Outcome of pancreaticojejunostomy after previous endoscopic stenting in patients with chronic pancreatitis

Evidence-based clinical practice guidelines for chronic pancreatitis 2021

BACKGROUND

Chronic pancreatitis (CP) is defined according to the recently proposed mechanistic definition as a pathological fibro-inflammatory syndrome of the pancreas in individuals with genetic, environmental, and/or other risk factors who develop persistent pathological responses to parenchymal injury or stress.

METHODS

The clinical practice guidelines for CP in Japan were revised in 2021 based on the 2019 Japanese clinical diagnostic criteria for CP, which incorporate the concept of a pathogenic fibro-inflammatory syndrome in the pancreas. In this third edition, clinical questions are reclassified into clinical questions, background questions, and future research questions.

RESULTS

Based on analysis of newly accumulated evidence, the strength of evidence and recommendations for each clinical question is described in terms of treatment selection, lifestyle guidance, pain control, treatment of exocrine and endocrine insufficiency, and treatment of complications. A flowchart outlining indications, treatment selection, and policies for cases in which treatment is ineffective is provided. For pain control, pharmacological treatment and the indications and timing for endoscopic and surgical treatment have been updated in the revised edition.

CONCLUSIONS

These updated guidelines provide clinicians with useful information to assist in the diagnosis and treatment of CP.

Endoscopic versus Surgical Intervention for Painful Obstructive Chronic Pancreatitis: A Systematic Review and Meta-Analysis

There is limited evidence on the standard care for painful obstructive chronic pancreatitis (CP), while comparisons of endoscopic and surgical modes for pain relief have yielded conflicting results from small sample sizes. We aimed to obtain a clear picture of the matter by a meta-analysis of these results. We searched the Pubmed, Embase, and Cochrane Library databases to identify studies comparing endoscopic and surgical treatments for painful obstructive CP. Pooled effects were calculated by the random effect model. Primary outcomes were overall pain relief (complete and partial), and secondary outcomes were complete and partial pain relief, complication rate, hospitalization duration, and endocrine insufficiency. Seven studies with 570 patients were included in the final analysis. Surgical drainage was associated with superior overall pain relief [OR 0.33, 95% CI 0.23–0.47, p < 0.001, I² = 4%] and lesser incidence of endocrine insufficiency [OR 2.10, 95% CI 1.20–3.67, p = 0.01, I² = 0%], but no significant difference in the subgroup of complete [OR 0.57, 95% CI 0.32–1.01, p = 0.054, I² = 0%] or partial [OR 0.67, 95% CI 0.37–1.22, p = 0.19, I² = 0%] pain relief, complication rates [OR 1.00, 95% CI 0.41–2.46, p = 0.99, I² = 49%], and hospital stay [OR −0.54, 95% CI −1.23–0.15, p = 0.13, I² = 87%] was found. Surgery is associated with significantly better overall pain relief and lesser endocrine insufficiency in patients with painful obstructive CP. However, considering the invasiveness of surgery, no significant differences in complete or partial pain relief, and heterogeneity of a few parameters between two groups, endoscopic drainage may be firstly performed and surgical drainage may be considered when endoscopic drainage fails.

International consensus guidelines for surgery and the timing of intervention in chronic pancreatitis

BACKGROUND/OBJECTIVES

Chronic pancreatitis (CP) is a complex inflammatory disease with pain as the predominant symptom. Pain relief can be achieved using invasive interventions such as endoscopy and surgery. This paper is part of the international consensus guidelines on CP and presents the consensus guideline for surgery and timing of intervention in CP.

METHODS

An international working group with 15 experts on CP surgery from the major pancreas societies (IAP, APA, JPS, and EPC) evaluated 20 statements generated from evidence on 5 questions deemed to be the most clinically relevant in CP. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was used to evaluate the level of evidence available for each statement. To determine the level of agreement, the working group voted on the 20 statements for strength of agreement, using a nine-point Likert scale in order to calculate Cronbach's alpha reliability coefficient.

RESULTS

Strong consensus was obtained for the following statements: Surgery in CP is indicated as treatment of intractable pain and local complications of adjacent organs, and in case of suspicion of malignant (cystic) lesion; Early surgery is favored over surgery in a more advanced stage of disease to achieve optimal long-term pain relief; In patients with an enlarged pancreatic head, a combined drainage and resection procedure, such as the Frey, Beger, and Berne procedure, may be the treatment of choice; Pancreaticoduodenectomy is the most suitable surgical option for patients with groove pancreatitis; The risk of pancreatic carcinoma in patients with CP is too low (2% in 10 year) to recommend active screening or prophylactic surgery; Patients with hereditary CP have such a high risk of pancreatic cancer that prophylactic resection can be considered (lifetime risk of 40-55%). Weak agreement for procedure choice in patients with dilated duct and normal size pancreatic head: both the extended lateral pancreaticojejunostomy and Frey procedure seems to provide equivalent pain control in patients.

CONCLUSIONS

This international expert consensus guideline provides evidenced-based statements concerning key aspects in surgery and timing of intervention in CP. It is meant to guide clinical practitioners and surgeons in the treatment of patients with CP.

Morphological and immunohistochemical comparison of intrapancreatic nerves between chronic pancreatitis and type 1 autoimmune pancreatitis

OBJECTIVES

The abdominal pain associated with chronic pancreatitis (CP) may be related to the increased number and size of intrapancreatic nerves. On the other hand, patients with type 1 autoimmune pancreatitis (AIP) rarely suffer from the pain syndrome, and there are no previous studies concerning the histopathological findings of intrapancreatic nerves in patients with type 1 AIP. The current study is aimed at investigating the differences in the histopathological and immunohistochemical findings of intrapancreatic nerves in patients with CP and type 1 AIP.

METHODS

Neuroanatomical differences between CP and type 1 AIP were assessed by immunostaining with a pan-neuronal marker, protein gene product 9.5 (PGP9.5). The number (neural density) and area (neural hypertrophy) of PGP9.5-immunopositive nerves were quantitatively analyzed. Furthermore, the expression of nerve growth factor (NGF), and a high affinity receptor for NGF, tyrosine kinase receptor A (TrkA), was assessed by immunohistochemistry.

RESULTS

Both neural density and hypertrophy were significantly greater in pancreatic tissue samples from patients with CP than those with normal pancreas or type 1 AIP. NGF expression was stronger in type 1 AIP than in CP, whereas TrkA expression in type 1 AIP was poorer than in CP.

CONCLUSIONS

Although CP and type 1 AIP are both characterized by the presence of sustained pancreatic inflammation, they are different in terms of the density and hypertrophy of intrapancreatic nerve fibers. It is possible that this may be related to the difference in the activity of the NGF/TrkA-pathway between the two types of pancreatitis.

Narcotic Independence After Pancreatic Duct Stenting Predicts Narcotic Independence After Lateral Pancreaticojejunostomy for Chronic Pancreatitis

OBJECTIVE

This study aimed to determine if the improved pain response to endoscopic retrograde cholangiopancreatogrphy (ERCP) and pancreatic stent placement (EPS) predicts pain response in patients with chronic pancreatitis after modified lateral pancreaticojejunostomy (LPJ).

METHODS

A multi-institutional, retrospective review of patients who underwent successful EPS before LPJ between 2001 and 2010 was performed. The primary outcome was narcotic independence (NI) within 2 months after ERCP or LPJ.

RESULTS

A total of 31 narcotic-dependent patients with chronic pancreatitis underwent successful EPS before LPJ. Ten (32%) achieved post-LPJ NI (median follow-up, 8.5 months; interquartile range [IQR], 2-38 months). Eight (80%) of 10 patients with NI post-ERCP achieved NI post-LPJ. Two (10%) without NI post-ERCP achieved NI post-LPJ. Narcotic independence post-EPS was associated strongly with NI post-LPJ with an odds ratio of 38 (P = 0.0025) and predicted post-LPJ NI with a sensitivity, specificity, positive predictive value, and negative predictive value of 80%, 90.5%, 80%, and 90.5%, respectively.

CONCLUSIONS

Narcotic independence after EPS is associated with NI after LPJ. Failure to achieve NI post-ERCP predicts failure to achieve NI post-LPJ. These results support the need for larger studies to confirm the predictive value of pancreatic duct stenting for better selection of chronic pancreatitis patients who will benefit from LPJ.

Endoscopic ultrasonography-guided pancreatic duct access: techniques and literature review of pancreatography, transmural drainage and rendezvous techniques

Endoscopic ultrasonography-guided (EUS)-guided pancreatic interventions have gained increasing attention. Here we review EUS-guided pancreatic duct (PD) access techniques and outcomes. EUS-guided PD intervention is divided into two types, antegrade and rendezvous techniques, following EUS-guided pancreatography. In the antegrade technique, pancreaticoenterostomy is carried out by stent placement between the PD and the stomach, duodenum, or jejunum. Transenteric antegrade PD stenting is conducted by stent placement, advancing anteriorly into the PD through the pancreatic tract. The rendezvous technique is carried out by using a guidewire through the papilla or anastomotic site for retrograde stent insertion. In terms of EUS-guided PD stenting, 11 case reports totaling 75 patients (35 normal anatomy, 40 altered anatomy) have been published. The technical success rate was greater than 70%. Early adverse events, including severe hematoma and severe pancreatitis,occurred in seven (63.6%) of 11 reports. Regarding the rendezvous technique, 12 case reports totaling 52 patients (22 normal anatomy, 30 altered anatomy) have been published. The technical success rate ranged from 25% to 100%. It was 48% in one report that involved more than 20 cases. Once stents were placed, all patients became free of symptoms. Early mild adverse events occurred in four (36.4%) of 11 reports. In conclusion, although it can be risky because of possible serious or even fatal adverse events, including pancreatic juice leakage, perforation and severe acute pancreatitis, EUS-PD access seems to be promising for treating symptomatic pancreatic diseases caused by PD stricture and pancreaticoenterostomy stricture.

Endoscopic stent therapy in patients with chronic pancreatitis: A 5-year follow-up study

AIM: This study analyzed clinical long-term outcomes after endoscopic therapy, including the incidence and treatment of relapse.

METHODS: This study included 19 consecutive patients (12 male, 7 female, median age 54 years) with obstructive chronic pancreatitis who were admitted to the 2^nd Medical Department of the Technical University of Munich. All patients presented severe chronic pancreatitis (stage III°) according to the Cambridge classification. The majority of the patients suffered intermittent pain attacks. 6 of 19 patients had strictures of the pancreatic duct; 13 of 19 patients had strictures and stones. The first endoscopic retrograde pancreatography (ERP) included an endoscopic sphincterotomy, dilatation of the pancreatic duct, and stent placement. The first control ERP was performed 4 wk after the initial intervention, and the subsequent control ERP was performed after 3 mo to re-evaluate the clinical and morphological conditions. Clinical follow-up was performed annually to document the course of pain and the management of relapse. The course of pain was assessed by a pain scale from 0 to 10. The date and choice of the therapeutic procedure were documented in case of relapse.

RESULTS: Initial endoscopic intervention was successfully completed in 17 of 19 patients. All 17 patients reported partial or complete pain relief after endoscopic intervention. Endoscopic therapy failed in 2 patients. Both patients were excluded from further analysis. One failed patient underwent surgery, and the other patient was treated conservatively with pain medication. Seventeen of 19 patients were followed after the successful completion of endoscopic stent therapy. Three of 17 patients were lost to follow-up. One patient was not available for interviews after the 1^st year of follow-up. Two patients died during the 3^rd year of follow-up. In both patients chronic pancreatitis was excluded as the cause of death. One patient died of myocardial infarction, and one patient succumbed to pneumonia. All three patients were excluded from follow-up analysis. Follow-up was successfully completed in 14 of 17 patients. 4 patients at time point 3, 2 patients at time point 4, 3 patients at time point 5 and 2 patients at time point 6 and time point 7 used continuous pain medication after endoscopic therapy. No relapse occurred in 57% (8/14) of patients. All 8 patients exhibited significantly reduced or no pain complaints during the 5-year follow-up. Seven of 8 patients were completely pain free 5 years after endoscopic therapy. Only 1 patient reported continuous moderate pain. In contrast, 7 relapses occurred in 6 of the 14 patients. Two relapses were observed during the 1^st year, 2 relapses occurred during the 2^nd year, one relapse was observed during the 3^rd year, one relapse occurred during the 4^th year, and one relapse occurred during the 5^th follow-up year. Four of these six patients received conservative treatment with endoscopic therapy or analgesics. Relapse was conservatively treated using repeated stent therapy in 2 patients. Analgesic treatment was successful in the other 2 patients.

CONCLUSION: 57% of patients exhibited long-term benefits after endoscopic therapy. Therefore, endoscopic therapy should be the treatment of choice in patients being inoperable or refusing surgical treatment.

A comparative study of surgery and endoscopy for the treatment of bile duct stricture in patients with chronic pancreatitis

BACKGROUND

This study aimed to compare the outcomes of endoscopic treatment (ET) and surgical treatment (ST) for common bile duct (CBD) stricture in patients with chronic pancreatitis (CP).

METHODS

From 2004 to 2009, 39 patients (35 men and 4 women; median age, 52 years; range, 38-66 years) were referred for CBD stricture in CP. Of these 39 patients, 33 (85 %) underwent primary ET, and 6 underwent primary ST. Treatment success was defined in both groups as the absence of signs denoting recurrence, with normal serum bilirubin and alkaline phosphatase levels after permanent stent removal in ET group. The follow-up period was longer than 12 months for all the patients.

RESULTS

For the patients treated with ET, the mean number of biliary procedures was 3 (range, 1-10) per patient including extractible metallic stents in 35 % and multiple plastic stents in 65 % of the patients. The mean duration of stent intubation was 11 months. The surgical procedure associated with biliary drainage (4 choledochoduodenostomies, 1 choledochojejunostomy, and 1 biliary decompression within the pancreatic head) was a Frey procedure for five patients and a pancreaticojejunostomy for one patient. The overall morbidity rate was higher in the ST group. The total hospital length of stay was similar in the two groups (16 vs 24 days, respectively; p = 0.21). In terms of intention to treat, the success rates for ST and ET did not differ significantly (83 % vs 76 %; p = 0.08). Due to failure, 17 patients required ST after ET. Event-free survival was significantly longer in the ST group (16.9 vs 5.8 months; p = 0.01). The actuarial success rates were 74 % at 6 months, 74 % at 12 months, and 65 % at 24 months in the ST group and respectively 75 %, 69 %, and 12 % in the ET group (p = 0.01). After more than three endoscopic procedures, the success rates were 27 % at 6 months and 18 % at 18 months.

CONCLUSION

For bile duct stricture in CP, surgery is associated with better long-term outcomes than endoscopic therapy. After more than three endoscopic procedures, the success rate is low.

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.

[Lateral anastomosis techniques: Partington-Rochelle and V-shaped excision]

Characteristic symptoms of chronic pancreatitis are difficult to manage conservatively. They include severe pain and endocrine and exocrine insufficiency. Surgical treatment with simple and extended draining procedures addresses pain relief and the management of chronic pancreatitis-associated complications of adjacent organs. Following the assumption that pancreatic duct changes with intraductal hypertension are the reason for pain, simple drainage procedures have reduced pain in up to 80% of patients, with low morbidity and mortality. In case of complications involving adjacent organs with inflammatory pancreatic head tumor and stenosis of the distal bile duct, extended drainage procedures with limited pancreatic head resection according to Frey and V-shaped excision of the ventral aspect of the pancreas have been performed successfully.

[Management of chronic pancreatitis: endoscopy or surgery?]

The indications for interventional treatment (endoscopic or surgical) of chronic pancreatitis can be classified in several major groups of lesions or symptoms: pain, consequences of fibrosis on neighboring organs (biliary, duodenal or even colic stenosis, thrombosis of the splenic vein with segmental portal hypertension), consequences of duct rupture above the obstacle (persistent symptomatic pseudocyst, refractory pancreatic ascites), and suspected cancer. Finally, surgery is indicated for patients for whom endoscopic procedures are impossible (papillae inaccessible) or too close together. Recently, two new criteria have been suggested: the number of procedures necessary for achieving the objective set, and the duration of hospitalization.

Endotherapy for pain in chronic pancreatitis

Pain is the most distressing symptom of chronic pancreatitis. Although the pathogenesis of pain is still poorly understood, an increase in intraductal pressure may be the dominant factor. The management of pain can involve medical, endoscopic, neurolytic, and surgical therapies. Endotherapy includes pancreatic sphincterotomy, extraction of stones, placement of stent, and dilatation of strictures, sometimes preceded or followed by extracorporeal shock-wave lithotripsy. Several studies have now shown that endotherapy provides partial or complete relief of pancreatic pain in a majority of patients with an acceptable frequency of early and late complications. Endotherapy should now graduate from an experimental form of treatment to a realistic treatment option in patients with chronic or relapsing pain, particularly in the setting of calcific chronic pancreatitis.

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.

Review article: Surgical management of chronic pancreatitis

BACKGROUND

The therapeutic approach to patients with chronic pancreatitis (CP) is complicated by the fact that patients are presented to the physician at different stages of disease and in the presence of varying clinical symptoms. Generally, an expectant approach is justified for patients with asymptomatic CP. At present, patients with symptoms related to gland destruction are initially treated by endoscopic means, while surgical treatment of CP is usually reserved for intractable abdominal pain, suspicion of cancer, and complications such as persistent pseudocysts.

AIM

To review the studies currently available evaluating surgical and/or endoscopic management of CP.

RESULTS

Improvements in imaging techniques, as well as a better understanding of the pathophysiology of CP and mechanisms causing pain, have led to a more conscious selection of patients for surgery. Type of surgery depends on whether the pancreatic duct is dilated, presence of an inflammatory mass and occurrence of complications (pseudocysts, gastric outlet obstruction). Eventually, after initial endoscopic treatment, a substantial number of patients still need surgery for persistent complaints.

CONCLUSIONS

For patients with symptomatic CP, a multidisciplinary approach is indicated with low threshold to surgical intervention, since long-term pain relief is accomplished more often after surgical treatment than after endoscopic treatment.

Endoscopic versus surgical drainage of the pancreatic duct in chronic pancreatitis

BACKGROUND

For patients with chronic pancreatitis and a dilated pancreatic duct, ductal decompression is recommended. We conducted a randomized trial to compare endoscopic and surgical drainage of the pancreatic duct.

METHODS

All symptomatic patients with chronic pancreatitis and a distal obstruction of the pancreatic duct but without an inflammatory mass were eligible for the study. We randomly assigned patients to undergo endoscopic transampullary drainage of the pancreatic duct or operative pancreaticojejunostomy. The primary end point was the average Izbicki pain score during 2 years of follow-up. The secondary end points were pain relief at the end of follow-up, physical and mental health, morbidity, mortality, length of hospital stay, number of procedures undergone, and changes in pancreatic function.

RESULTS

Thirty-nine patients underwent randomization: 19 to endoscopic treatment (16 of whom underwent lithotripsy) and 20 to operative pancreaticojejunostomy. During the 24 months of follow-up, patients who underwent surgery, as compared with those who were treated endoscopically, had lower Izbicki pain scores (25 vs. 51, P<0.001) and better physical health summary scores on the Medical Outcomes Study 36-Item Short-Form General Health Survey questionnaire (P=0.003). At the end of follow-up, complete or partial pain relief was achieved in 32% of patients assigned to endoscopic drainage as compared with 75% of patients assigned to surgical drainage (P=0.007). Rates of complications, length of hospital stay, and changes in pancreatic function were similar in the two treatment groups, but patients receiving endoscopic treatment required more procedures than did patients in the surgery group (a median of eight vs. three, P<0.001).

CONCLUSIONS

Surgical drainage of the pancreatic duct was more effective than endoscopic treatment in patients with obstruction of the pancreatic duct due to chronic pancreatitis. (Current Controlled Trials number, ISRCTN04572410 [controlled-trials.com].).

Interventional endoscopic therapy in chronic pancreatitis including temporary stenting: a definitive treatment?

OBJECTIVE

In the past 15 years there have been tremendous advances in endoscopic management of chronic pancreatitis (CP). However, the value of endoscopic pancreatic stenting is still debatable.

MATERIAL AND METHODS

In 98 patients suffering from symptomatic CP (84 M, 14 F, 49+/-12, age range 23-83 years) endotherapy including temporary stenting of the pancreatic duct was performed. After final stent removal, indicating the primary end-point of endotherapy, 96 patients were followed for 35+/-28 (8 days-111) months. All data were assessed retrospectively.

RESULTS

As well as other endoscopic procedures, a total of 358 prostheses were inserted in the pancreatic duct and left in place for 3+/-1 (1 day-11) months. Total stent treatment time was 10+/-10 (6 days-49) months. At 46+/-27 (4-111) months after limited endotherapy, 57 patients had no need for secondary intervention, two-thirds were even without further pain sensations. In 22 patients, surgical treatment and in 17 patients further endoscopic therapy became necessary, which was significantly correlated with continued alcohol consumption.

CONCLUSIONS

Temporary stent placement as a part of interventional endoscopic therapy in CP shows a high rate of technical and long-term clinical success, with no need for secondary treatment in a remarkable number of patients. Continued cessation of alcohol consumption supports the treatment benefit significantly.

Endoscopic therapy for chronic pancreatitis

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

Surgical and interventional treatment of chronic pancreatitis

The management of patients with chronic pancreatitis (CP) remains a challenging problem. Main indications for surgery are intractable pain, suspicion of malignancy, and involvement of adjacent organs. The main goal of surgical treatment is improvement of patient quality of life. The surgical treatment approach usually involves proximal pancreatic resection, but lateral pancreaticojejunal drainage may be used for large-duct disease. The newer duodenum-preserving head resections of Beger and Frey provide good pain control and preservation of pancreatic function. Thoracoscopic splanchnicectomy and the endoscopic approach await confirmatory trials to confirm their efficiency in the management of CP. Common bile duct obstruction is addressed by distal Roux-en-Y choledochojejunostomy but when combined with dudodenal obstruction must be treated by pancreatic head resection. Pancreatic ascites due to disrupted pancreatic duct should be treated by internal drainage. The approach to CP is multidisciplinary, tailoring the various therapeutic options to meet each individual patient's needs.

Management of bleeding and leakage after pancreatic surgery

Pancreatic surgery has advanced considerably during the past decades. Recent studies report reduced morbidity rates and virtually no mortality after resection. However, postoperative complications are still a formidable menace. In this chapter we discuss the management of postoperative bleeding and leakages which are considered the most feared complications, and discuss the advent of minimal invasive methods for management of these complications. Patients who develop postoperative bleeding almost always present with septic complications and a sentinel bleed before onset of bleeding. These patients should undergo early diagnostic angiography followed by embolisation. If this does control the bleeding an emergency laparotomy should be performed as last resort. Patients who develop pancreatic leakage are generally managed conservatively by means of percutaneous drainage. Aggressive surgery should be performed at the first sign of severe sepsis. The condition of the pancreatic remant found during reoperation dictates the type of surgical intervention best performed.

Dérivation pancréaticojéjunale dans le traitement des pancréatites chroniques

INTRODUCTION

The aim of this retrospective study was to evaluate the immediate and long-term outcome of pancreaticojejunostomy (PJ) in the treatment of chronic pancreatitis. MATERIAL AND METHODS. - From 1980 to 1997, 140 patients with chronic pancreatitis with dilated Wirsung duct were treated by PJ and were studied retrospectively. There were 123 men and 17 women, with a mean age of 46 years (range: 18-79 years). Ongoing alcoholic addiction was present in 116 patients (83%). Chronic pain uncontrolled by major analgesics was the indication of PJ in 126 patients (90%).

RESULTS

The mortality rate was 1.4% (n = 2). The morbidity rate was 11% (n = 16). Mean hospital stay was 16 days (range: 8-25 days). The mean follow-up was 7.4 years (range: 2-15 years) in 94 patients. Functional results were good or mild in 93% of cases (n = 87). In seven patients (7%), the results were bad with persistence of chronic pain requiring major analgesics. A mean weight increase of 5.8 kg (range: 1-16 kg) was observed in 74 patients (79%). Twelve patients (13%) developed de novo diabetes mellitus. In the 43 patients with preoperative diabetes, 24 patients suffered deterioration of their status. No patient recovered from exocrine insufficiency.

CONCLUSIONS

In case of dilated Wirsung, PJ must be indicated preferentially because of its good efficiency on pain relief with low mortality and morbidity rates.