Efficacy of s-type stents for the treatment of the main pancreatic duct stricture in patients with chronic pancreatitis

Current status and future perspectives for endoscopic treatment of local complications in chronic pancreatitis

Chronic pancreatitis is a progressive disease characterized by irregular fibrosis, cellular infiltration, and parenchymal loss within the pancreas. Chronic pancreatitis treatment includes lifestyle modifications based on disease etiology, dietary adjustments appropriate for each stage and condition, drug therapy, endoscopic treatments, and surgical treatments. Although surgical treatments of symptomatic chronic pancreatitis provide good pain relief, endoscopic therapies are recommended as the first-line treatment because they are minimally invasive. In recent years, endoscopic therapy has emerged as an alternative treatment method to surgery for managing local complications in patients with chronic pancreatitis. For pancreatic stone removal, a combination of extracorporeal shock wave lithotripsy and endoscopic extraction is used. For refractory pancreatic duct stones, intracorporeal fragmentation techniques, such as pancreatoscopy-guided electrohydraulic lithotripsy and laser lithotripsy, offer additional options. Interventional endoscopic ultrasound has become the primary treatment modality for pancreatic pseudocysts, except in the absence of disconnected pancreatic duct syndrome. This review focuses on the current status of endoscopic therapies for common local complications of chronic pancreatitis, including updated information in the past few years.

Fully Covered Self-expandable Metallic Stents for Refractory Benign Pancreatic Duct Strictures: A Systematic Review and Meta-analysis

BACKGROUND

Endoscopic treatment of refractory pancreatic duct (PD) strictures includes the placement of multiple plastic stents. Recent studies have shown the benefit of fully covered self-expandable metal stents (FCSEMS). This systematic review analyzes the efficacy and safety of FCSEMS in PD strictures.

METHODS

A comprehensive search of all suitable studies was conducted using the databases of MEDLINE, EMBASE, and Scopus from inception to November 2022. The outcomes assessed were efficacy and safety of FCSEMS in PD strictures. Using a random-effects inverse-variance model, the pooled proportions were calculated.

RESULTS

A total of 22 studies with 439 patients were included in the analysis. The pooled stricture resolution rate was 91.6% (95% CI: 87.4-95.7), while the pooled pain resolution rate was 84.9% (95% CI: 77.7-92.1). The pooled incidences of stent-related adverse events, including acute pancreatitis, pain requiring stent removal, and de novo stricture, were 3.9% (95% CI: 1.2-6.7), 0.8% (95% CI: 0.0-2.1), and 3.3% (95% CI: 0.7-5.8). The pooled incidence of stent migration, stricture recurrence, and the need for restenting were 12.9% (95% CI: 6.7-19.1), 9.3% (95% CI: 4.7-13.8), and 12.3% (95% CI: 6.9-17.8), respectively.

CONCLUSIONS

FCSEMSs can be considered in carefully selected patients with benign PD strictures with high resolution rate and acceptable adverse event rate. De-novo structure formation appears to be a significant problem. Further studies may help to decide the role of FCSEMS in the algorithm.

Long-term outcomes and risk factors of pancreatic insufficiency after a pancreatoduodenectomy: A retrospective study

BACKGROUND

An increasing number of patients are achieving long-term survival after pancreatoduodenectomy, meaning that risk assessments of endocrine and exocrine pancreatic insufficiency are needed. Herein, we investigated the risk factors for pancreatic insufficiency after pancreatoduodenectomy by incorporating pancreatic morphologic changes and perioperative factors.

METHODS

Patients who underwent pancreatoduodenectomy between January 2015 and December 2020 were enrolled in this single-center retrospective study. Clinicopathologic, surgical, and pancreatic morphologic factors were collected, and risk factors for exocrine pancreatic insufficiency and endocrine pancreatic insufficiency were analyzed. Exocrine pancreatic insufficiency was defined as steatorrhea requiring pancreatic enzymes and new onset steatosis, and endocrine pancreatic insufficiency was defined as postoperative new-onset diabetes mellitus. Multivariate analysis was performed.

RESULTS

Among the 206 patients enrolled, 14% and 24% developed endocrine pancreatic insufficiency and exocrine pancreatic insufficiency, respectively. Multivariate analysis revealed residual pancreatic stent 1 year postoperatively, lymph node metastasis, and postoperative pancreatic atrophy (P-atrophy) as independent risk factors for exocrine pancreatic insufficiency, whereas preoperative glycated hemoglobin levels, residual pancreatic stent, and postoperative main pancreatic duct dilatation were risk factors for endocrine pancreatic insufficiency. Subgroup analysis of pancreatic ductal adenocarcinoma revealed that exocrine pancreatic insufficiency in patients with pancreatic ductal adenocarcinoma was caused by preoperative decreased pancreatic function (high glycated hemoglobin and a low postoperative pancreatic fistula rate), whereas the high incidence of POPF influenced the development of exocrine pancreatic insufficiency in patients without pancreatic ductal adenocarcinoma.

CONCLUSION

Postoperative pancreatic atrophy and main pancreatic duct dilatation are risk factors for exocrine pancreatic insufficiency I and endocrine pancreatic insufficiency, respectively, and residual pancreatic stent affects both types of pancreatic dysfunction. Improving the surgical approach and stent management may help prevent these late complications.

Soft self-expandable metal stent to treat painful pancreatic duct strictures secondary to chronic pancreatitis: a prospective multicenter trial

BACKGROUND AND AIMS

Fully covered self-expandable metal stents (FCSEMSs) may offer a treatment option for pain associated with a dilated pancreatic duct (PD) in chronic pancreatitis (CP), but optimal patient selection and FCSEMS design, efficacy, and safety remain uncertain. We studied an investigational pancreatic FCSEMS for treatment of CP-associated pain.

METHODS

Patients with painful CP, a dominant distal PD stricture, and PD dilation upstream were enrolled in a prospective, multicenter, single-arm trial studying 6-month indwell of a 4- to 6-cm-long soft pancreatic FCSEMS. Primary efficacy and safety endpoints were pain reduction 6 months after FCSEMS indwell (performance goal ≥53%) and PD stenting-related serious adverse events (SAEs), respectively (performance goal <32%). The primary efficacy endpoint was assessed in patients with sufficiently severe and frequent pain at FCSEMS placement as a first stent or in exchange of a plastic stent.

RESULTS

Among 67 patients (mean age, 52.7 ± 12.5 years; mean time since CP diagnosis, 6.4 ± 6.4 years), 34 (50.7%) had plastic stent placement within 90 days of FCSEMS placement, and 46 patients were eligible for the primary efficacy endpoint analysis. Technical success was 97.0% (65/67). The observed primary efficacy (26.1%, 12/46) and safety endpoints (31.3%, 21/67) failed to meet the a priori study hypotheses. Study stent migration occurred in 47.7% of patients (31/65).

CONCLUSIONS

Six-month treatment with an FCSEMS did not lead to an expected degree of pain reduction, and migrations and SAEs were common. Further study is needed to clarify optimal decompressive strategy, FCSEMS design, and patient selection. (Clinical trial registration number: NCT02802020.).

Focal pancreatic ductal change induced by 10-Fr S-type plastic stent in chronic pancreatitis

BACKGROUND AND AIM

Stent-induced ductal change (SIDC) is a complication of endoscopic pancreatic stenting (EPS) in patients with chronic pancreatitis (CP). However, the evaluation of SIDC associated with S-type pancreatic plastic stent (PS) and large-caliber PS, such as 10 Fr, is limited. This study aimed to analyze the SIDC of the main pancreatic duct (MPD) associated with 10-Fr S-type PS in patients with CP.

METHODS

Between January 2008 and December 2021, 132 patients with CP in whom a 10-Fr S-type PS had been installed by EPS were retrospectively reviewed. The SIDC incidence rate was examined, and the clinical features of patients with and without SIDC were investigated, including the outcomes for detected SIDC.

RESULTS

Stent-induced ductal change during EPS was confirmed in 41 patients (31.1%) of 132 patients at a site coincident with the PS tip or distal flap in the MPD. All patients were asymptomatic during the development of SIDC. Morphological changes in the MPD were detected as elevated (75.6%) or bearing stricture changes (24.4%). A total of 90.2% of SIDC developed after the first 10-Fr PS installation. No significant differences were noted between the patients with and without SIDC. The outcomes of continued PS installment for SIDC showed persistence and secondary change.

CONCLUSIONS

Stent-induced ductal change-associated 10-Fr PS installation was performed in just under one-third of the patients, indicating a substantial incidence rate and a possible development of SIDC from early stages onwards. More emphasis should be placed on SIDC as the complication.

Pancreatic duct stents

Pancreatic duct stenting using endoscopy or surgery is widely used for the management of benign and malignant pancreatic diseases. Endoscopic pancreatic stents are mainly used to relieve pain caused by chronic pancreatitis and pancreas divisum, and to treat pancreatic duct disruption and stenotic pancreaticointestinal anastomosis after surgery. They are also used to prevent postendoscopic retrograde cholangiopancreatography pancreatitis and postoperative pancreatic fistula, treat pancreatic cancer, and locate radiolucent stones. Recent advances in endoscopic techniques, such as endoscopic ultrasonography and balloon enteroscopy, and newly designed stents have broadened the indications for pancreatic duct stenting. In this review we outlined the types, insertion procedures, efficacy, and complications of endoscopic pancreatic duct stent placement, and summarized the applications of pancreatic duct stents in surgery.

Covered self-expandable metal stents for pancreatic duct stricture: a systematic review and meta-analysis

Background and study aims  Placement of a covered (C)-self-expandable metal stent (SEMS) has been recently investigated as an alternative endoscopic treatment for main pancreatic duct stricture (MPDS) in chronic pancreatitis. Our aim was to carry out a systematic review and meta-analysis of studies quantifying efficacy and safety of C-SEMSs in the management of MPDS. Methods  A multiple database search was performed, including MEDLINE, Embase and Cochrane Library, from January 2000 to September 2020, to identify studies reporting the efficacy and safety of C-SEMSs in patients with MPDS. Stricture and pain resolution were investigated. Other outcomes included technical success, stent migration, stricture recurrence and need for repeated stent placement. Pancreatitis, severe abdominal pain requiring stent removal and de-novo stricture were recorded as complications. Results  Nineteen studies were identified, which included a total of 300 patients. C-SEMSs showed a pooled stricture resolution rate of 91 % [95 % confidence interval (CI), 85 %-96 %] and a pooled pain resolution rate of 92 % (95 % CI, 85 %-98 %). The pooled proportion for stricture recurrence was equal to 6 % (95 % CI, 1 %-14 %), while stent migration occurred in 33 of 300 patients, the pooled proportion being 7 % (95 % CI 1 %-15 %). The pooled mean stent duration was 133 days (95 % CI, 100-166 days). The most common complication was pancreatitis (3 %, 95 % CI 0 %-8 %), while de-novo stricture pooled proportion was 2 % (95 % CI, 0 %-5 %). Conclusions  C-SEMSs are effective and safe in the treatment of MPDS. However, there is a significant need for further high-quality, well-designed studies to produce evidence-based data on short and long-term efficacy, safety, costs of C-SEMSs, and also optimal stent duration.

Outpatient Pain Management in Children With Chronic Pancreatitis: A Scoping Systematic Review

OBJECTIVES

Although pain management is central to pediatric chronic pancreatitis (CP) care, no evidence-based guidelines exist. In this scoping systematic review, we sought promising strategies for CP pain treatment in children.

METHODS

We systematically reviewed literature on pain management in children and adults with CP, and 2 conditions with similar pain courses: juvenile idiopathic arthritis and sickle cell disease.

RESULTS

Of 8997 studies identified, 287 met inclusion criteria. There are no published studies of analgesic medications, antioxidants, dietary modification, integrative medicine, or regional nerve blocks in children with CP. In adults with CP, studies of nonopioid analgesics, pancreatic enzymes, and dietary interventions have mixed results. Retrospective studies suggest that endoscopic retrograde cholangiopancreatography and surgical procedures, most durably total pancreatectomy with islet autotransplant, improve pain for children with CP. Follow-up was short relative to a child's life. Large studies in adults also suggest benefit from endoscopic therapy and surgery, but lack conclusive evidence about optimal procedure or timing. Studies on other painful pediatric chronic illnesses revealed little generalizable to children with CP.

CONCLUSIONS

No therapy had sufficient high-quality studies to warrant untempered, evidence-based support for use in children with CP. Multicenter studies are needed to identify pain management "best practices."

Long-term outcomes of fully covered self-expandable metal stents versus plastic stents in chronic pancreatitis

Chronic pancreatitis (CP) related main pancreatic duct (MPD) stricture has been a challenge for endoscopists. Fully covered self-expandable metal stents (FC-SEMS) has been tried in CP patients, but the efficacy and safety are still controversial. Thus, we aim to compare the long-term clinical efficacy of FC-SEMS vs. plastic stent placement in persistent MPD strictures secondary to CP. Between 2007 and 2018, 80 chronic pancreatitis patients (58 males, median age 49 years), who underwent endoscopic placement of FC-SEMS (n = 26) and plastic stent (n = 54) for persistent MPD strictures after at least 3 months of initial single plastic stenting, were retrospectively analyzed during a median follow-up duration of 33.7 months. As a result, MPD stricture resolution rate was statistically higher in FC-SEMS group (87.0% vs. 42.0%, p < 0.001). Although immediate complications occurred similarly (38.5% vs. 37.0%, p = 0.902), spontaneous migration (26.9%) and de novo strictures (23.1%) were pronounced delayed complications in FC-SEMS group. Pain relief during follow-up was significantly higher in FC-SEMS group (76.9% vs. 53.7%, p = 0.046). The total procedure cost was similar in both groups ($1,455.6 vs. $1,596.9, p = 0.486). In comparison with plastic stent, FC-SEMS placement for persistent MPD strictures had favorable long-term clinical efficacy, with its typical complications like spontaneous migration and de novo strictures.

Current advances in the management of chronic pancreatitis

Chronic pancreatitis is characterized by irreversible destruction of pancreatic parenchyma and its ductal system resulting from longstanding inflammation, leading to fibrosis and scarring due to genetic, environmental, and other risk factors. The diagnosis of chronic pancreatitis is made based on a combination of clinical features and characteristic findings on computed tomography or magnetic resonance imaging. Abdominal pain is the most common symptom of chronic pancreatitis. The main aim of treatment is to relieve symptoms, prevent disease progression, and manage complications related to chronic pancreatitis. Patients who do not respond to medical treatment or not a candidate for surgical treatment are usually managed with endoscopic therapies. Endoscopic therapies help with symptoms such as abdominal pain and jaundice by decompression of pancreatic and biliary ducts. This review summarizes the risk factors, pathophysiology, diagnostic evaluation, endoscopic treatment of chronic pancreatitis, and complications. We have also reviewed recent advances in endoscopic retrograde cholangiopancreatography and endoscopic ultrasound-guided therapies for pancreatic duct obstruction due to stones, strictures, pancreatic divisum, and biliary strictures.

Impact of physiologically shaped pancreatic stent for chronic pancreatitis

Endoscopic pancreatic stenting is used to prevent main pancreatic duct obstruction and relieve painful symptoms of chronic pancreatitis. However, the stent typically needs to be exchanged and the rate of adverse events is high. Few studies have evaluated the effect of stent shape on those outcomes. We evaluated the adverse events, stent patency, and total medical cost within 90 days of patients who received an 8.5 French (Fr) physiologically shaped pancreatic stent by comparing these features with those associated with a conventional straight-type stent for ≥ 90 days. The total stent-related adverse event rate was significantly lower for the physiologically shaped pancreatic stent (physiologically shaped, 6.7% [2/30]; straight-type, 50.6% [44/87]; P < 0.001). Stent occlusion was significantly less frequent (P < 0.001) and the total medical costs were significantly lower (P = 0.002) for the physiologically shaped stent. The stent-related adverse event rate was significantly higher for the 10 Fr straight type stent than for the 8.5 Fr physiologically shaped stent (10 Fr, straight-type vs. 8.5 Fr, physiologically shaped: 36.1% [13/36] vs. 6.7% [2/30]; P = 0.007). In conclusion, a physiologically shaped pancreatic stent was superior to a straight-type stent in terms of the patency rate and medical costs.

The Role of Endoscopic and Surgical Treatment in Chronic Pancreatitis

Chronic pancreatitis is a long-term illness leading to hospital admissions and readmission. This disease is often caused by heavy alcohol consumption and smoking. Patients with chronic pancreatitis suffer from acute or chronic pain episodes, recurrent pancreatitis, and complications, such as pseudocysts, biliary duct strictures, and pancreatic duct fistulas. Pancreatic duct strictures and stones may increase intraductal pressure and cause pain. Endoscopic therapy is aiming at decompressing the pressure and relieving the pain, most commonly with pancreatic duct stents and pancreatic duct stone retrieval. Early surgery is another option to treat the pain. In addition, endotherapy has been successful in treating complications related to chronic pancreatitis. The therapy should be individually chosen in a multidisciplinary meeting. Endoscopic therapy and surgery as treatment options for chronic pancreatitis are discussed in this review.

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.

10 Fr S-Type Plastic Pancreatic Stents in Chronic Pancreatitis Are Effective for the Treatment of Pancreatic Duct Strictures and Pancreatic Stones

AIM

Endoscopic pancreatic stenting for refractory pancreatic duct strictures associated with impacted pancreatic stones in chronic pancreatitis cases has yielded conflicting results. We retrospectively evaluated the efficacy of endoscopic treatment in chronic pancreatitis patients with pancreatic duct strictures.

METHODS

Pancreatic sphincterotomy, dilatation procedures, pancreatic brush cytology, and pancreatic juice cytology were routinely performed, and malignant diseases were excluded. After gradual dilatation, a 10 Fr plastic pancreatic stent was inserted. The stents were replaced every 3 months and removed after the strictures were dilated. Statistical analyses were performed to determine the risk of main pancreatic duct restenosis.

RESULTS

Endoscopic pancreatic stents were successfully placed in 41 of a total of 59 patients (69.5%). The median duration of pancreatic stenting was 276 days. Pain relief was obtained in 37 of 41 patients (90.2%). Seventeen patients (41.5%) had recurrence of main pancreatic duct stricture, and restenting was performed in 16 patients (average placement period 260 days). During the follow-up period, pancreatic cancer developed in three patients (5.1%). Multivariate analysis revealed that the presence of remnant stones after stenting treatment was significantly associated with a higher rate of main pancreatic duct restenosis (p = 0.03).

CONCLUSION

The use of 10 Fr S-type plastic pancreatic stents with routine exchange was effective for both short-term and long-term outcomes in chronic pancreatitis patients with benign pancreatic duct strictures and impacted pancreatic stones.

Long-term outcomes of 6-mm diameter fully covered self-expandable metal stents in benign refractory pancreatic ductal stricture

BACKGROUND AND AIM

Fully covered self-expandable metal stent (FCSEMS) placement has been tried for pancreatic ductal strictures in chronic pancreatitis. However, the long-term outcome of this procedure remains unknown. The present study aimed to investigate the procedural and long-term outcomes of FCSEMS placement in patients with benign refractory pancreatic ductal strictures.

METHODS

Between August 2011 and September 2015, 18 patients underwent endoscopic treatment with FCSEMS for benign refractory pancreatic ductal stricture. Technical success, clinical success, radiological success, and adverse events were assessed.

RESULTS

Stent placement was successful in all patients (technical success rate, 100%). Reduction in pain score of >50% was achieved in 15 of the 18 patients (clinical success rate, 83.3%). In all patients, stents could easily be removed at a median of 7.5 months (interquartile range [IQR], 6-13.6) after their insertion. FCSEMS migration did not develop in any patient. Ductal stricture was improved in 15 patients (radiological success rate, 83.3%). After definite stent removal, 13 of the 15 (86.7%) patients who had responded to pancreatic stenting maintained the response during follow up (median of 47.3 months; IQR, 7.4-57.1).

CONCLUSIONS

FCSEMS placement appears to be safe and effective for the treatment of benign refractory pancreatic ductal strictures as it can provide persistent improvement in the stricture in long-term follow up.

[Endoscopic pancreatic stenting in pancreatic fistulas management]

AIM

To present 18-year experience of endoscopic transpapillary stenting in patients with pancreatic fistula.

MATERIAL AND METHODS

The study included 48 patients with pancreatic fistula resistant to conservative management. Pancreatic stenting was successful in 32 (66.7%) patients. In 30 (93.8%) of them stenting appeared as the final stage of pancreatic fistula treatment.

RESULTS

Inclidence of complications after endoscopic treatment was 4.2%. We evaluated long-term results in 23 cases within 8-184 months. There were good results in 21 (91.3%) cases and satisfactory - in 2 (8.7%) cases. We had not unsatisfactory results in our experience.

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.

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.

Endoscopic therapy in chronic pancreatitis: current perspectives

Endoscopic therapy in chronic pancreatitis (CP) aims to provide pain relief and to treat local complications, by using the decompression of the pancreatic duct and the drainage of pseudocysts and biliary strictures, respectively. This is the reason for using it as first-line therapy for painful uncomplicated CP. The clinical response has to be evaluated at 6-8 weeks, when surgery may be chosen. This article reviews the main possibilities of endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) therapies. Endotherapy for pancreatic ductal stones uses ultrasound wave lithotripsy and sometimes additional stone extractions. The treatment of pancreatic duct strictures consists of a single large stenting for 1 year. If the stricture persists, simultaneous multiple stents are applied. In case of unsuccessful ERCP, the EUS-guided drainage of the main pancreatic duct (MPD) or a rendezvous technique can solve the ductal strictures. EUS-guided celiac plexus block has limited efficiency in CP. The drainage of symptomatic or complicated pancreatic pseudocysts can be performed transpapillarily or transgastrically/transduodenally, preferably by EUS guidance. When the biliary stricture is symptomatic or progressive, multiple plastic stents are indicated. In conclusion, as in many fields of symptomatic treatment, endoscopy remains the first choice, either by using ERCP or EUS-guided procedures, after consideration of a multidisciplinary team with endoscopists, surgeons, and radiologists. However, what is crucial is establishing the right timing for surgery.

Treatment options for chronic pancreatitis

This Review covers the latest developments in the treatment options for chronic pancreatitis. Pain is the most frequent and dominant symptom in patients with chronic pancreatitis, which ranges from severe disabling continuous pain to mild pain attacks and pain-free periods. Conventional treatment strategies and recent changes in the treatment of pain in patients with chronic pancreatitis are outlined. The different treatment options for pain consist of medical therapy, endoscopy or surgery. Their related merits and drawbacks are discussed. Finally, novel insights in the field of genetics and microbiota are summarized, and future perspectives are discussed.

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.

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.

The Spanish Pancreatic Club's recommendations for the diagnosis and treatment of chronic pancreatitis: part 2 (treatment)

Chronic pancreatitis (CP) is a complex disease with a wide range of clinical manifestations. This range comprises from asymptomatic patients to patients with disabling symptoms or complications. The management of CP is frequently different between geographic areas and even medical centers. This is due to the paucity of high quality studies and clinical practice guidelines regarding its diagnosis and treatment. The aim of the Spanish Pancreatic Club was to give current evidence-based recommendations for the management of CP. Two coordinators chose a multidisciplinary panel of 24 experts on this disease. These experts were selected according to clinical and research experience in CP. A list of questions was made and two experts reviewed each question. A draft was later produced and discussed with the entire panel of experts in a face-to-face meeting. The level of evidence was based on the ratings given by the Oxford Centre for Evidence-Based Medicine. In the second part of the consensus, recommendations were given regarding the management of pain, pseudocysts, duodenal and biliary stenosis, pancreatic fistula and ascites, left portal hypertension, diabetes mellitus, exocrine pancreatic insufficiency, and nutritional support in CP.

Pancreatic stents

Use of stents in the pancreas has been confined and limited to referral centers that specialize in the treatment of patients with severe pancreatitis and acute relapsing pancreatitis. With therapeutic development in endoscopic treatment of pancreatic diseases and a better understanding of the cause and prevention of ERCP related complications, the use of stents has been extended to transmural drainage of pancreatic fluid collection or of pancreatic ducts has well as to prophylaxis of post-ERCP pancreatitis. As a result, indication for pancreatic stenting and the kind of stents to be used as well as the followup after placement varies. This article reviews the major indication for pancreatic stent placement and focuses on the choice of stent, technique of implantation and followup.

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

Endoscopic treatment of chronic pancreatitis (CP) aims to relieve pain by draining the main pancreatic duct (MPD) and to treat loco-regional complications. Half of patients have complete pain relief five years after treatment, with best results obtained if treatment is performed early after the first pain attack. If MPD obstruction is caused by calcifications, ambulatory extracorporeal shock wave lithotripsy has become a first-line treatment (9-30% of patients require ERCP during follow-up). If MPD obstruction is caused by stricture(s), insertion of single plastic stent is effective but it requires multiple ERCPs for stent exchanges; other protocols are being investigated. Pseudocysts represent an excellent indication for endoscopic treatment with long-term results similar to those of surgery; endosonography-guided techniques allow treatment of almost any pancreatic pseudocyst. Biliary strictures related to CP are challenging due to a high relapse rate and requirement for multiple ERCP sessions. Significant progress has recently been made with new protocols of temporary biliary stenting (multiple simultaneous plastic stents or covered metallic stents).

Effect of pancreatic duct stent diameter on hospitalization in chronic pancreatitis: does size matter?

OBJECTIVE

Endoscopic therapy with pancreatic duct (PD) stenting in painful chronic pancreatitis is effective at reducing pain. Few studies have compared response to different PD stent diameters. In this study, we retrospectively analyzed the effect of PD stent diameter on hospitalization for abdominal pain in chronic pancreatitis.

METHODS

An existing database was queried to identify individuals who received PD stenting for chronic pancreatitis. Each patient was grouped according to stent diameter: (1) 8.5F stents or smaller and (2) 10F stents. The main outcome was number of hospitalizations adjusting for varying follow-up time and controlling for age, sex, and etiology of pancreatitis using a negative binomial model.

RESULTS

One hundred sixty-three patients underwent PD stent placement for chronic pancreatitis from October 1995 to September 2007. One hundred twenty-nine patients (79%) received predominantly PD stents 8.5F or smaller in diameter, and 34 patients (21%) received predominantly PD stents 10F in diameter. There was no statistically significant difference in population characteristics between the 2 groups. The 10F stent group had a statistically significant (P = 0.003) lower rate of hospitalization.

CONCLUSIONS

Patients who received larger diameter PD stents had fewer hospitalizations for abdominal pain. Outcome-based prospective studies are needed.

A randomized trial comparing endoscopic stenting to a sham procedure for chronic pancreatitis

Background A number of studies support the use of endoscopically placed pancreatic duct (PD) stents to decrease pain in chronic pancreatitis (CP). Nevertheless, flaws in study design have prevented experts from reaching a consensus.

Purpose (1) Evaluate the efficacy of PD stenting to ameliorate abdominal pain in patients with CP and ductal strictures; (2) evaluate the placebo response rate from sham endoscopic therapy; (3) compare pain medication usage, healthcare utilization, psychological distress, and quality of life before and after endoscopic stenting; (4) prospectively evaluate the durability of the response.

Methods Patients with typical abdominal pain, imaging confirmation of CP and endoscopic retrograde cholangiopancreatography (ERCP) confirmation of PD stricture will complete questionnaires to assess quality of life, psychological distress, pain intensity/unpleasantness, pain medication usage, and healthcare utilization. Enrolled patients will be randomized to ERCP with sphincterotomy and PD stenting versus sham procedure. Pain level and medication usage will be assessed weekly with telephone interviews. At 6—8 weeks, patients treated with stents will undergo stent removal; those randomized to the sham procedure without significant improvement (<50% reduction in pain score) will cross over to the treatment group; and those randomized to sham procedure who experienced improvement (>50% reduction) will be followed clinically. Patients will be followed in clinic or by phone biannually (up to 3 years). The primary endpoint is improvement in abdominal pain. The secondary endpoints are reduction in narcotic use, healthcare utilization, and work days missed; return to employment; improvement in quality of life and weight gain.

Results Proposed study.

Limitations Strict inclusion criteria may limit enrollment.

Conclusion The proposed study represents the first trial of endoscopic stenting for symptomatic CP and ductal strictures with a credible sham procedure, assessment of multiple dimensions of pain, and psychosocial factors. Clinical Trials 2009; 6: 455—463. http://ctj.sagepub.com

Feasibility and safety of placement of a newly designed, fully covered self-expandable metal stent for refractory benign pancreatic ductal strictures: a pilot study (with video)

BACKGROUND

Painful chronic pancreatitis with main pancreatic ductal strictures is usually managed with endotherapy with a plastic stent. To date, the role of placement of metallic stents, especially uncovered ones in benign pancreatic ductal stricture, has been unsatisfactory as a result of stent dysfunction related to mucosal hyperplasia.

OBJECTIVE

We explored the feasibility and safety of temporary placement of a newly designed, fully covered self-expandable metal stent (FCSEMS) in painful chronic pancreatitis and refractory benign pancreatic ductal strictures.

DESIGN

A prospective pilot and feasibility study.

SETTING

A tertiary academic center.

PATIENTS

Thirteen patients with chronic painful pancreatitis of alcoholic (8) or idiopathic (5) etiology.

INTERVENTION

ERCP with temporary FCSEMS placement (2 months). Endoscopic removal of FCSEMSs was performed with a snare or rat-tooth forceps.

MAIN OUTCOME MEASUREMENTS

End points were feasibility, safety, and morbidity.

RESULTS

Successful FCSEMS placement was performed in all enrolled patients. After immediate placement of FCSEMS, 2 patients had mild acute pancreatitis related mainly to the stricture dilation procedure (Soehendra stent retriever or balloon dilation). Complications associated with stent placement included 5 migrations (39%, 1 proximal and 4 distal) and 2 incidents of cholestatic liver dysfunction associated with the compression of the bile duct orifice by expansion of FCSEMSs. In 1 patient with proximal migration, the stent was repositioned by an inflated retrieval balloon. Additional endoscopic biliary sphincterotomy with or without biliary stenting was performed in 2 patients with cholestatic liver dysfunction. There was no occurrence of pancreatic sepsis among any patients. FCSEMSs were removed from 9 of 9 patients without stent migration (100% [9/9] as per protocol, and 69% [9/13] as intention to treat, respectively). Improvement or resolution of the pancreatic ductal strictures was confirmed in all 13 patients on follow-up ERCP (2 months after stent placement), regardless of stent migration.

LIMITATIONS

Small patient populations without long-term follow-up.

CONCLUSIONS

Two-month placement of FCSEMSs in patients with refractory benign pancreatic ductal strictures may be feasible and relatively safe. However, stent migration was not uncommon. A further investigation with ideal stent design may therefore be needed before recommending FCSEMSs as a therapeutic option for refractory benign pancreatic ductal strictures.

Temporary placement of a fully covered self-expandable metal stent in the pancreatic duct for management of symptomatic refractory chronic pancreatitis: preliminary data (with videos)

BACKGROUND

Pancreatic duct (PD) stenting is beneficial for the treatment of pain in patients with PD strictures associated with chronic pancreatitis. Placement of metal stents has been reported but failed secondary to hyperplasia or migration.

OBJECTIVE

To investigate the outcome of patients with symptomatic and refractory PD strictures who had temporary placement of a covered self-expandable metal stent (CSEMS).

DESIGN

Patients with refractory PD strictures were offered temporary CSEMS placement. Pain scores were evaluated before and after CSEMS placement.

SETTING

A tertiary-care center.

PATIENTS

Six patients (4 men, mean age +/- SD 55 +/- 8 years) received a CSEMS, and 5 patients had removal of a CSEMS after a mean time of 92 days.

INTERVENTION

Placement of CSEMS (8-mm or 10-mm diameter VIABIL) in the PD, with removal after 3 months.

MAIN OUTCOME MEASUREMENTS

The pain score before and after stent placement and the sustained response after removal. Morbidity associated with stent placement and removal was also noted.

RESULTS

Pain scores after CSEMS placement significantly improved (P = .024), from 6.4 to 1.6. Of the 5 patients who underwent CSEMS removal, 3 developed recurrent symptomatic pancreatic stricture, of whom 2 required repeat stenting with a larger-diameter CSEMS (10 mm) and 2 remained pain free. The CSEMS was not removed in 1 patient because pancreatic malignancy was diagnosed. There were no complications during placement or removal of CSEMSs.

LIMITATION

This was a pilot study.

CONCLUSION

Temporary placement of CSEMSs in patients with symptomatic refractory PD stricture offers transient relief of pain. Further investigation is needed to determine the optimal diameter and duration of placement.

Endoscopic pancreatic duct stent placement for inflammatory pancreatic diseases

The role of endoscopic therapy in the management of pancreatic diseases is continuously evolving; at present most pathological conditions of the pancreas are successfully treated by endoscopic retrograde cholangio-pancreatography (ERCP) or endoscopic ultrasound (EUS), or both. Endoscopic placement of stents has played and still plays a major role in the treatment of chronic pancreatitis, pseudocysts, pancreas divisum, main pancreatic duct injuries, pancreatic fistulae, complications of acute pancreatitis, recurrent idiopathic pancreatitis, and in the prevention of post-ERCP pancreatitis. These stents are currently routinely placed to reduce intraductal hypertension, bypass obstructing stones, restore lumen patency in cases with dominant, symptomatic strictures, seal main pancreatic duct disruption, drain pseudocysts or fluid collections, treat symptomatic major or minor papilla sphincter stenosis, and prevent procedure-induced acute pancreatitis. The present review aims at updating and discussing techniques, indications, and results of endoscopic pancreatic duct stent placement in acute and chronic inflammatory diseases of the pancreas.

Endoscopic pancreatic duct stent placement for inflammatory pancreatic diseases

The role of endoscopic therapy in the management of pancreatic diseases is continuously evolving; at present most pathological conditions of the pancreas are successfully treated by endoscopic retrograde cholangio-pancreatography (ERCP) or endoscopic ultrasound (EUS), or both. Endoscopic placement of stents has played and still plays a major role in the treatment of chronic pancreatitis, pseudocysts, pancreas divisum, main pancreatic duct injuries, pancreatic fistulae, complications of acute pancreatitis, recurrent idiopathic pancreatitis, and in the prevention of post-ERCP pancreatitis. These stents are currently routinely placed to reduce intraductal hypertension, bypass obstructing stones, restore lumen patency in cases with dominant, symptomatic strictures, seal main pancreatic duct disruption, drain pseudocysts or fluid collections, treat symptomatic major or minor papilla sphincter stenosis, and prevent procedure-induced acute pancreatitis. The present review aims at updating and discussing techniques, indications, and results of endoscopic pancreatic duct stent placement in acute and chronic inflammatory diseases of the pancreas.

The role of endoscopy in the therapy of chronic pancreatitis

Almost all the therapeutic efforts in the treatment of chronic pancreatitis are directed towards pain control. Endoscopic techniques available for this purpose are endoscopic retrograde cholangiopancreatography (combined or not with extracorporeal shock wave lithotripsy) and endoscopic ultrasound. Pancreatic stones and strictures, pancreatic pseudocysts, and common bile duct strictures complicating chronic pancreatitis can be treated by endoscopy. The development of endoscopic ultrasound extended the possibilities in the treatment of pancreatic pseudocysts and main pancreatic duct drainage. Endoscopy is considered the first-line treatment in chronic pancreatitis and can be useful also as a 'bridge to surgery'. In fact the endoscopic approach to chronic pancreatitis can predict the response to surgical therapy as a definitive treatment. Medical, endoscopic and surgical methods for the management of chronic pancreatitis should all be considered in decision-making, and the best treatment should be chosen case by case and according to the local expertise.

Preoperative endoscopic pancreatic stenting for prophylaxis of pancreatic duct disruption during extirpation of a pancreatic head tumor

BACKGROUND

Pancreatic fistula is a major problem in minimal invasive surgery of the pancreas. To prevent the disruption of the pancreatic duct, the surgeon must recognize the site of the pancreatic duct exactly.

METHODS

We reviewed the cases of 7 patients who underwent preoperative endoscopic pancreatic stenting for the prophylaxis of pancreatic fistula development after enucleation of a benign pancreatic head tumor.

RESULTS

Preoperative endoscopic pancreatic stenting was successfully performed in all 7 patients. The level of serum amylase increased to 1500 IU/L on postoperative day 1, but levels recovered to normal within 3 days. None of the patients developed a pancreatic fistula.

CONCLUSIONS

Preoperative pancreatic duct stenting is a feasible, effective, and safe technique to prevent pancreatic duct disruption during enucleation of a benign tumor of the pancreatic head.

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.