Endoscopic Management of Chronic Pancreatitis

Abstract

The indications of endoscopic management for chronic pancreatitis are strictly related to the classification of severe types and to the particular anatomy of the ducts. (1) Impacted or distal calculi without stricture: ESWL followed by EPS and extraction of fragments. (2) Stone(s) and stricture: ESWL, EPS, NPC, and then 10-french plastic stenting. (3) Relapsing strictures (with upward dilatation) after 6-12 months’ stenting: coated self-expanding stent (in a prospective trial), versus surgical laterolateral pancreaticojejunostomy (Partington-Ro-chelle operation). (4) Paraduodenal cyst bulging into the duodenum: ECD ± stenting. (5) Retrogastric pseudocyst: ECG and stenting. (6) Jaundice and/or cholestasis due to stricture of the intrapancreatic CBD: 10-french single or multiple plastic stents for calibration during 3 months. For relapsing cholestasis and stricture, 30-french metal mesh stent versus surgical hepaticojejunostomy. Due to the tremendous variations of the ducts’ anatomy, the method includes drainage through the minor papilla for patients with a dominant Santorini or dorsal duct (table 6). The indications of endoscopic management for chronic pancreatitis are specific and require complete imaging and functional check-up (ERCP, CT scanner, endosonography, pancreatic function tests). The technique is quite difficult and requires high-definition fluoroscopy, appropriate devices and experienced gastrointestinal assistents and radiologists. On these conditions, the complication rate is very low and can usually be medically controlled. Treatment does not compromise any further surgery. Endoscopy makes it possible to avoid or to postpone surgery, the indication for which might become better defined and the patients more carefully selected in the future.

Endoscopic retrograde cholangiopancreatography stents: indications, risks and novel uses

“…Some, but not all, authors have reported high success rates (75-94%) in treating pain by stenting of pancreatic duct strictures. [85][86][87] In addition, although some authors have correlated clinical improvement to a decrease in the diameter of the main pancreatic duct upstream, others have not. Pancreatic stents are prone to occlusion and patients undergoing endoscopic therapy for pancreatic duct strictures may require frequent stent exchanges.…”

The endoscopic approach to pancreatic duct stones

“…The length of the cut varies between 5 and 15 mm, dependent upon the sphincter length, duct diameter, and the length of the intramural sphincter segment 26. Some authorities favor performing a biliary sphincterotomy prior to the pancreatic sphincterotomy because of the possible risk of cholangitis if this is not done 28. Such complications were not reported by others 26,27.…”

“…Clinical steatorrhea improved in 11 out of 15 patients (73%). Table 1 summarizes five selected series reporting the results of pancreatic stone removal by endoscopic methods alone. Complete stone clearance was achieved in 53 of 94 patients (56%).…”

Imaging and imaging-guided therapy in severe acute pancreatitis

“…Pancreatic duct stents placed endoscopically with simultaneous fluoroscopic guidance can be used in both acute and chronic pancreatitis to bridge a pancreatic duct stenosis or rupture, or to bypass an obstructing calculus 92,93. Placement of stents across the minor papilla in patients with recurrent acute pancreatitis and associated pancreas divisum has been shown to reduce the number of attacks and the severity of abdominal pain 94.…”