Endoscopic treatment of chronic pancreatitis

Abstract

Treatment of chronic pancreatitis has been exclusively surgical for a long time. Recently, endoscopic therapy has become widely used as a primary therapeutic option. Initially performed for drainage of pancreatic cysts and pseudocysts, endoscopic treatments were adapted to biliary and pancreatic ducts stenosis. Pancreatic sphincterotomy which allows access to pancreatic ducts was firstly reported. Secondly, endoscopic methods of stenting, dilatation, and stones extraction of the bile ducts were applied to pancreatic ducts. Nevertheless, n e w i m p r o v e m e n t s w e r e n e c e s s a r y : f a i l u r e s o f pancreatic stone extraction justified the development of extra-corporeal shock wave lithotripsy; dilatation of pancreatic stenosis was improved by forage with a new device; moreover endosonography allowed guidance for celiac block, gastro-cystostomy, duodeno-cystostomy and pancreatico-gastrostomy. Although endoscopic treatments are more and more frequently accepted, indications are still debated. METHODSEndoscopic treatment needs a team (operator, anaesthesiologist) aware with Endoscopic Retrograde Cholangiopancreatography (ERCP) procedures. Specific material is necessary: good fluoroscopy with the possibility to magnify pictures, and a duodenoscope with a 4.2 channel allowing insertion of high calibre stent (10 Fr). Moreover, a wide variety of endoscopic ancillar y instruments is essential: metallic and hydrophilic guidewire, sphincterotomes, Dormia basket, balloon dilatators and bougie dilatators (5-11.5 Fr), but also very thin guide wire (0.025 inches), fine-tipped sphincterotomes, Soehendra extractors (cf infra) [1] . Impaction of stones in pancreatic ducts needs the use of extracorporeal shock wave lithotripsy before endoscopic stone extraction [2]

ERCP with per-oral pancreatoscopy–guided laser lithotripsy for calcific chronic pancreatitis: a multicenter U.S. experience

“…Even in expert hands, complete stone clearance is achieved in less than 50% of cases with standard ERCP techniques and devices. 1,3,[23][24][25] Not only are lithotriptercompatible baskets used off-label in the PD, mechanical lithotripsy is technically challenging and carries an AE risk up to 12%, including the dreaded basket impaction. 26,27 Herein we present a multicenter series of POP-LL for the treatment of main PD stones, showing it was feasible and effective with moderate to mild AEs.…”

“…Standard ERCP techniques, including balloon or basket extraction and dilation of strictures, have limited efficacy in CCP. 3 Although effective, pancreatic surgery carries high morbidity and even mortality, and rates of recurrent narcotic-requiring pain approach 50%. 4 Extracorporeal shock-wave lithotripsy (ESWL) has been used successfully to facilitate stone fragmentation and removal during ERCP.…”

Application of per oral cholangiopancreatoscopy in pancreatobiliary diseases

“…Extracting stones in the pancreatic duct detected by conventional ERP‐guided endotherapy is more difficult than those in the bile duct with a success rate of less than 70% 61–63 . In patients with chronic calcific pancreatitis with ductal stones, successful pancreatoscopy‐guided EHL leads to immediate improvement of pain score and need for narcotic analgesia in 77–100% of patients.…”

“…Long‐term data suggest that sustained improvement in pain following this treatment is achieved in 54–86% of patients 64,65 . Laser lithotripsy of pancreatic stones is technically more difficult to perform because of the associated ductal strictures that frequently prevent an adequate direct approach 62 …”

Endoscopic treatment for chronic pancreatitis: indications, technique, results

“…Pancreatic sphincterotomy (5–6 mm) is a basic technique for improving access to the pancreatic duct, which is oriented at 13 h and limited to the ampullary bulge. It employs a pure cutting current or an endocut mode in a single step procedure or after biliary sphincterotomy [8, 12]. Minor papilla sphincterotomy can also be done if necessary.…”