Pancreatic stents in chronic pancreatitis: do they function as a tube, a wick, or a placebo?

Treatment of pancreatic strictures

The diagnosis and treatment of patients with pancreatic strictures presents a multitude of clinical challenges. The etiology of pancreatic strictures is varied, including benign strictures subsequent to acute pancreatitis, trauma, postsurgical, post-endoscopic retrograde cholangiopancreatography (ERCP), and malignancy. Patients with strictures usually present with symptoms of recurrent pancreatitis, abdominal pain, weight loss, and/or steatorrhea. The absence of a prior history of pancreatitis or surgery increases the likelihood of malignancy. High-quality imaging studies of the pancreas, CT, MRI/magnetic resonance cholangiopancreatography, or endoscopic ultrasound (EUS) scanning are utilized for better definition. Imaging detects an associated mass and/or demonstrates the ductal anatomy. Invasive procedures such as ERCP are performed to better define the causal relationships of the patient's symptoms or to obtain tissue diagnosis. Treatment goals include ameliorating symptoms, dilating the stricture, and ruling out cancer. The risk of malignancy underlies much of the intervention, which includes serology, cytologic analysis, and serial imaging. EUS has become the procedure of choice to rule out a mass, to evaluate the parenchyma for evidence of chronic pancreatitis, and to obtain fine-needle biopsies for tissue confirmation. In symptomatic patients or patients with indeterminate strictures, ERCP is used for direct pancreatography, tissue acquisition, and endoscopic treatment. Endotherapy includes sphincterotomy, dilation, and stenting to provide drainage. We view ERCP as the optimal first-line treatment modality. ERCP offers the potential of curative treatment and is less invasive than surgery, especially as some patients' symptoms are not severe enough to justify surgery. If patients do not experience relief of symptoms after several sessions of endoscopic therapy, surgery is the logical next step for definitive, long-term treatment.

Low symptomatic premature stent occlusion of multiple plastic stents for benign biliary strictures: comparing standard and prolonged stent change intervals

BACKGROUND

Benign biliary strictures are typically managed endoscopically whereby an increasing size or number of plastic stents is placed at ERCP. Stents are often changed every 3 to 4 months based on the known median patency of a single biliary stent, but patency data for multiple biliary stents are lacking.

OBJECTIVE

To assess the incidence of occlusion-free survival of multiple plastic biliary stents and the rate of premature occlusion if left in longer than 6 months.

DESIGN

Retrospective.

SETTING

Tertiary-care medical center (Charleston, SC).

PATIENTS

Consecutive patients who received multiple plastic stents for benign nonhilar biliary strictures from 1994 to 2008 were identified.

INTERVENTIONS

Exchange of multiple plastic biliary stents within 6 months (group 1) or 6 months or longer (group 2) after placement.

MAIN OUTCOME MEASUREMENTS

Symptomatic stent occlusion.

RESULTS

Seventy-nine patients with nonhilar extrahepatic benign biliary stricture underwent 125 ERCPs with multiple plastic biliary stents. Stents were scheduled for removal/exchange within 6 months in 52 patients (86 ERCPs) compared with after 6 months in 22 patients (26 ERCPs). The median interval between multiple stent placement and removal/exchange was 90 days for group 1 and 242 days for group 2. Premature stent occlusion occurred in 4 of 52 (7.7%) patients in group 1 versus 1 of 22 (4.5%) in group 2, with significantly longer occlusion-free survival in group 2 (log-rank P < .0001).

LIMITATIONS

Retrospective study at a single tertiary referral center.

CONCLUSION

Multiple plastic biliary stents for benign nonhilar strictures were associated with a low rate of premature symptomatic stent occlusion at more than 6 months and a longer occlusion-free survival.

A long-term follow-up study on endoscopic management of children and adolescents with chronic pancreatitis

OBJECTIVES

Data on therapeutic endoscopic retrograde cholangiopancreatography (ERCP) for chronic pancreatitis (CP) in children and adolescents, especially with long-term follow-up of consequences, are rarely reported. The aim of this study was to determine the long-term follow-up results of therapeutic ERCP for CP in children and adolescents.

METHODS

All patients with CP who received therapeutic ERCP at Changhai Hospital from January 1997 to May 2009, with the age at first onset of pain being less than 18.0 years, were included. Attempts were made to contact all adolescents and follow-up data were recorded. Clinical data were assessed before and after every ERCP.

RESULTS

Follow-up information was available in 42 (91.3%) of the 46 patients who received therapeutic ERCP. There were 20 boys and 22 girls, with the age at first onset being 11.8+/-4.5 years. A total of 110 therapeutic ERCP sessions were performed in the 42 patients. The post-ERCP complication rate was 17.3%, including mild and moderate pancreatitis (n=17) and mild cholangitis (n=2). The mean follow-up period of time was 61.4 (range: 24-132) months. Five patients underwent subsequent surgery because of refractory abdominal pain after endotherapy. Of the remaining 37 patients who received therapeutic ERCP alone, abdominal pain improved in 30 (81.1%) patients, and was completely relieved in 24 (64.9%) patients during the period of follow-up.

CONCLUSIONS

Therapeutic ERCP may offer long-term improvement in pain in children and adolescents with CP.

Endoscopic therapy for chronic pancreatitis: technical success, clinical outcomes, and complications

Chronic pancreatitis (CP) can cause failure of both the exocrine and endocrine portions of the gland. Pain is the most recalcitrant clinical complaint in CP. Generally, conservative measures are first attempted to manage pain. These include cessation of alcohol use and smoking, enzyme replacement therapy, and finally, opioid analgesia. Endoscopy can be employed to treat the pain and complications due to CP. The results of the only two prospective randomized controlled trials suggest that surgery has a more durable effect than endoscopic therapy in controlling pain. Both trials suffer from severe limitations, however, and endoscopy remains the preferred approach for many patients because of its minimally invasive nature. Endoscopic ultrasound celiac plexus block has limited value in helping to control pain. More randomized trials are needed, along with further technologic innovation to improve the current treatment modalities. When considering interventional therapy for a patient with CP, a tailored and multidisciplinary therapeutic approach should be taken.

Chronic pancreatitis

PURPOSE OF REVIEW

As in previous reviews in this journal, this review is focused on the most important new observations in chronic pancreatitis made in the past year and the beginning of this year.

RECENT FINDINGS

Important observations include the following: first, the natural history and course of chronic pancreatitis; second, that smoking enhances the risk of chronic pancreatitis; third, possible new function tests in combination with imaging procedures; fourth, the superiority of surgery compared with endotherapy for long-term pain relief; fifth, new insights in autoimmune pancreatitis.

SUMMARY

All in all, little progress has recently been made in the field of diagnosis and therapy of chronic pancreatitis. There are some studies in the field of endotherapy and autoimmune pancreatitis that are promising however.

Endoscopic pancreatic-stent placement and sphincterotomy for relief of pain in tropical pancreatitis: results of a 1-year follow-up

BACKGROUND

Tropical chronic pancreatitis frequently presents with intractable abdominal pain. Surgical treatment has its own morbidity and mortality, and long-term results may not be satisfactory.

OBJECTIVE

To analyze the results of endoscopic pancreatic-stent placement and sphincterotomy for the pain of tropical pancreatitis.

DESIGN

Retrospective review.

SETTING

Tertiary-referral hospital.

PATIENTS

Twenty-four patients with tropical pancreatitis with severe, persistent pain not responding to standard medical therapy over a period of 30 months beginning January 1998.

INTERVENTIONS

Stent placement of the pancreatic duct, along with sphincterotomy.

MAIN OUTCOME MEASUREMENTS

At least 80% global improvement in pain as reported by the patient during follow-up after the procedure.

RESULTS

In the 19 evaluable patients, the intended procedure, pancreatic stent placement along with sphincterotomy, was successful in 14 (73.7%); 3 others had sphincterotomy alone. Over a follow-up period of 6 to 38 months, 12 of the 14 patients (85.7%) who underwent stent placement plus sphincterotomy and 2 of the 3 patients who had sphincterotomy alone responded. Twelve of these were completely free of pain, and the remaining 2 patients had mild infrequent pain that occurred once in 2 to 4 months, lasting a few hours at a time and never needing hospitalization. The only major complication was the development of pancreatic sepsis, which required stent removal in 1 patient. Eight patients were stent free at the end of 6 months, and, over a further follow-up of 6 to 20 months, the pattern of pain relief persisted in them.

LIMITATIONS

The retrospective nature of the study, the limited numbers studied, and the lack of assessment of pain on a standard visual analog scale.

CONCLUSIONS

Stent placement of the pancreatic duct with pancreatic sphincterotomy constitutes an important nonsurgical therapeutic option for the intractable pain of tropical pancreatitis.

Analysis of the effects of stent insertion and the factors related to stent retrieval in chronic pancreatitis accompanying main pancreatic duct obstruction

BACKGROUND/AIMS

Obstruction of the main pancreatic duct (MPD) has been considered one of the major causes for pain in chronic pancreatitis (CP). In this study, we evaluated the efficacy of MPD stenting in painful CP, and tried to determine a guideline for stent removal.

METHODS

Sixteen patients with painful CP who underwent MPD stenting were included. Follow up ERCP was performed 3 months after stenting in all patients. Stents were removed in patients who achieved pain relief, complete stone clearance, and decreased MPD diameter after 3 months.

RESULTS

Before stenting, ERCP showed MPD stricture in 11 cases, MPD dilatation by stone in 1 case, concomitant stricture and stone in 4 cases. After stenting, complete pain relief was achieved in 13 patients (81.3%) and partial pain relief was achieved in 3 patient (18.7%). There was no patient whose pain was not relieved. Stents were removed in 7 patients who achieved pain relief, complete stone clearance, and decreased MPD diameter after 3 months. Decrease of MPD diameter was significantly greater in patient who could remove stent than those who could not (72.9% vs. 127.9% of initial MPD diameter, p=0.008).

CONCLUSIONS

If partial or full pain relief is achieved after MPD stenting and follow up ERCP after 3 months shows decreased MPD diameter compared to the initial one, stent removal might be considered.

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. Topics recently reviewed were truncated to accommodate a surge in publications on clinical aspects of chronic pancreatitis, which contained new observations or insights into new or old concepts.

RECENT FINDINGS

Cystic fibrosis carriers have been found to be at increased risk of pancreatitis. Autoimmune pancreatitis may belong to a multiorgan immunoglobulin G4-related autoimmune disease, and the natural history of chronic pancreatitis differs among the etiologies. Diffusion-weighted magnetic resonance imaging improves upon previous methodologies for diagnosing reduced pancreatic exocrine secretion, and fecal elastase-1 has been found to be a poor test for diagnosing pancreatic malabsorption. Visceral hyperalgesia or heightened central pain perception may contribute to pain in chronic pancreatitis. Instruments are evolving to assess quality of life in chronic pancreatitis, and fibrolytic agents have been found to have therapeutic promise.

SUMMARY

Researchers this past year have further characterized genetic, molecular and clinical aspects of chronic pancreatitis. Advancing the understanding of fibrogenesis, mechanisms of exocrine insufficiency, calcification, and pain and continuing development/modification of diagnostic tests should lead to improved prevention, detection and treatment of the condition. More accurate quantification of outcomes is critical for translating potential therapies from bench to bedside.