Stenting in Severe Chronic Pancreatitis: Results of Medium-Term Follow-Up in Seventy-Six Patients

Abstract

Between January 1985 and September 1989, 75 patients presenting with severe chronic pancreatitis with distal stricture and upstream dilatation underwent stenting of the main pancreatic duct (MPD) through the major papilla (n = 54) or minor papilla (n = 21) in order to drain the predominant duct through a 10 F plastic prosthesis. All patients had undergone biliary and pancreatic sphincterotomy with a few cases of complications, and the majority (84%) also ESWL in the period from October 1987 onwards without complications. Relief of pain (94%) occurred parallel to a decrease in the MPD diameter. In a mean follow-up period of 37 months improvement of the nutrition status and relief of pain was seen. Clogging of these large plastic stents was treated by replacement or by another endoscopic or surgical procedure. Complications were treated endoscopically. Further measures necessary due to failure of stenting consisted of laterolateral pancreatico-jejunostomy in 15% of patients and placement of self-expanding 18 F metal mesh stents in 29%. There was no mortality due to surgery. It is concluded that stenting of distal strictures in the MPD can lead to rapid resolution of pancreatic pain due to ductal hypertension and is the best means for determining the cause of pain, providing an alternative to surgery. Significant improvement of a stricture by prolonged stenting is however unusual, and such patients treated endoscopically require close follow-up with stent replacement approximately once a year.

Italian consensus guidelines for chronic pancreatitis

“…In two randomized controlled trials, long-term results of endoscopic treatment of pain compared to derivative surgery are conflicting [36,174]. Endoscopic therapy can be successfully repeated in case of pain relapses [175,176]. The spontaneous burn-out of pain in the natural history of chronic pancreatitis may interfere in the assessment of efficacy of endoscopic therapy [177].…”

“…Insertion of a pancreatic stent is indicated in case of dominant main pancreatic duct stricture (prepapillary stricture with upstream dilation). Current strategy calls for unscheduled stent replacement when patients become symptomatic (abdominal pain) and pancreatic duct dilation is shown by abdominal ultrasound or MRCP [175,[193][194][195][196]. Early removal of a pancreatic stent can be considered if it has no effect on pain.…”

“…Early removal of a pancreatic stent can be considered if it has no effect on pain. Currently there are two strategies in pancreatic stenting: either removing the pancreatic stent after a period of 6−12 months irrespective of the resolution of the stricture of the main pancreatic duct or substitution of pancreatic stents until stricture disappearance [175,176,[193][194][195][196][197][198][199][200]. Long-term pain relief was experienced by two-thirds of patients after 12 months stenting, though resolution of the stricture was observed in a minority of patients [176,193].…”

Endoscopic pancreatic duct stent placement for inflammatory pancreatic diseases

“…In chronic pancreatitis patients with dominant stricture, pain relief was obtained in 52%-95% of cases over a follow-up ranging from 8 to 72 mo [1,[7][8][9][10][11][12][13][14][15][16][17][18][19] . Stenting was also associated with weight gain and fewer hospital visits.…”

Endoscopic management of chronic pancreatitis

“…Pancreatic strictures can be caused by prior stones, recurrent inflammation or fibrosis [29] . In cases of pancreatic stricture, where malignancy is suspected it is crucial to obtain cross sectional imaging followed by endoscopic ultrasound with fine needle aspiration (EUS-FNA) of any pancreatic masses.…”