Treatment of pancreatic strictures

Abstract

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.

Percutaneous transluminal angioplasty balloons for endoscopic ultrasound-guided pancreatic duct interventions

“…Patients can present with chronic abdominal pain, recurrent pancreatitis, steatorrhea, and unexplained weight loss. Decompression of the PD is the mainstay of treatment for symptomatic patients, and endoscopic therapy has become the preferred treatment modality due to its safety profile when compared to surgery[ 3 , 4 ].…”

Management of Benign and Malignant Pancreatic Duct Strictures

“…Benign etiologies include chronic pancreatitis, recurrent acute pancreatitis, trauma, surgical complications, and pseudocysts. Pancreatic strictures can also be a manifestation of malignancy [ 1 , 2 ]. The diagnosis and treatment of pancreatic strictures have proven challenging for physicians.…”