Endoscopic treatment of chronic pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) Guideline – Updated August 2018

Abstract

Main RecommendationsESGE suggests endoscopic therapy and/or extracorporeal shockwave lithotripsy (ESWL) as the first-line therapy for painful uncomplicated chronic pancreatitis (CP) with an obstructed main pancreatic duct (MPD) in the head/body of the pancreas. 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 and surgical options should be considered.Weak recommendation, low quality evidence.ESGE suggests, for the selection of patients for initial or continued endoscopic therapy and/or ESWL, taking into consideration predictive factors associated with a good long-term outcome. These include, at initial work-up, absence of MPD stricture, a short disease duration, non-severe pain, absence or cessation of cigarette smoking and of alcohol intake, and, after initial treatment, complete removal of obstructive pancreatic stones and resolution of pancreatic duct stricture with stenting.Weak recommendation, low quality evidence.ESGE recommends ESWL for the clearance of radiopaque obstructive MPD stones larger than 5 mm located in the head/body of the pancreas and endoscopic retrograde cholangiopancreatography (ERCP) for MPD stones that are radiolucent or smaller than 5 mm. Strong recommendation, moderate quality evidence.ESGE suggests restricting the use of endoscopic therapy after ESWL to patients with no spontaneous clearance of pancreatic stones after adequate fragmentation by ESWL.Weak recommendation, moderate quality evidence.ESGE suggests treating painful dominant MPD strictures with a single 10-Fr plastic stent for one uninterrupted year if symptoms improve after initial successful MPD drainage. The stent should be exchanged if necessary, based on symptoms or signs of stent dysfunction at regular pancreas imaging at least every 6 months. ESGE suggests consideration of surgery or multiple side-by-side plastic stents for symptomatic MPD strictures persisting beyond 1 year after the initial single plastic stenting, following multidisciplinary discussion. Weak recommendation, low quality evidence.ESGE recommends endoscopic drainage over percutaneous or surgical treatment for uncomplicated chronic pancreatitis (CP)-related pseudocysts that are within endoscopic reach.Strong recommendation, moderate quality evidence.ESGE recommends retrieval of transmural plastic stents at least 6 weeks after pancreatic pseudocyst regression if MPD disruption has been excluded, and long-term indwelling of transmural double-pigtail plastic stents in patients with disconnected pancreatic duct syndrome.Strong recommendation, low quality evidence.ESGE suggests the temporary insertion of multiple side-by-side plastic stents or of a fully covered self-expandable metal stent (FCSEMS) for treating CP-related benign biliary strictures.Weak recommendation, moderate quality evidence.ESGE recommends maintaining a registry of patients with biliary stents and recalling them for stent removal or exchange.Strong recommendation, low quality evidence.

Risk factors and nomogram for diabetes mellitus in idiopathic chronic pancreatitis

“…36 Initial manifestations were defined as the first symptom or clinical signs related to ICP, including abdominal pain and pancreatic exocrine and endocrine function. 38 Surgical treatment, such as pancreaticoduodenectomy and distal pancreatectomy, was considered when endoscopic treatment was ineffective, especially in ICP patients with pancreatic pseudocysts or pseudoaneurysms. Morphology of main pancreatic duct (MPD) was classified as four types: pancreatic stone alone, MPD stenosis alone, MPD stenosis combined with stone, and complex pathologic changes (patients with stricture, stones, and also ductal dilatation in the body/tail area of pancreas).…”

“…Jaundice, upper gastrointestinal bleeding, and asymptomatic pancreatic stones found coincidently were classified as "Others" in initial manifestations in our study. 38 For ICP patients who did not experience pain, interventions were performed only when complications such as biliary stricture, infection, or pancreatic pseudocyst enlargement occurred. 37 Treatment strategy.…”

“…Endoscopic treatment was the principle therapy, including extracorporeal shockwave lithotripsy/endoscopic retrograde cholangiopancreatography for stone removal and MPD drainage. 38 Surgical treatment, such as pancreaticoduodenectomy and distal pancreatectomy, was considered when endoscopic treatment was ineffective, especially in ICP patients with pancreatic pseudocysts or pseudoaneurysms. 38 For ICP patients who did not experience pain, interventions were performed only when complications such as biliary stricture, infection, or pancreatic pseudocyst enlargement occurred.…”

“…38 Surgical treatment, such as pancreaticoduodenectomy and distal pancreatectomy, was considered when endoscopic treatment was ineffective, especially in ICP patients with pancreatic pseudocysts or pseudoaneurysms. 38 For ICP patients who did not experience pain, interventions were performed only when complications such as biliary stricture, infection, or pancreatic pseudocyst enlargement occurred. 39 Steatorrhea and/or DM were not indications for invasive treatment of ICP.…”

Combined extracorporeal shock wave lithotripsy and endoscopic treatment for pain in chronic pancreatitis (SCHOKE trial): study protocol for a randomized, sham-controlled trial

“…When complete runoff of contrast material is observed after removal of the stent and an extraction balloon can be passed through the pancreatic duct, endoscopic treatment is considered completed, and further stenting will be stopped. Persistent strictures will be treated by repeated endoscopic dilations and sequential insertion of new stents in agreement with the European Society of Gastrointestinal Endoscopy guidelines [32].…”