Endoscopic treatment of chronic pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline

Abstract

Background and aims: Clarification of the position of the European Society of Gastrointestinal Endoscopy (ESGE) regarding the interventional options available for treating patients with chronic pancreatitis. Methods: Systematic literature search to answer explicit key questions with levels of evidence serving to determine recommendation grades. The ESGE funded development of the Guideline. Summary of selected recommendations For treating painful uncomplicated chronic pancreatitis, the ESGE recommends extracorporeal shockwave lithotripsy/endoscopic retrograde cholangiopancreatography as the first-line interventional option. The clinical response should be evaluated at 6???8 weeks; if it appears unsatisfactory, the patient?s case should be discussed again in a multidisciplinary team. Surgical options should be considered, in particular in patients with a predicted poor outcome following endoscopic therapy (Recommendation grade B). For treating chronic pancreatitis associated with radiopaque stones???5?mm that obstruct the main pancreatic duct, the ESGE recommends extracorporeal shockwave lithotripsy as a first step, combined or not with endoscopic extraction of stone fragments depending on the expertise of the center (Recommendation grade B). For treating chronic pancreatitis associated with a dominant stricture of the main pancreatic duct, the ESGE recommends inserting a single 10-Fr plastic stent, with stent exchange planned within 1 year (Recommendation grade C). In patients with ductal strictures persisting after 12 months of single plastic stenting, the ESGE recommends that available options (e.?g., endoscopic placement of multiple pancreatic stents, surgery) be discussed in a multidisciplinary team (Recommendation grade D). For treating uncomplicated chronic pancreatic pseudocysts that are within endoscopic reach, the ESGE recommends endoscopic drainage as a first-line therapy (Recommendation grade A). For treating chronic pancreatitis-related biliary strictures, the choice between endoscopic and surgical therapy should rely on local expertise, patient co-morbidities and expected patient compliance with repeat endoscopic procedures (Recommendation grade D). If endoscopy is elected, the ESGE recommends temporary placement of multiple, side-by-side, plastic biliary stents (Recommendation grade A).

Evidence-based clinical practice guidelines for chronic pancreatitis 2015

“…Inability to lead a social life, worsening nutritional conditions because of inability to ingest food, etc., are grave concerns that often confront practicing physicians. These guidelines refer to various pharmacotherapies and also describe the application of endoscopic and surgical treatments [69][70][71]. The utility of an elemental diet (ED) in patients with chronic pancreatitis with pain has been demonstrated; therefore, ED is recommended in these guidelines.…”

Impacted wire basket in the main pancreatic duct; How to Jailbreak

“…According to The European Society of Gastrointestinal Endoscopy (ESGE) guidelines, MPD stones >5 mm should undergo ESWL to fragment them before attempting ERCP, as ERCP alone reults in higher failure rates [8]. ESWL can be used in all uncomplicated PD stones.…”

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“…Infected collections may be sampled by EUS-guided fine needle aspiration (EUS-FNA) to obtain microbial analysis, which guides antibiotic treatment [119,120]. With a sterile collection, luminal or biliary extrinsic compression and persistent severe abdominal pain are indications for drainage [100,121,122].…”

“…EUS-guided drainage is the preferred modality when there is no visible luminal bulge or when there is a clinical suspicion of portal hypertension and collaterals or in coagulopathy [175 -179]. Transmural cystoduodenostomy has a higher long-term success rate than cystogastrostomy [122].…”

“…Retrograde pancreatic stenting is technically successful in 85 -98 % of cases, with immediate clinical respite seen in 65 -95 % but lower pain relief on follow-up only in 32 -68 %. Stenting can be used as a bridging procedure prior to surgical intervention, as surgery is superior to endoscopic treatment [122,311,312]. When ERP fails or surgical intervention is not feasible, alternative techniques are required.…”