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

Efficacy of endoscopic interventions versus surgery for pain management in patients with chronic calcific pancreatitis: a systematic review and meta-analysis

INTRODUCTION

Chronic calcific pancreatitis (CCP) is a debilitating inflammatory condition characterized by the accumulation of calcific deposits in the pancreatic tissue, leading to chronic abdominal pain and functional insufficiencies. This study aims to systematically review and meta-analyse comparative studies assessing the efficacy of endotherapy versus surgery in managing CCP-related pain.

METHODS

MEDLINE, EMBASE, and Cochrane library (CENTRAL and CDSR), from inception to October 2023, were searched. The inclusion criteria encompassed randomized controlled trials (RCTs) and non-randomized controlled trials (NRS), and cohort studies comparing endoscopic interventions to surgery for pain management in patients with CCP. Pain relief, procedural technical success, and procedural-related complications were the outcomes of interest. Two review authors (CN, KK) independently assessed study eligibility criteria and performed data extraction. Using a random-effects model, pooled odds ratios (OR) with 95% confidence intervals (CI) were calculated. The level of certainty of the evidence was assessed using the GRADE approach.

RESULTS

Five studies were included. For the outcome of pain relief, a meta-analysis of five studies (3 RCTs and 2 cohort studies) demonstrated a significant therapeutic effect in favour of surgery with an OR of 2.36 (95% CI: 1.12 to 5.00, I2 = 41.70), with moderate level of certainty of evidence. In the analysis of five studies (3 RCTs, 1 NRS and 2 cohort studies), procedural technical success was comparable between the two groups (OR of 3.02, 95% CI: 0.47 to 19.59, I2 = 79.27%) as were adverse events (OR 1.31, 95% CI: 0.47 to 3.70, I2 = 50.93%).

CONCLUSION

In conclusion, this systematic review and meta-analysis suggest that surgery may be more effective in relieving pain in patients with CCP compared to endoscopic interventions. Disease stage may be important to determine the appropriateness of each procedure. PROSPERO (CRD42023476153).

International consensus guidelines on interventional endoscopy in chronic pancreatitis. Recommendations from the working group for the international consensus guidelines for chronic pancreatitis in collaboration with the International Association of Pancreatology, the American Pancreatic Association, the Japan Pancreas Society, and European Pancreatic Club

BACKGROUND/OBJECTIVES

This paper is part of the international consensus guidelines on chronic pancreatitis, presenting for interventional endoscopy.

METHODS

An international working group with experts on interventional endoscopy evaluated 26 statements generated from evidence on 9 clinically relevant questions. The Grading of Recommendations Assessment, Development, and Evaluation approach was used to evaluate the level of evidence. To determine the level of agreement, a nine-point Likert scale was used for voting on the statements.

RESULTS

Strong consensus was obtained for 15 statements relating to nine questions including the recommendation that endoscopic intervention should be offered to patients with persistent severe pain but not to those without pain. Endoscopic decompression of the pancreatic duct could be used for immediate pain relief, and then offered surgery if this fails or needs repeated endoscopy. Endoscopic drainage is preferred for portal-splenic vein thrombosis and pancreatic fistula. A plastic stent should be placed and replaced 2-3 months later after insertion. Endoscopic extraction is indicated for stone fragments remaining after ESWL. Interventional treatment should be performed for symptomatic/complicated pancreatic pseudocysts. Endoscopic treatment is recommended for bile duct obstruction and afterwards surgery if this fails or needs repeated endoscopy. Surgery may be offered if there is significant calcification and/or mass of the pancreatic head. Percutaneous endovascular treatment is preferred for hemosuccus pancreaticus. Surgical treatment is recommended for duodenal stenosis due to chronic pancreatitis.

CONCLUSIONS

This international expert consensus guideline provides evidenced-based statements concerning indications and key aspects for interventional endoscopy in the management of patients with chronic pancreatitis.

Pancreatitis

Acute pancreatitis is an inflammation of the glandular parenchyma of the retroperitoneal organ that leads to injury with or without subsequent destruction of the pancreatic acini. This inflammatory process can either result in a self-limited disease or involve life-threatening multiorgan complications. Chronic pancreatitis consists of endocrine and exocrine gland dysfunction that develops secondary to progressive inflammation and chronic fibrosis of the pancreatic acini with permanent structural damage. Recurrent attacks of acute pancreatitis can result in chronic pancreatitis; acute and chronic pancreatitis are different diseases with separate morphologic patterns. Acute pancreatitis has an increasing incidence but a decreasing mortality.

The Use of Interventional Radiology Techniques in the Treatment of Pancreatic Fistula

One of the complications of pancreatic disease is the formation of pancreatic fistulae. The presence of fistula leads to body wasting and cachexia. The standard treatment is intubation of the Wirsung duct and in cases where there are no improvements the next proposed form of treatment is surgery. The aim of the study was to evaluate the efficacy of pancreatic fistula closure using interventional radiology techniques. In 2009 to 2014, 46 patients diagnosed with pancreatic fistula were treated with interventional radiology techniques. Treatment consisted of vascular coil implanted at the entry of the fistula and then sealed with tissue glue adhesive during endoscopic procedure. Technical success of vascular coil implantation and the use of tissue glue adhesive were reported in all patients. Pancreatic fistula recurred in 7 patients (15.2%). The latter group of patients underwent statistical analysis to determine what the risk factors in recurring pancreatic fistulas were. The results indicate a significant relationship between etiology of the fistula and treatment effect.

IN CONCLUSION

(1) the use of interventional radiology methods in the closure of pancreatic fistula is an effective and safe procedure; and (2) the recurrence of fistula is dependent on the etiology and often occurs after surgery or trauma.

Progression of recurrent acute and chronic pancreatitis: A short-term follow up study from a southern Indian centre

BACKGROUND

Little data exist on the progression of recurrent acute (RAP) and chronic pancreatitis (CP) from regions from where the entity of tropical chronic pancreatitis was originally described. The study aimed to follow up patients with RAP and CP seen at a southern Indian centre for progression of disease over time.

METHODS

Prospectively enrolled patients with RAP and CP were followed up, and the alcoholic and idiopathic subgroups were assessed for progression of structural and functional changes in the organ.

RESULTS

One hundred and forty patients (RAP = 44; 31.4 %, CP = 96; 68.5 %) were followed up over a median 12.2 (interquartile range 12.0-16.8) months. The cause was alcohol in 31 (22.1 %) and not evident in 109 (77.8 %). The disease progressed from RAP to CP in 7 (15.9 %), 6 (16.2 %) out of 37 in the idiopathic and 1 (14.2 %; p = 1.00) out of 7 in the alcoholic subgroups. Three (42.8 %) and 1 (14.2 %) developed steatorrhea and diabetes mellitus (DM), respectively, and 2 (4.5 %) developed calcification. Established CP progressed in 19 (19.7 %), 1 (1.0 %), 5 (5.2 %), 2 (2.0 %) and 11 (11.4 %) newly developed DM, steatorrhea, calcification and duct dilation during follow up. Among the idiopathic and alcoholic CP, disease progression was seen in 15 (20.8 %) out of 72 and 4 (16.6 %) out of 24 respectively.

CONCLUSIONS

Idiopathic RAP and CP progressed during the short-term follow up. This is similar to other etiological forms of pancreatitis, as described from elsewhere in the world.

Modern treatment of patients with chronic pancreatitis

CP remains a challenging disease. Endoscopic and surgical management, along with antioxidants, have helped in reducing chronic pain. Management of exocrine and endocrine insufficiency forms the cornerstone for improving nutrition in these patients. Newer therapeutic targets that will transcend the management of CP beyond just pain control and enzyme supplementation are required in the future.

Asian chronic pancreatitis: the common and the unique

Chronic pancreatitis (CP) is a disabling condition worldwide that presents as pain, maldigestion, and diabetes. It is usually perceived as alcohol related, or classified as idiopathic otherwise. However, this is true only for Western countries. Asian CP comprises not only alcohol-related CP but also tropical pancreatitis (TP). Tropical pancreatitis is a unique entity commonly found in South Asia. It shares similar presentations with other CPs for pain and maldigestion. However, its diabetes is more ketosis resistant. Non-surgical approach like endoscopic therapy plus extracoporeal shock wave lithotripsy provides better outcome for TP than other CPs, because of its less strictured pancreatic duct that is more amenable to endoscopic stone clearance. Diagnosis of CP in Asia mainly relies on image studies such as ultrasonography ± computed tomography (CT) scan, and non-invasive tests on fecal chymotrypsin, serum trypsin, and serum pancreatic isoamylase. Endoscopic ultrasonography and intestinal tubing tests are used mainly in some research centers. Autoimmune pancreatitis (AIP) is another CP originated from Asia in large series and subsequently being recognized in the West. AIP patients seldom present with maldigestion until the disease progresses to a very late stage and this occurs in less than one third of patients. In contrast, AIP is usually presented as pseudotumor of the pancreatic head, causing obstructive jaundice. Immunoglobulin G4 level is typically elevated in AIP and can be used as a marker for responsiveness. Without a need of surgery, steroids are the standard treatment. Those who relapse and are resistant to steroids should be placed on long-term immunosuppressive agents.

Endoscopic treatment as first-line therapy for pancreatic ascites and pleural effusion

BACKGROUND

Ascites and pleural effusion are well recognized complications of pancreatic diseases. Drug therapy of these is limited by high cost, prolonged hospitalization and failure rates; surgery is invasive and is associated with considerable morbidity and mortality.

OBJECTIVE

To analyze the data on patients with pancreatic ascites and/or pleural effusion treated endoscopically over a ten-year period.

METHODS

Patients with symptomatic ascites/pleural effusion for at least 3 weeks with a fluid amylase level of > 1000 S units/dl and underlying pancreatic disease were included. The interventions were a 5 mm sized pancreatic sphincterotomy and placement of a 7 Fr pancreatic stent. Somatostatin/octreotide and parenteral nutrition were not used after endoscopic therapy.

RESULTS

Of the 28 patients included (22 men), 17 (60.7%) had chronic pancreatitis. The causes were tropical pancreatitis (13, 46.4%), alcohol abuse (10, 35.7%), idiopathic acute pancreatitis (4, 14.3%) and resective surgery for gastric cancer (1, 3.6%). Ascites alone was seen in 15, pleural effusion alone in 6 and both in 7 patients. Ten patients (35.7%) had 14 pseudocysts. Endotherapy was successful in 27 (96.4%). Twenty-six (92.8%) patients had complete resolution of ascites/effusion over a median 5 weeks. The stents were removed 3-6 weeks later without any recurrence over the next 6-36 (median = 17) months. Complications (7, 25%) included severe pain in 2 (7.1%) and fever in 5 (17.8%) of which 3 (10.7%) had infection of residual fluid collections. No patient died.

CONCLUSION

Endoscopic therapy offers an excellent therapeutic alternative in patients with pancreatic ascites and pleural effusion.

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 last year.

RECENT FINDINGS

Important observations included the search for biomarkers and alternative methods for the detection of early chronic pancreatitis; stellate cell activation and their role in fibrogenesis; the natural history of chronic pancreatitis; reports outlining the complexity in diagnosis of autoimmune pancreatitis; emerging roles of endoscopic ultrasound and magnetic resonance cholangiopancreatography in chronic pancreatitis diagnosis; a better understanding of neurobiology of chronic pancreatitis pain; and the potential role of surgery as first-line therapy in advanced chronic pancreatitis.

SUMMARY

In 2007, major advances were made in our understanding of central processing in chronic pancreatitis pain. New techniques are being utilized in search of a better means to diagnose early chronic pancreatitis. Important prospective studies are emerging, which compare endoscopic and surgical interventions. Furthermore, the complexities of diagnosing autoimmune pancreatitis are being recognized. Overall, the future is promising as advances in genomic and proteomic techniques are applied to improve our understanding of chronic pancreatitis.

Acute suppuration of the pancreatic duct in a patient with tropical pancreatitis

Background/Aim

Pancreatic sepsis secondary to infected necrosis, pseudocyst, or pancreatic abscess is a well-known clinical entity. Acute suppuration of the pancreatic duct (ASPD) in the setting of chronic calcific pancreatitis and pancreatic ductal obstruction with septicemia is a rare complication that is seldom reported. It is our aim to report a case of ASPD with Klebsiella ornithinolytica, in the absence of pancreatic abscess or infected necrosis.

Case Report

A 46-year-old Asian-Indian man with chronic tropical pancreatitis who was admitted with recurrent epigastric pain that rapidly evolved into septic shock. A CT scan of abdomen revealed a dilated pancreatic duct with a large calculus. Broad-spectrum antibiotics, vasopressors and activated recombinant protein C were initiated. Emergency ERCP showed the papilla of Vater spontaneously expelling pus. Probing and stenting was instantly performed until pus drainage ceased. Repeat CT scan confirmed the absence of pancreatic necrosis or fluid collection, and decreasing ductal dilatation. Dramatic clinical improvement was observed within 36 hours after intervention. Blood cultures grew Klebsiella ornithinolytica. The patient completed his antibiotic course and was discharged.

Conclusion

ASPD without pancreatic abscess or infected necrosis is an exceptional clinical entity that should be included in the differential diagnosis of pancreatic sepsis. A chronically diseased pancreas and diabetes may have predisposed to the uncommon pathogen. The presence of intraductal pancreatic stones obstructing outflow played a major role in promoting bacterial growth, suppuration and septicemia. Immediate drainage of the pancreatic duct with endoscopic intervention is critical and mandatory.