). Levels of quality of life and pancreatic function were comparable.

CONCLUSIONS

In the long term, symptomatic patients with advanced chronic pancreatitis who underwent surgery as the initial treatment for pancreatic duct obstruction had more relief from pain, with fewer procedures, than patients who were treated endoscopically. Importantly, almost half of the patients who were treated with endoscopy eventually underwent surgery.

Endoscopic pancreatic duct and biliary duct stenting in treatment of chronic pancreatitis with distal benign biliary stricture: a single-center experience

BACKGROUND

The development of endoscopic techniques such as endoscopic retrograde cholangiopancreatography (ERCP), endoscopic sphincterotomy (EST) and stenting are relatively new alternatives to surgery for the treatment of benign lesions in the biliary duct and pancreas. The objective of this study was to assess the value of stenting in the endoscopic pancreatic duct and biliary duct in the treatment of chronic pancreatitis with distal benign biliary stricture.

METHODS

Twenty-two patients diagnosed with chronic pancreatitis with distal benign biliary stricture underwent endoscopic treatment in our center, with ERCP, EST, endoscopic retrograde biliary drainage (ERBD) and endoscopic retrograde pancreatic drainage (ERPD) with stents. A numeric rating scale was used to assess pain intensity. The clinical data on endoscopic therapies and recovery of the patients were recorded and compared.

RESULTS

ERCPs were successfully performed in 21 patients and 1 (4.5%) failed because of pancreatic ductal variation. A total of 68 ERCPs were performed with 47 pancreatic duct stents and 39 biliary duct stents. The rate of complications was 13.2% (9/68). The abdominal pain score after endoscopic treatment was significantly reduced. The levels of bilirubin and alanine transaminase in all 21 patients were improved compared to those before endoscopic treatment.

CONCLUSION

Endoscopic stent drainage of the pancreatic duct and biliary duct for chronic pancreatitis with distal biliary benign stricture can be selected as a safe, effective and minimally invasive therapeutic method.