Chronic Pancreatitis
Chronic Pancreatitis
Endoscopic management of chronic pancreatitis is aimed at decreasing pain and treating associated complications, such as strictures (biliary and pancreatic), ductal leaks, intraductal calculi, or pseudocysts.
Chronic pancreatitis related biliary strictures occur because of progressive fibrosis of pancreatic parenchyma and are more resistant to endoscopic dilation than other benign biliary strictures. Wagh et al. prospectively evaluated the efficacy of fully covered self-expandable metal stents as an alternative to plastic stenting in patients with biliary strictures, including those due to chronic pancreatitis. Short-term stricture resolution was seen in 96% of the patients, long-term success was seen in 83% of the patients. All of the failures were seen in patients with biliary strictures in the setting of chronic calcific pancreatitis. Similar findings were reported by Irani et al.. These data underscore the recalcitrant nature of chronic pancreatitis associated biliary strictures, and imply that surgical biliary bypass is often preferable. Stenting is initially recommended in patients who present with jaundice or cholangitis as well as in patients unfit for surgery, or those who refuse surgery. Use of fully covered self-expandable metal stents by virtue of their larger diameter, better biliary drainage, and longer patency is a feasible alternative in treatment of common bile duct strictures related to chronic pancreatitis in nonsurgical patients.
Pseudocysts can be managed with endoscopic, surgical, or percutaneous methods. A recent randomized trial by Varadarajulu et al. noted similar efficacy and less cost for endoscopic drainage compared with surgical cystgastrostomy. This trial suggests that endoscopic therapy should be the first-line treatment at centers with appropriate endoscopic expertise in EUS-guided drainage.
Endoscopic Management of Chronic Pancreatitis Associated Bile Duct Stricture or Pseudocyst
Endoscopic management of chronic pancreatitis is aimed at decreasing pain and treating associated complications, such as strictures (biliary and pancreatic), ductal leaks, intraductal calculi, or pseudocysts.
Chronic pancreatitis related biliary strictures occur because of progressive fibrosis of pancreatic parenchyma and are more resistant to endoscopic dilation than other benign biliary strictures. Wagh et al. prospectively evaluated the efficacy of fully covered self-expandable metal stents as an alternative to plastic stenting in patients with biliary strictures, including those due to chronic pancreatitis. Short-term stricture resolution was seen in 96% of the patients, long-term success was seen in 83% of the patients. All of the failures were seen in patients with biliary strictures in the setting of chronic calcific pancreatitis. Similar findings were reported by Irani et al.. These data underscore the recalcitrant nature of chronic pancreatitis associated biliary strictures, and imply that surgical biliary bypass is often preferable. Stenting is initially recommended in patients who present with jaundice or cholangitis as well as in patients unfit for surgery, or those who refuse surgery. Use of fully covered self-expandable metal stents by virtue of their larger diameter, better biliary drainage, and longer patency is a feasible alternative in treatment of common bile duct strictures related to chronic pancreatitis in nonsurgical patients.
Pseudocysts can be managed with endoscopic, surgical, or percutaneous methods. A recent randomized trial by Varadarajulu et al. noted similar efficacy and less cost for endoscopic drainage compared with surgical cystgastrostomy. This trial suggests that endoscopic therapy should be the first-line treatment at centers with appropriate endoscopic expertise in EUS-guided drainage.
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