2012 Chronic Pancreatitis PDF

784 Guidelines
Endoscopic treatment of chronic pancreatitis:

European Society of Gastrointestinal Endoscopy (ESGE)
Clinical Guideline
Authors J.-M. Dumonceau1, M. Delhaye2, A. Tringali3, J. E. Dominguez-Munoz4, J.-W. Poley5, M. Arvanitaki2, G. Costamagna3,
F. Costea6, J. Devire2, P. Eisendrath7, S. Lakhtakia8, N. Reddy8, P. Fockens9, T. Ponchon10, M. Bruno5
Institutions Institutions are listed at the end of article.
submitted 14. March 2012 Background and aims: Clarification of the posi- fragments depending on the expertise of the cen-
accepted 20. March 2012 tion of the European Society of Gastrointestinal ter (Recommendation grade B).
Endoscopy (ESGE) regarding the interventional For treating chronic pancreatitis associated with a
Bibliography options available for treating patients with chron- dominant stricture of the main pancreatic duct,
DOI http://dx.doi.org/ ic pancreatitis. the ESGE recommends inserting a single 10-Fr
10.1055/s-0032-1309840 Methods: Systematic literature search to answer plastic stent, with stent exchange planned within
Published online: 2.7.2012 explicit key questions with levels of evidence ser- 1 year (Recommendation grade C). In patients
Endoscopy 2012; 44: 784796
ving to determine recommendation grades. The with ductal strictures persisting after 12 months
Georg Thieme Verlag KG
Stuttgart New York
ESGE funded development of the Guideline. of single plastic stenting, the ESGE recommends
ISSN 0013-726X Summary of selected recommendations that available options (e. g., endoscopic placement
For treating painful uncomplicated chronic pan- of multiple pancreatic stents, surgery) be discus-
Corresponding author creatitis, the ESGE recommends extracorporeal sed in a multidisciplinary team (Recommenda-
J.-M. Dumonceau, MD PhD
shockwave lithotripsy/endoscopic retrograde tion grade D).
Division of Gastroenterology
and Hepatology
cholangiopancreatography as the first-line inter- For treating uncomplicated chronic pancreatic
Geneva University Hospitals ventional option. The clinical response should be pseudocysts that are within endoscopic reach,
Rue Gabrielle Perret Gentil 4 evaluated at 6 8 weeks; if it appears unsatisfac- the ESGE recommends endoscopic drainage as a
1211 Geneva tory, the patients case should be discussed again first-line therapy (Recommendation grade A).
Switzerland in a multidisciplinary team. Surgical options For treating chronic pancreatitis-related biliary
Fax: + 41223729366 should be considered, in particular in patients strictures, the choice between endoscopic and
[email protected]
with a predicted poor outcome following endo- surgical therapy should rely on local expertise,
scopic therapy (Recommendation grade B). For patient co-morbidities and expected patient com-
treating chronic pancreatitis associated with pliance with repeat endoscopic procedures (Re-
radiopaque stones 5 mm that obstruct the main commendation grade D). If endoscopy is elected,
pancreatic duct, the ESGE recommends extracor- the ESGE recommends temporary placement of
poreal shockwave lithotripsy as a first step, com- multiple, side-by-side, plastic biliary stents (Re-
bined or not with endoscopic extraction of stone commendation grade A).
1. Introduction tion of the main pancreatic duct (MPD). In a large

! multicenter study of endoscopic therapy in
Endoscopic therapy of chronic pancreatitis aims chronic pancreatitis, MPD obstruction was caused
at relieving pain. Pain is generally considered to by strictures (47 %), stones (18 %) or a combination
be multifactorial, caused by pancreatic neural re- of both (32 %) [1]. Drainage of pseudocysts and
modeling and neuropathy, increased intraductal treatment of CBD strictures were performed in
and parenchymal pressure, pancreatic ischemia 17 % and 23 % of patients, respectively.
and acute inflammation during an acute relapse. This Guideline on endoscopic treatment in chron-
Complications such as pseudocysts, strictures of ic pancreatitis has been endorsed by the Europe-
the common bile duct (CBD) and pancreatic can- an Society for Gastrointestinal Endoscopy (ESGE).
cer may also cause pancreatic-type pain. Most A quick reference guide summarizing its recom-
nonsurgical interventions for pain in patients mendations is available online (Appendix e1).
with chronic pancreatitis who do not present
these complications (with uncomplicated chron-
ic pancreatitis) aim at relieving outflow obstruc-
Dumonceau J-M et al. ESGE Guideline for endoscopic treatment of chronic pancreatitis Endoscopy 2012; 44: 784796
Guidelines 785
2. Methods Chronic pancreatitis is associated with an increased risk of pancreat-

! ic cancer. The differential diagnosis of chronic pancreatitis vs. pan-
The European Society of Gastrointestinal Endoscopy (ESGE) com- creatic cancer may be challenging (Evidence level 1 +). In patients
missioned and funded this Guideline. The methodology, includ- with a pancreatic mass or an MPD or CBD stricture in the context of
ing assessment of evidence levels and recommendation grades, chronic pancreatitis, an adequate work-up should be performed to
was similar to that used for other ESGE Guidelines [2]. Briefly, reasonably rule out a pancreatic cancer (Recommendation grade A).
subgroups were formed, each charged with a series of clearly de- Special attention to the possibility of concurrent pancreatic can-
fined key questions (see Appendix e2, available online). The com- cer should be paid in patients > 50 years, of female gender, of
mittee chair worked with subgroup leaders to identify pertinent white race, presenting with jaundice, in the absence of pancreatic
search terms that always included chronic pancreatitis and calcifications, or in the presence of exocrine insufficiency, as well
words pertinent to specific key questions. Evidence tables were as in patients with hereditary pancreatitis [7 9]. The accuracy of
generated for each key question based on the best available evi- standard CT scanning for the detection of pancreatic cancer is
dence (see Appendix e3, available online). Subgroups agreed by limited in the context of chronic pancreatitis [10, 11]. Triple-
online communication on draft proposals that were presented phase CT scanning with time-attenuation curves has yielded
to the entire group for general discussion during a meeting held 90 % accuracy for differentiating chronic pancreatitis from pan-
in Brussels in May 2011. The results of that discussion were incor- creatic cancer; this examination has been recommended as a
porated into the subsequent Guideline draft version and again first-choice procedure in an evidence-based algorithm for the
discussed using online communication until unanimous agree- work-up of mass lesions in chronic pancreatitis, followed by
ment was reached. Searches were re-run in June 2011 (this date MRCP, EUS-FNA and positron emission tomography (PET)-CT
should be taken into account for future updates). All members of [12, 13]. With EUS, the differentiation between pancreatic can-
the Guideline development group approved the final draft; it was cer and focal pancreatitis is difficult (accuracy < 75 %) [14, 15];
peer-reviewed and, after modifications, sent to all individual adding EUS-guided sampling to EUS significantly improved the
ESGE members in February 2012 for their comments. The final diagnostic yield in one retrospective study [14]. Interestingly, in
guideline was endorsed by the ESGE Governing Board. three retrospective studies involving 1131 patients in total, the
Evidence statements and recommendations are shown in italics negative predictive value of EUS-guided sampling for pancreatic
for easier reference; key evidence statements and recommenda- cancer was higher in the presence vs. in the absence of chronic
tions are in bold. This Guideline will be considered for revision in pancreatitis (89 94 % vs. 45 93 %) [8, 16, 17]. If EUS-guided
2015, or sooner if important new evidence becomes available sampling is inconclusive, repeat EUS-guided sampling with ra-
(any interim updates will be noted on the ESGE website: http:// pid on-site cytopathological examination, PET-CT, or surgical
www.esge.com/esge-guidelines.html). resection are recommended [13, 18]. If a CBD stricture is treated
by ERCP in the context of chronic pancreatitis, adequate biliary
sampling should be obtained before stent insertion [19, 20].
3. Initial work-up and choice of treatment Other diseases that may be difficult to differentiate from chronic
! pancreatitis include autoimmune pancreatitis and intraductal
Computed tomography (CT) scanning is the most sensitive and ac- papillary mucinous neoplasm. For the diagnosis of these dis-
curate noninvasive method to identify pancreatic calcifications eases, the reader is referred to recent guidelines [18, 21, 22]. In
(Evidence level 2 + ). Magnetic resonance with cholangiopancreato- this regard, demographic data may also prove helpful because,
graphy (MRCP) is the best noninvasive technique to assess the compared with patients with chronic pancreatitis, those with in-
anatomy of the biliary tree (Evidence level 2 + +), of the pancreatic traductal papillary mucinous neoplasm are significantly more of-
ducts, and of post-necrotic pancreatic fluid collections (Evidence ten females, are older, drink less alcohol, and smoke fewer cigar-
level 2 +). ettes [23].
The ESGE recommends performing CT scanning to plan treatment of The choice between surgical and endoscopic therapy in patients
chronic pancreatitis (Recommendation C). A combination of other with painful uncomplicated chronic pancreatitis may be influenced
imaging modalities (e. g., MRCP or endoscopic ultrasonography by the following considerations: (i) two randomized controlled
[EUS] plus CT scanning or abdominal X-ray) may be preferable in trials (RCTs) have shown better pain control following surgery
specific circumstances (e. g., suspected anatomical variants of the compared with endoscopic therapy; (ii) endoscopic therapy does
pancreatic ducts, CBD strictures, or drainage of post-necrotic pan- not preclude surgical treatment of chronic pancreatitis and it is
creatic fluid collections) (Evidence level B). safer; (iii) predictors of satisfactory outcome following endoscopic
CT scanning allows detection of pancreatic calcifications and therapy have been identified (Evidence level 1 + ).
broad assessment of the pancreatic parenchyma. The anatomy of The ESGE recommends endoscopic therapy as the first-line therapy
pancreatic ducts, including MPD strictures and anatomical var- for painful uncomplicated chronic pancreatitis. The clinical response
iants (e. g., pancreas divisum), is best assessed using MRCP [3, 4], should be evaluated at 6 8 weeks; if it appears unsatisfactory, the
including intravenous injection of secretin in selected cases [5]. patients case should be discussed again in a multidisciplinary team
For the work-up of pancreatic fluid collections, a prospective with endoscopists, surgeons, and radiologists and surgical options
comparative study concluded that magnetic resonance imaging should be considered, in particular in patients with a predicted poor
(MRI) was superior to CT scanning because it depicts solid necro- outcome following endoscopic therapy (Recommendation grade B).
tic debris that may impede effective drainage [6]. EUS provides The RCTs that have compared interventions for the treatment of
similar information. These imaging modalities have not been painful uncomplicated chronic pancreatitis are summarized in
compared for the detection of pseudoaneurysms close to pseudo- " Table 1. In the first RCT comparing endoscopic therapy vs.
cysts, which is another potentially important consideration when surgery [24], pain was absent after 5 years of follow-up in 15 %
planning treatment. vs. 34 % of endoscopic therapy vs. surgery patients, respectively,
showing that neither of these options is entirely satisfactory. In
786 Guidelines
Table 1 Randomized controlled trials of interventions for pain in uncomplicated chronic pancreatitis (excluding celiac plexus block and surgery-only trials).
Dite et al., 2003 [24] Cahen et al., 2007 [25, 26] Dumonceau et al., 2007 [34]
(Follow-up, 5 years) (Follow-up, 6 years) (Follow-up, 4 years)
ERCP Surgery ESWL + ERCP Surgical pancrea- ESWL ESWL + ERCP

tico-jejunostomy
n 36 36 19 20 26 29
Pain relief, %
Complete 15 34 1 16 40 1 58 55
Partial 46 52 16 35 n.d. n.d.
ERCP, endoscopic retrograde cholangiopancreatography; ESWL, extracorporeal shockwave lithotripsy; n.d., no data.
1
P < 0.05.
Table 2 Long-term outcome after endoscopic treatment of chronic pancreatitis.
First author, year n Follow-up, months Surgery Ongoing endoscopic No further

treatment intervention
Binmoeller, 1995 [68] 93 58 26 % 13 % 61 %
Rsch, 2002 [1] 1018 58 24 % 16 % 60 %
Delhaye, 2004 [36] 56 173 21 % 18 % 61 %
Tadenuma, 2005 [38] 70 75 1% 20 % 79 %
Inui, 2005 [45] 555 44 4%
Farnbacher, 2006 [37] 98 46 23 % 18 % 59 %
this RCT, endoscopic therapy was not optimal (extracorporeal cated chronic pancreatitis applies only to patients with moderate
shockwave lithotripsy [ESWL] and cumulative stenting were or marked changes of chronic pancreatitis at pancreatography ac-
not used, endoscopic therapy was not repeated in the case of cording to the Cambridge classification.
recurring symptoms). In the second RCT of endoscopic therapy Factors independently associated with long-term ( 2 years) pain
vs. surgery [25, 26], the initial stenting period was relatively relief following endoscopic therapy of chronic pancreatitis in-
short as stents were removed when the stricture had disap- clude the location of obstructive calcifications in the head of the
peared on the pancreatogram, but resumed in the case of pain pancreas (most robust predictor of good outcome, identified in
and stricture recurrence. This is in contrast to most other stud- an RCT) [34], a short disease duration and a low frequency of
ies in which stenting is continued for 1 to 2 years. Moreover, pain attacks before endoscopic therapy, complete MPD stone
this RCT included only patients with advanced chronic pancrea- clearance and absence of MPD stricture at initial endoscopic ther-
titis (most of them were opioid-dependent; 79 % had strictures apy, as well as discontinuation of alcohol and tobacco during fol-
and stones). For these reasons, the results cannot be extrapola- low-up [35 38]. Although MPD stones and strictures located in
ted to all patients with chronic pancreatitis. the tail of the pancreas are accessible to endoscopic therapy, this
Independent series from different parts of the world have report- is more challenging compared with endoscopic therapy of similar
ed the long-term outcome after endoscopic therapy in a total of lesions located in the head of the pancreas and clinical success is
1890 patients with chronic pancreatitis; no pancreatic surgery less certain. For that reason, when stones/dominant strictures
was performed in 83 % of them ( " Table 2). The reluctance of are located in the pancreatic tail exclusively and are deemed
some gastroenterologists to consider surgery for the treatment responsible for pain, pancreatic tail resection is a possible first-
of chronic pancreatitis (in particular as a first interventional pro- intent option to be discussed with the patient and surgical team.
cedure) may be explained by the relatively high morbidity and
mortality associated with pancreatic surgery in the setting of
chronic pancreatitis (18 53 % and 0 5 %, respectively, for resec- 4. Management of pancreatic stones
tions [27], and 0 4 % mortality for MPD drainage [28]). In con- !
trast, morbidity and mortality rates for endoscopic therapy for 4.1. Definitions
chronic pancreatitis are in the ranges 3 9 % and 0 0.5 %, respec- Different classifications of pancreatic stones have been proposed,
tively (chronic pancreatitis is likely a protective factor against the based on radiopacity (radiolucent vs. radiopaque stones) or loca-
most frequent complication of ERCP, i. e., pancreatitis) [1, 29 31]. tion (head, body, or tail; in the MPD, secondary ducts, or intrapar-
In painful chronic pancreatitis with mild changes at pancreato- enchymal) [39]. Successful stone fragmentation following ESWL
graphy according to the Cambridge classification [32], pancreatic has been defined as stones broken into fragments 2 or 3 mm
sphincterotomy as a single therapeutic maneuver has been pro- [29, 34,40], or by the demonstration of a decreased stone density
posed but this has not been well studied. For example, mild at X-ray, an increased stone surface and an heterogeneity of the
chronic pancreatitis was recorded in 14 /40 and 26 /398 patients stone which may fill the MPD and adjacent side branches [41].
included in two series of endoscopic therapy for chronic pancrea- The Guideline group prefers the latter definition.
titis but the outcome has not been reported for this particular
subgroup of patients [30, 33]. Therefore, our recommendation of
endoscopic therapy as the first-line therapy for painful uncompli-
Guidelines 787
4.2. Methods and results Morbidity related to ESWL alone or combined with ERCP was re-
4.2.1. ESWL combined or not with ERCP viewed based on four large ( > 100 patients) series: significant
Endoscopic attempts at MPD stone extraction without prior stone complications were reported in 104 of 1801 patients, including
fragmentation are plagued with low success and relatively high one death (morbidity and mortality rates, 5.8 % and 0.05 %,
morbidity rates; complications may be severe and may be ob- respectively) [29, 38,41,45]. Complications related to the treat-
served even with pancreatic stones < 10 mm in diameter (Evidence ment of chronic pancreatitis by ESWL alone were reported in
level 2 +). ESWL consistently provides stone fragmentation in 90 % three series that involved 165 patients; the morbidity rate was
of patients (Evidence level 1 + ); it facilitates endoscopic extraction 6.0 % [34, 38,49]. For both ESWL alone or ESWL plus ERCP, compli-
of MPD stones (Evidence level 2 + ). Spontaneous elimination of cations consisted of pancreatitis in the majority of cases.
stone fragments resulting from ESWL occurs in approximately 80 % Contraindications to ESWL include coagulation disorders, preg-
of patients. ESWL alone is more cost-effective than ESWL systemati- nancy, implanted cardiac pacemakers or defibrillators, and pres-
cally combined with ERCP (Evidence level 1 + ). ence in the shockwave path of bone, calcified aneurysms, or lung
For treating patients with uncomplicated painful chronic pancreati- tissue [50]. Of note, implanted cardiac pacemakers are not uni-
tis and radiopaque stones 5 mm obstructing the MPD, the ESGE re- versally recognized as a contraindication to ESWL [51].
commends ESWL as a first step, immediately followed by endoscopic
extraction of stone fragments. In centers with considerable experi- 4.2.2. Other methods
ence with ESWL, ESWL alone should be preferred over ESWL system- Intraductal laser or electrohydraulic lithotripsy have provided
atically combined with ERCP (Recommendation grade B). Endoscopic discordant success rates for stone fragmentation (47 83 %) in
attempts to extract radiopaque MPD stones without prior stone small case series, after failure of ESWL to fragment stones [52,
fragmentation should be considered only for stones < 5 mm, prefer- 53]. These techniques require nonstandard equipment and mate-
ably low in number, and located in the head or body of the pancreas. rials and are technically demanding; they are considered to be
Intraductal lithotripsy should be attempted only after failure of second-line interventions after failed ESWL.
ESWL (Recommendation grade D). Dissolution of pancreatic stones using various substances has
Nonsurgical clearance of stones obstructing the MPD can be been anecdotally reported [54, 55]. The efficacy of such treat-
achieved by ESWL alone, by ERCP alone (always including pan- ments has never been tested in comparative trials, and side ef-
creatic sphincterotomy), or by a combination of these techniques. fects may be significant. Therefore, stone dissolution therapy
However, endoscopic attempts at MPD stone extraction using may have a role only in patients in whom all other, more conven-
Dormia baskets without prior stone fragmentation have yielded tional, methods have failed and who are not surgical candidates.
unsatisfactory results: (i) a success rate of 9 % was reported in a
retrospective series of 125 patients [42]; (ii) in another retrospec-
tive multicenter series of 712 mechanical lithotripsies, the com- 5. Management of main pancreatic duct strictures
plication rate was three times higher for pancreatic compared !
with biliary stones [43]. 5.1. Definitions
ESWL is highly effective at fragmenting radiopaque pancreatic In chronic pancreatitis, MPD strictures may be single or multiple
stones: in a systematic review of 11 series involving 1149 pa- and classified as dominant or nondominant. Dominant MPD
tients in total, the success of stone fragmentation by ESWL was strictures are defined by the presence of at least one of the fol-
89 % [44]. More recently, a large prospective single-center series lowing characteristics: upstream MPD dilatation 6 mm in diam-
achieved stone fragmentation in 935 (93 %) of 1006 patients eter, prevention of contrast medium outflow alongside a 6-Fr
[29]. Lower fragmentation rates have been reported, particularly catheter inserted upstream from the stricture or abdominal pain
in low case-volume centers; this may be due to technical factors during continuous infusion of a nasopancreatic catheter inserted
and skill [45]. Performance of ESWL prior to endoscopic attempt upstream from the stricture with 1 L saline for 12 24 h [56].
at stone removal was independently associated with the success Treatment of a dominant MPD stricture is defined as technically
of MPD stone clearance in a retrospective study [35]. A meta-a- successful if at least one stent is inserted across the stricture
nalysis of 17 studies (total of 491 patients) showed that ESWL is (treatment by dilation alone has been abandoned). With regard
useful for clearing MPD stones and for decreasing pain [46]. to clinical success, many definitions have been used, ranging
In the majority of series, stones targeted by ESWL were mostly from doctors opinion to validated pain scores. The ESGE recom-
obstructive radiopaque MPD stones with a minimal diameter in mends that future studies should use validated pain scores for
the range of 2 5 mm [29, 34, 35, 40, 42, 45, 47, 48]. Factors signifi- both short-term and long-term evaluation of clinical success. For
cantly associated with the success of MPD stone clearance after long-term evaluation, absence of pain (relapse) at 1 year post
ESWL included the presence of a single stone [35, 47], and con- stent retrieval seems a reasonable and workable definition.
finement of calculi to the head of the pancreas [35]. These asso-
ciations were found only in univariate analysis and in a minority 5.2. Methods and results
of studies. The reader is referred to a recent ESGE publication for an over-
The use of ESWL alone for painful chronic pancreatitis was review of the principles and technique of stricture treatment by
ported in two uncontrolled series and an RCT. The uncontrolled continued dilation using temporary stent placement [57]. Points
series included 350 patients followed up for 44 months; sponta- relevant to pancreatic stenting only are briefly discussed below:
neous MPD stone clearance was reported in 70 88 % of patients Pancreatic sphincterotomy (at the level of the major or minor
and long-term pain relief in 78 % of patients [45, 49]. The RCT papilla) has consistently been performed prior to MPD stent-
compared ESWL alone vs. ESWL followed by ERCP in 55 patients ing in all large studies [37, 58 65], in contrast to what has
[34]. The only significant differences between groups were a been reported for biliary stenting.
longer hospital stay and a higher treatment cost in the ESWL Biliary sphincterotomy should be combined with pancreatic
plus ERCP group. sphincterotomy only in selected cases according to an RCT, i. e.
788 Guidelines
Table 3 Selected series of treatment with plastic stents for main pancreatic duct (MPD) strictures in chronic pancreatitis.
First author, year n Stent sizes, Fr Follow-up, Early pain relief, % Sustained pain Patients undergoing
months relief, % operation, %
Cremer, 1991 [58] 75 10 37 94 n.a. 15
Ponchon, 1995 [59] 23 10 14 74 52 15
Smits, 1995 [60] 49 10 34 82 82 6
Binmoeller, 1995 [68] 93 5 7 10 58 74 65 26
Morgan, 2003 [69] 25 5 7 8.5 n.a. 65 n.a. n.a.
Vitale, 2004 [61] 89 5 7 10 43 83 68 12
Eleftheriadis, 2005 [62] 100 8.5 10 69 70 62 4
Ishiara, 2006 [63] 20 10 21 95 90 n.a.
Weber, 2007 [64] 17 7 8.5 10 11.5 24 89 83 n.a.
n.a., not available.
in patients with cholangitis, jaundice (bilirubin 3 mg/dL), a catheter through the stricture location [60, 62, 68]. After pro-
dilated CBD ( 12 mm) associated with elevated alkaline phos- longed MPD stenting, relapsing pain was observed in 36 48 % of
phatases (> 2 upper limit of normal values), or in case of diffi- patients after definitive stent removal, re-stenting was indica-
cult access to the MPD [66]. ted in 22 30 % of patients, and 4 26 % of patients had pancreatic
Stricture dilation is performed prior to stenting in most cases surgery. A pancreas divisum anatomy might require longer/mul-
because chronic pancreatitis-related MPD strictures may be tiple stenting because it is associated with more frequent relapse
very tight and resilient. If bougies or balloons cannot pass the of MPD stricture and of pain after stent removal compared with
stricture, the Soehendra stent retriever may serve as a rescue MPD stenting in patients with a fused pancreas [62].
option [67]. Stent occlusion is the most frequent complication of MPD stent-
Pancreatic stenting is technically successful in 85 98 % of at- ing; it is treated by stent exchange that may be performed either
tempted cases [58 60, 64]; it is immediately followed by pain re- at regular intervals (e. g., 3 months) [61], or on-demand, i. e.,
lief in 65 95 % of patients [58 61, 63 65, 68]; during follow-up when symptoms develop [62, 68]. The aim of an on-demand
(14 58 months), pain relief has been reported in 32 % 68 % of stent exchange schedule is to reduce the number of ERCP ses-
patients [25, 37, 59 61, 63, 64, 68]. sions; it is based on the fact that pain relapse most frequently oc-
curs a long time after stent occlusion [69]. Drawbacks of the on-
5.2.1. Plastic stents demand stent exchange schedule include rare occurrence of
Polyethylene 10-Fr pancreatic stents tailored to the shape of the pancreatic abscesses and sepsis [58, 68], and failure to decrease
MPD and length of the stricture are most commonly used. Occlusion the number of ERCP sessions (four to five in large studies) [62,
of MPD stents usually occurs within 2 3 months (Evidence level 2 ) 68].
while symptoms of chronic pancreatitis usually recur between 6 and Stents measuring 8.5 Fr or 10 Fr in diameter are used in most
12 months (Evidence level 2 + ). Thinner MPD stents ( 8.5 Fr) are studies. In a retrospective study of 163 patients, those who had
associated with more frequent hospitalizations for abdominal pain received thin stents ( 8.5 Fr) were 3.2 times more likely to be
than 10-Fr stents. Placement of a single pancreatic plastic stent hospitalized for abdominal pain than those who had received
achieves MPD stricture resolution in nearly 60 % of cases (Evidence 10-Fr stents [70].
level 2 + ) while simultaneous placement of multiple pancreatic The role of multiple pancreatic stents was investigated in a single
stents was reported to be of additional benefit in a single study (Evi- study that involved 19 patients [71]. The stricture was located in
dence level 2 ). Complications related to MPD stenting are usually the head of the pancreas and it persisted after at least two place-
mild and managed conservatively (Evidence level 2 + ). ments of a single stent. A median of three simultaneous stents
The ESGE recommends treating dominant MPD stricture by inserting were inserted for a mean period of 7 months; persistent pain re-
a single 10-Fr plastic stent, with stent exchange planned within 1 lief was noted in 84 % of the patients after 38 months of follow-
year even in asymptomatic patients to prevent complications related up.
to long-standing pancreatic stent occlusion (Recommendation grade The morbidity of pancreatic stenting is in the range of 6 39 %
C). Simultaneous placement of multiple, side-by-side, pancreatic [37, 58 62, 64, 65, 68]. It most frequently consists of mild pan-
stents could be applied more extensively, particularly in patients creatitis; proximal or distal stent migration as well as pancreatic
with MPD strictures persisting after 12 months of single plastic stent- abscesses requiring surgery have rarely been reported.
ing. At this time point, the ESGE recommends that available options
(e. g., endoscopic placement of multiple simultaneous MPD stents, 5.2.2. Self-expandable metallic stents (SEMSs)
surgery) be discussed by a multidisciplinary team (Recommendation Patency of pancreatic SEMSs is short with regard to the life expec-
grade D). tancy of patients with chronic pancreatitis (Evidence level 2 ). Pre-
" Table 3 summarizes selected studies of MPD stenting. Because liminary studies suggest that temporary placement of fully covered
MPD stenting for a short predefined (6-month) duration has SEMS is safe and allows resolution of MPD strictures plus pain relief
been shown to be poorly effective [59], MPD stenting is per- in a majority of patients but no follow-up longer than 1 year is
formed for longer periods. Criteria used for terminating MPD available (Evidence level 2 +).
stenting are as follows: (i) adequate pancreaticoduodenal out- Uncovered SEMSs should not be inserted in MPD strictures (Recom-
flow of contrast medium 1 2 minutes after ductal filling up- mendation grade D); temporary placement of fully covered SEMSs
stream from the stricture location, and (ii) easy passage of a 6-Fr holds promise but it should be performed only in the setting of trials
Guidelines 789
with approval of the institutional review board (Recommendation The ESGE recommends considering CPB only as a second-line treat-
grade C). ment for pain in chronic pancreatitis; EUS-guided CPB should be
Historical series have shown that the patency duration of SEMSs preferred over percutaneous CPB (Recommendation grade C).
left in place in the MPD was limited to approximately 1 year [72]. During CPB, a mixture of corticoids with a local anesthetic is in-
Therefore, SEMS insertion without scheduled removal is not per- jected into celiac plexus nerves to disrupt the signaling of painful
formed anymore, as is the case for benign biliary strictures [19]. stimuli through pancreatic afferent nerves (celiac plexus neuro-
More recently, two centers have reported three prospective ser- lysis, it should be noted, uses alcohol and is reserved to patients
ies that used temporary placement of fully covered SEMSs to with cancer-related pain) [82].
treat chronic pancreatitis-related MPD strictures. Three different Meta-analyses have reported that EUS-guided CPB provides pain
types of SEMS were inserted and left in place for 2 3 months in relief in 51 % 59 % of patients with painful chronic pancreatitis
51 patients [73 75]. Stent removal was successful in all of 46 at- [83, 84]; however, pain relief is transient [84]. For example, in a
tempted cases. No pain relapse was noted in 43 of 50 patients prospective series of 90 patients, the proportion of patients with
(86 %) during mean follow-up periods of 5 months following pain relief decreased from 55 % immediately after EUS-guided
SEMS removal. Complications included SEMS migration in a sin- CPB to 10 % at 24 weeks [85]. Because no RCT has included a
gle study (31 % of 13 patients) and de novo focal MPD strictures sham group, a placebo effect cannot be excluded. A recent RCT
(16 % of 32 patients) [73, 75]. has assessed the benefit of adding triamcinolone to bupivacaine
for patients with painful chronic pancreatitis [86]; only 15 % of
5.2.3. Endosonography-guided access and drainage the patients had a significant pain decrease at 1 month with ad-
(ESGAD) of the MPD dition of triamcinolone showing no difference.
Experience with ESGAD of the MPD is limited to a small number of In two RCTs, EUS was superior to CT guidance for CPB in terms of
reported cases with short follow-up. ESGAD was effective in obtain- duration of pain relief and of patient preference [87, 88]. Another
ing MPD drainage and pain relief in selected patients with chronic theoretical advantage of the EUS-guided route is the absence of
pancreatitis, with morbidity usually being mild and no reported reported severe complications such as paraplegia and aortic
mortality (Evidence level 3). ESGAD of the MPD is indicated in care- pseudoaneurysms [89, 90]. The most common complications of
fully selected patients; patients considered for ESGAD should be re- EUS-guided CPB include transient diarrhea, hypotension, and
ferred to tertiary centers with appropriate equipment and exper- pain exacerbation, with an incidence of up to 33 % [84].
tise (Recommendation grade D).
Potential indications for ESGAD of the MPD include patients with
a symptomatic MPD obstruction and failed conventional transpa- 7. Pancreatic pseudocysts
pillary MPD drainage. Briefly, the technique consists of punctur- !
ing the MPD through the gastric or duodenal wall, obtaining a 7.1. Definitions
pancreatogram and advancing a guide wire into the MPD to pro- Pancreatic pseudocysts (PPC) develop during the course of chron-
ceed with transpapillary (rendezvous technique) or transmural ic pancreatitis in 20 40 % of patients [91]. The Atlanta classifica-
drainage [44]. tion defines a PPC as a collection of pancreatic juice enclosed by a
Approximately 75 cases of ESGAD of the MPD have been reported wall of fibrous granulation tissue, which arises as a consequence
[76 81]; follow-up for individual cases ranges from a few weeks of acute pancreatitis, pancreatic trauma, or chronic pancreatitis
up to 55 months (median, 1 year). Immediate pain relief after suc- [92]. It further distinguishes acute PPC (associated with acute
cessful ESGAD of the MPD has been reported in a majority of pa- pancreatitis more than 4 weeks previously) and chronic PPC
tients with painful obstructive chronic pancreatitis (range, 50 % (arising in patients with chronic pancreatitis and no antecedent
100 %). In the largest series to date (n = 36), complete or major acute pancreatitis). Endoscopic therapy of PPC consists of insert-
pain relief was achieved in 69 % of patients but the probability of ing a drain from the digestive lumen into the PPC, through the di-
remaining free of pain sharply dropped with time, to 20 % after gestive wall (transmural drainage), through the papilla (trans-
450 days [79]. A malignant etiology for complete MPD obstruc- papillary drainage), or a combination of these routes. Transpa-
tion should always be sought as 5 patients out of 36 in this series pillary PPC drainage is feasible only in the case of direct commu-
had a diagnosis of cancer within a year of the procedure [79]. nication between the PPC and the MPD, which occurs in 40 66 %
The morbidity rate of ESGAD of the MPD varies between 0 and 44 of all PPCs [93 95]. Technical success is usually defined as the
%; it mostly consists of relatively mild post-procedure pain, but ability to insert at least one stent from the PPC to the digestive lu-
severe pancreatitis, perforation, bleeding, and hematoma have men [96, 97], or resolution of the fluid collection but not neces-
been reported [76 81]. No procedure-related mortality has sarily of symptoms [98]. Short-term clinical success is usually de-
been reported. Migration and occlusion of stents frequently occur fined as complete relief of the initial symptoms with a decrease in
(20 % to 55 % of patients), necessitating endoscopic re-interven- PPC diameter of at least 30 50 % at 1 month [99].
tion. ESGAD is a technically challenging procedure [79].
7.2. Indications for treatment
Universally accepted indications for PPC treatment include the
6. Endoscopic ultrasound-guided celiac plexus block presence of symptoms (abdominal pain, gastric outlet obstruction,
! early satiety, weight loss, or jaundice) and infected or enlarging
EUS-guided celiac plexus block (CPB) provides temporary pain re- PPC. Compared with surgery, endoscopic drainage of uncompli-
lief in approximately half of patients with chronic pancreatitis. cated PPC provides similar long-term results at a lower cost, with
EUS-guided CPB is superior to percutaneous CT-guided CPB in shorter hospital stay, and better quality of life during the first
terms of pain control and of patient preference (Evidence level 1 ). months following treatment. Procedure-related mortality is slightly
lower with the endoscopic method (Evidence level 1 +).
790 Guidelines
The ESGE recommends endoscopic therapy as the first-line therapy Transpapillary and transmural PPC drainages were compared in
for uncomplicated chronic PPCs for which treatment is indicated three nonrandomized studies that included 173 patients (chronic
and that are within endoscopic reach (Recommendation grade A). pancreatitis was diagnosed in 40 92 % of them) [95, 98,108].
Besides the universally accepted indications for PPC treatment Transpapillary drainage was used for smaller PPCs than trans-
that are listed above [100], treatment for prophylaxis of potential mural drainage. We calculated that transpapillary drainage was
PPC-related complications in asymptomatic patients has been ad- associated with lower morbidity (1 /56 [1.8 %] vs. 18 /117 [15.4 %]
vocated by some authors (although such complications occur in < patients; P = 0.008) and similar long-term success (53 /56 [94.6 %]
10 % of patients during follow-up) [101, 102]. Suggested indica- vs. 105 /117 [89.7 %] patients; P = 0.391) than transmural drain-
tions for prophylactic treatment include compression of major age.
vessels, intracystic hemorrhage, pancreaticopleural fistula, PPC > For transmural PPC drainage, technical success was higher with
5 cm without any regression after > 6 weeks, cyst wall > 5 mm, and EUS compared with conventional guidance in two RCTs
PPC in the setting of chronic pancreatitis with advanced MPD [97, 109]. All patients with failed conventional drainage had a
changes or pancreaticolithiasis [103]. Treatment of asymptomat- successful EUS-guided drainage. Per-protocol analysis showed
ic PPC in chronic pancreatitis is supported by the low (0 9 %) rate no difference between groups in terms of morbidity and clinical
of spontaneous PPC resolution in patients with established outcome. Failures of conventional drainage were related to the
chronic pancreatitis in most series [104]. A single series reported absence of intraluminal bulging, which is observed in approxi-
a higher (26 %) resolution rate, which was observed after a long mately half of PPCs [95].
follow-up (median time to resolution, 29 weeks) [105]. In a review of seven historical series that reported results sep-
In an RCT that compared endoscopic (EUS-guided) drainage vs. arately for 121 patients treated by either cystoduodenostomy or
surgery for uncomplicated PPC, endoscopic drainage was signifi- cystogastrostomy, cystoduodenostomy more frequently yielded
cantly better than surgery in terms of cost, length of hospital stay, long-term success (59 /71 [83.1 %] vs. 32 /50 [64.0 %]; P = 0.019),
and quality of life up to 3 months post-procedure [106]. At a me- with identical morbidity (10 %) [110]. This could be related to a
dian follow-up of 18 months, clinical outcomes and quality of life longer patency of cystoduodenal compared with cystogastric fis-
were similar for both allocation groups. A large review of non- tulas [110 112].
comparative historical series of endoscopic and surgical treat- After transmural PPC drainage and PPC resolution, early stent re-
ments that included 787 patients showed similar morbidity moval was associated with more PPC recurrences compared with
(13.3 % vs. 16.0 %, respectively) and long-term pseudocyst recur- stent maintenance in an RCT of 28 patients (15 had chronic pan-
rence (10.7 % vs. 9.8 %, respectively) but lower mortality with the creatitis) [113]. In a retrospective study of 92 patients, PPC drain-
endoscopic method (0.2 % vs. 2.5 %, respectively) [107]. age with a single stent and a stenting duration 6 weeks were in-
dependently associated with failure of endoscopic treatment (de-
7.3. Methods and results fined as severe procedure-related complication or need for an-
In the absence of luminal bulging, transmural drainage of PPC is other treatment modality) [96]. In this series, straight stents
feasible under EUS guidance only, with complication and success were used and they were associated with frequent bleeding (7 %
rates similar to those of conventional transmural drainage (Evi- of patients, with surgery required in two thirds of them) and
dence level 1 +). Compared with transmural drainage, transpapil- stent migration. The authors advocated using double-pigtail
lary drainage provides similar long-term success and is associated stents.
with fewer complications but it has been performed for relatively Pseudoaneurysms may be detected in the setting of chronic pan-
small collections only (generally 50 mm). Compared with cysto- creatitis, particularly where there is complication with a PPC
gastrostomy, cystoduodenostomy may provide better long-term [114]. In the largest review of hemorrhages associated with a
success (Evidence level 2 ). After transmural PPC drainage, early PPC (126 episodes), overall mortality was 19 % [114]. Therefore,
(2-month) stent removal is associated with a high likelihood of some authors recommend embolization of arterial pseudoaneur-
PPC recurrence (Evidence level 1 ). Single transmural stents do ysms before attempting drainage of PPCs close to pseudoaneur-
not yield long-term success as frequently as multiple stents; ysms [115]. Finally, extrahepatic portal hypertension develops
straight transmural stents are associated with relatively frequent during the course of chronic pancreatitis in 15 % of patients
and severe complications (Evidence level 2 ). Mortality associated [116]. Some authors recommend EUS-guided PPC drainage in
with hemorrhage from pseudoaneurysms close to PPCs is high (Evi- cases of portal hypertension, to decrease the risk of bleeding
dence level 1 +). [117]; this strategy has not been compared with conventional
If transmural pseudocyst drainage is indicated in the absence of lu- transmural drainage but it has been reported to be safe in a small
minal bulging, it should be performed under EUS guidance (Recom- series of patients [118].
mendation grade A). For small collections communicating with the
MPD in the head or body of the pancreas, the ESGE recommends at- 7.4. Particular case: complete MPD rupture
tempting transpapillary drainage first. Cystoduodenostomy should PPC resolution in the case of a complete MPD rupture is achieved
be preferred over cystogastrostomy if both routes are deemed equal- less frequently compared with clinical situations without complete
ly feasible. For transmural PPC drainage, the ESGE recommends in- MPD rupture; the risk of PPC relapse may also be higher. A stent
serting at least two double-pigtail plastic stents (Recommendation bridging the MPD rupture (which may allow MPD healing) and a
grade D); these should not be retrieved before cyst resolution as de- long stenting duration are associated with better long-term success
termined by cross-sectional imaging and not before at least 2 (Evidence level 2 ).
months of stenting (Recommendation grade B). In the case of portal The ESGE recommends, besides transmural PPC drainage, attempt-
hypertension, transmural drainage should be performed under EUS ing transpapillary bridging of MPD ruptures with a plastic stent. If
guidance. If arterial pseudoaneurysms are detected in the vicinity of the MPD rupture cannot be bridged, transmural stents should be
the PPC, arterial embolization should be considered prior to PPC left in place for as long as the disconnected pancreatic tail secretes
drainage (Recommendation grade D). pancreatic juice (typically, for years) (Recommendation grade D).
Guidelines 791
In the case of complete MPD rupture without effective drainage, tures (65 %); complete therapy requires approximately four ERCPs
the disconnection of the pancreatic tail may lead to fluid accu- over a 12-month period. Possible stricture relapses after stenting
mulation. Initial PPC resolution after endoscopic treatment has are usually successfully re-treated by ERCP. Temporary placement
been reported in 61 % of 97 patients with a complete MPD rup- of single plastic stents provides poorer patency rates; treatment
ture (with or without chronic pancreatitis) [119 122]. Bridging with uncovered SEMSs is plagued with a high long-term morbidity;
of complete MPD ruptures is possible in some cases [121, 122]. A temporary placement of covered SEMSs is an investigational option
combination of transmural PPC drainage and a transpapillary (Evidence level 1 +). Some series of patients treated with plastic
stent bridging the MPD rupture may improve success [123]. In a stents for CBD strictures related to alcoholic chronic pancreatitis
retrospective study of 97 patients with partial or complete MPD have been reported to have a relatively high incidence of cholangi-
rupture treated transpapillarily, factors associated with a suc- tis, including fatal cases, due to poor patient compliance with
cessful outcome included a partial MPD rupture, a stent bridging scheduled stent exchanges. Comparative studies of surgical and en-
the rupture and a long stenting duration [120]. In a series in doscopic treatments in patients with benign biliary strictures
which transmural stents were removed once PPC had resolved, related to a trauma have reported similar long-term results; no
half of the PPCs recurred [119]. In contrast, persisting long-term comparative data are available for chronic pancreatitis-related
success was reported in 11 of 12 patients who had prolonged biliary strictures (Evidence level 2 ).
stenting [121]. The choice between endoscopic and surgical treatment should rely
on local expertise, local or systemic patient co-morbidities (e. g., por-
7.5. Complications tal cavernoma, cirrhosis) and expected patient compliance with re-
Morbidity and mortality of endoscopic PPC drainage are approxi- peat endoscopic procedures (Recommendation grade D). If endo-
mately 13 % and 0.3 %, respectively. Secondary PPC infection may scopic therapy is elected, the ESGE recommends temporary (1-year)
complicate PPC drainage (Evidence level 1 +); no data on the effica- placement of multiple, side-by-side, plastic biliary stents (Recommen-
cy of antibiotic prophylaxis in this setting are available. dation grade A). Because of the risk of fatal septic complications, a
The ESGE recommends antibiotic prophylaxis for endoscopic PPC recall system should be set up to care for patients who do not pres-
drainage (Recommendation grade D). ent for scheduled stent exchanges. In cases of relapsing stricture
Figures stated above were reported in a recent review of 24 stud- after stent removal at 1 year, the options available, including surgi-
ies involving a total of 1126 patients with wide variations in mor- cal biliary drainage, should be evaluated by a multidisciplinary
bidity between studies (3 % 34 %) [44, 103]. Major complications team (Recommendation grade D).
included hemorrhage, perforation, and infection; most of these A malignant etiology of the stricture should always be sought, at
were managed by nonoperative means, including local coagulati- least by biliary brushing, as patients treated for supposedly be-
on or arterial embolization for bleeding, repeat endoscopic drain- nign chronic pancreatitis-related biliary stricture may have a fi-
age for secondary infection, and antibiotics for retroperitoneal nal diagnosis of malignancy [20, 130]. The principle of endoscopic
perforation [99, 124,125]. Antibiotic administration immediately treatment for biliary strictures consists of temporary stricture di-
before transmural or transpapillary PPC drainage is recommen- lation using plastic stents (single or multiple side-by-side) or
ded in recent guidelines based on expert opinion [126]. The deci- covered SEMSs. Definitive SEMS insertion has also been reported.
sion about antibiotics continuation after the procedure should be In patients treated with plastic stents, various criteria have been
guided by the adequacy of PPC drainage and the presence or ab- used to decide on when to remove stents, including cholangio-
sence of necrosis [100]. gram and a minimum stenting duration of 1 year [131]. Amongst
benign biliary strictures, those related to chronic pancreatitis are
the most difficult to treat by temporary biliary stenting: stric-
8. Chronic pancreatitis-related biliary strictures tures less frequently resolve at the time of stent removal and
! they relapse more frequently during follow-up [130, 132]. The
8.1. Definitions presence of pancreatic calcifications has been associated with
Biliary obstruction complicates the course of chronic pancreatitis long-term failure of single plastic biliary stenting [133], but this
in 3 % 23 % of patients [127]. Different cholangiographic types of factor may be less relevant if simultaneous multiple plastic stents
chronic pancreatitis-related biliary strictures have been de- are used [134].
scribed, the type being suggestive of the etiology of biliary ob- Short-term (1-month) results for biliary stenting are similar for
struction (fibrosis, compression by a pseudocyst or cancer) [128]. plastic stents and SEMSs in all respects, including success rates
and complication rates (approximately 5 %). For the selection of
8.2. Indications for treatment particular models of stents, the reader is referred to other recent
The ESGE recommends treating chronic pancreatitis-related biliary ESGE Guidelines [19, 57].
strictures in the case of symptoms, secondary biliary cirrhosis, bili- Long-term results of temporary biliary stenting for chronic pan-
ary stones, progression of biliary stricture, or asymptomatic eleva- creatitis-related biliary strictures are summarized in " Table 4.
tion of serum alkaline phosphatase (> 2 or 3 times the upper limit of Successful treatment was reported in 31 % of 350 patients with
normal values) and/or of serum bilirubin for longer than 1 month single plastic stents and 62 % of 50 patients with simultaneous
(Recommendation grade A). multiple plastic stents. A single nonrandomized series has com-
The abovementioned indications are generally accepted [129]. pared long-term results after temporary treatment with single
vs. multiple simultaneous plastic stents; it showed overall clinical
8.3. Methods and results success in 24 % vs. 92 % patients, respectively (P < 0.01), after sim-
Temporary placement of simultaneous multiple plastic stents is ilar follow-up durations [134].
technically feasible in > 90 % of patients with benign CBD strictures; In series that used simultaneous multiple plastic stents, stent ex-
it is the endoscopic technique that provides the highest long-term changes were scheduled at 3-month intervals and the mean ob-
biliary patency rate in chronic pancreatitis-related biliary stric- served stenting duration was 12 21 months (mean number of
792 Guidelines
Table 4 Selected series of temporary stenting for common bile duct (CBD) strictures in chronic pancreatitis.
First author, year n Long-term Stenting duration, Stent dysfunction Follow-up post Patients who
success, % months of any cause per stent removal, underwent surgi-
patient, % months cal drainage, %
Single plastic stent
Deviere, 1990 [155] 25 12 n.a. 72 14 24
Barthet, 1994 [156] 19 10 10 NA 18 21
Smits, 1996 [157] 58 28 10 64 49 28
Vitale, 2000 [158] 25 80 1 13 20 32 8
Farnbacher, 2000 [159] 31 32 10 52 28 6
Eickoff, 2001 [160] 39 31 9 43 58 28
Kahl, 2003 [133] 61 26 12 34 40 49
Catalano, 2004 [134] 34 24 21 41 50 41
Cahen, 2005 [161] 58 38 9 48 45 28
Multiple plastic stents
Draganov, 2002 [136] 9 44 14 n.a. 48 n.a.
Pozsar, 2004 [135] 29 60 21 n.a.2 12 13
Catalano, 2004 [134] 12 92 14 8 47 8
Covered SEMS
Cahen, 2008 3 [140] 6 50 5 33 28 17
Behm, 2009 4 [144] 20 80 5 5 22 0
Mahajan, 2009 5 [132] 19 n.a. 3 11 4 n.a.
SEMS, self-expandable metal stent; n.a., not available
1
The unusually high success rate reported by Vitale et al. was related, according to the authors, to a low prevalence of calcifying chronic pancreatitis in their series (23 % vs. 60 70 %
in other series).
2
20 episodes of cholangitis were reported.
3
Fully covered Hanaro stent (Hanaro, M.I.Tech Co., Ltd., Seoul, South Korea).
4
Partially covered Wallstent (Boston Scientific, Natick, Massachusetts, USA).
5
Fully covered Viabil stent (Conmed, Utica, New York, USA).
ERCPs, 4.0 4.7) [134 136]. According to a recent retrospective function has been reported in 8 69 % and 5 33 % of patients
study, the interval between stent exchanges could be extended treated with temporary insertion of multiple plastic stents and
[137]. However, in patients with alcoholic chronic pancreatitis, of covered SEMSs, respectively [132, 134 136, 140, 144]. The
compliance with stent exchange may be problematic: in a retro- costs of these two methods have not been compared.
spective series of 14 patients, only two (14.3 %) patients present- No study has compared endoscopic biliary stenting vs. surgical
ed for elective stent exchanges although written instructions biliodigestive anastomosis for chronic pancreatitis-related biliary
were given to the patients and primary care physicians for doing stricture. Two nonrandomized studies have compared endoscopy
so [138]. Another retrospective series reported an observed vs. surgery for the treatment of benign biliary strictures related
mean interval between stent exchanges of 6.4 months although to trauma (cholecystectomy in most cases). One of these studies
these were scheduled at 3-month intervals; there were at least reported similar morbidity (35 % vs. 26 %) and absence of stricture
20 episodes of cholangitis in a total of 29 patients, of which two relapse (17 % in both groups) during follow-up in 101 patients
were fatal [135]. Of note, in the latter series, stents were exchan- [145]. The other study found that endoscopic treatment was
ged at ERCP only if they were clogged. Protocols aiming at lower- associated with a higher morbidity rate (45 % vs. 9 %; P = 0.01),
ing stenting duration and/or the number of ERCPs are being ex- shorter total hospital stay (6 vs. 11 days; P = 0.001), and similar
plored: success at 5 years (80 % vs. 77 %) in 42 patients [146].
In patients with biliary strictures complicating orthotopic liver
transplantation, plastic stents were exchanged with a higher
number of stents every 2 weeks until complete waist disap- 9. Treatment of chronic pancreatitis in children
pearance at the level of the anastomosis, and were then left in !
place for 3 months [139]. The main indication for endoscopic therapy of chronic pancreatitis
In patients with chronic pancreatitis, temporary treatment in children is pain. (Evidence level 2 +). After endoscopic therapy for
with partially or fully covered SEMSs has been reported in chronic pancreatitis the majority of children have lesser symptoms
small series of patients using different SEMS models and with and less hospital admission during long-term follow-up. The main
different results. Limitations include failure to remove stents complication of endoscopic therapy for chronic pancreatitis in chil-
and short follow-up after covered SEMS removal in currently dren is acute pancreatitis, which is usually mild or moderate. (Evi-
available studies [140]. dence level 2 ).
Definitive insertion of uncovered or partially covered SEMS The ESGE recommends endoscopic therapy as a first-line therapy
has been abandoned because of disappointing long-term re- for chronic pancreatitis in children starting at 8 years in the same
sults in benign biliary strictures [141 143]. conditions as in adults (Recommendation grade C).
No comparison of various stenting durations has been reported A recent, retrospective, large Danish study of chronic pancreatitis
in the literature (scheduled stenting duration with multiple plas- in young adults (< 30 years old) showed that the standardized
tic stents and covered SEMSs has generally been for 1 year and for prevalence ratio of chronic pancreatitis increased between
3 6 months, respectively) [132, 134 136, 140, 144]. Stent dys- 1980 1984 and 2000 2004 [147]. The most frequent etiologies
Guidelines 793
are idiopathic and genetic; a retrospective case series from Ger- giopancreaticography in suspected chronic pancreatitis. Magn Reson
Imaging 2008; 26: 1367 1373
many found genetic mutations in 30 % of 146 patients with
6 Morgan DE, Baron TH, Smith JK et al. Pancreatic fluid collections prior
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tric patients had less severe chronic pancreatitis stages, and a dence on causation. Clin Gastroenterol Hepatol 2008; 6: 275 282
8 Varadarajulu S, Tamhane A, Eloubeidi MA. Yield of EUS-guided FNA of
lower prevalence of pseudocysts, of calcifications, and of chronic
pancreatic masses in the presence or the absence of chronic pancreati-
pancreatitis-related CBD biliary strictures [150]. tis. Gastrointest Endosc 2005; 62: 728 736 ; quiz 751, 753
Three retrospective case series evaluated endoscopic therapy for 9 Arvanitakis M, Van Laethem J-L, Parma J et al. Predictive factors for
pain in children with chronic pancreatitis [151 153]. In two pancreatic cancer in patients with chronic pancreatitis in association
studies [151, 153], the majority of patients had a subjective im- with K-ras gene mutation. Endoscopy 2004; 36: 535 542
10 Bipat S, Phoa SSKS, van Delden OM et al. Ultrasonography, computed to-
provement of their disease and a decrease in hospital admissions
mography and magnetic resonance imaging for diagnosis and deter-
following endoscopic therapy. In the third study, recurrence of a mining resectability of pancreatic adenocarcinoma: a meta-analysis. J
flare of chronic pancreatitis was more frequent after endoscopic Comput Assist Tomogr 2005; 29: 438 445
as compared with surgical treatment (75 % of 12 patients vs. 39 % 11 Balthazar EJ. Pancreatitis associated with pancreatic carcinoma. Preo-
perative diagnosis: role of CT imaging in detection and evaluation.
of 25 patients, respectively). Regarding treatment-related com-
Pancreatology 2005; 5: 330 344
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Abdom Imaging 2010; 35: 163 171
13 Gerstenmaier JF, Malone DE. Mass lesions in chronic pancreatitis: be-
nign or malignant? An evidence-based practice approach. Abdom
10. Use of the Guideline
Imaging 2011; 36: 569 577
!
14 Ardengh JC, Lopes CV, Campos AD et al. Endoscopic ultrasound and fine
The disclaimer regarding ESGE guidelines applies to this Guide- needle aspiration in chronic pancreatitis: differential diagnosis be-
line [154]. tween pseudotumoral masses and pancreatic cancer. JOP 2007; 8:
413 421
15 Kaufman AR, Sivak MV. Endoscopic ultrasonography in the differential
Competing interests: Guido Costamagna, Nageshwar Reddy, Jac-
diagnosis of pancreatic disease. Gastrointest Endosc 1989; 35: 214
ques Devire, and Marco Bruno have received research support 219
from Cook Endoscopy Inc., Limerick, Ireland, and from Boston 16 Fritscher-Ravens A, Brand L, Knfel WT et al. Comparison of endoscopic
Scientific, Natick, Massachusetts, USA. Nageshwar Reddy also re- ultrasound-guided fine needle aspiration for focal pancreatic lesions in
ceived research support from TaeWoong Medical, Korea. Marco patients with normal parenchyma and chronic pancreatitis. Am J Gas-
troenterol 2002; 97: 2768 2775
Bruno also received research support from MiTech, Seoul, South 17 Krishna NB, Mehra M, Reddy AV et al. EUS/EUS-FNA for suspected pan-
Korea. creatic cancer: influence of chronic pancreatitis and clinical presenta-
tion with or without obstructive jaundice on performance characteris-
Institutions tics. Gastrointest Endosc 2009; 70: 70 79
1
Service of Gastroenterology and Hepatology, Geneva University Hospitals, 18 Dumonceau J-M, Polkowski M, Larghi A et al. Indications, results, and
Geneva, Switzerland clinical impact of endoscopic ultrasound (EUS)-guided sampling in
2
Department of Gastroenterology and Hepato-Pancreatology, Erasme gastroenterology: European Society of Gastrointestinal Endoscopy
University Hospital, Brussels, Belgium (ESGE) Clinical Guideline. Endoscopy 2011; 43: 897 912
3
Digestive Endoscopy Unit, Catholic University, Rome, Italy 19 Dumonceau JM, Tringali A, Blero D et al. Biliary stenting: indications,
4
Department of Gastroenterology and Hepatology, University Hospital choice of stents and results. ESGE Clinical Guideline. Endoscopy 2012;
of Santiago de Compostela, Santiago de Compostela, Spain
5 44: 277 298
Department of Gastroenterology and Hepatology, Erasmus Medical Center,
20 Dumonceau J-M, Macias GomezC, Casco C et al. Grasp or brush for bili-
Rotterdam, The Netherlands
6
Fribourg, Switzerland ary sampling at endoscopic retrograde cholangiography? A blinded
7
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Montral, Montral, Qubec, Canada 21 Shimosegawa T, Chari ST, Frulloni L et al. International consensus diag-
8 nostic criteria for autoimmune pancreatitis: guidelines of the Interna-
Department of Gastroenterology, Asian Institute of Gastroenterology,
Hyderabad, India tional Association of Pancreatology. Pancreas 2011; 40: 352 358
9
Department of Gastroenterology and Hepatology, Academic Medical Center, 22 Tanaka M, Chari S, Adsay V et al. International consensus guidelines for
Amsterdam, The Netherlands management of intraductal papillary mucinous neoplasms and muci-
10
Hpital Edouard Herriot, Department of Digestive Diseases, Lyon, France nous cystic neoplasms of the pancreas. Pancreatology 2006; 6: 17 32
23 Talamini G, Zamboni G, Salvia R et al. Intraductal papillary mucinous
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784 Guidelines

Endoscopic treatment of chronic pancreatitis:

Institutions Institutions are listed at the end of article.

1. Introduction tion of the main pancreatic duct (MPD). In a large

2. Methods Chronic pancreatitis is associated with an increased risk of pancreat-

ERCP Surgery ESWL + ERCP Surgical pancrea- ESWL ESWL + ERCP

Table 2 Long-term outcome after endoscopic treatment of chronic pancreatitis.

First author, year n Follow-up, months Surgery Ongoing endoscopic No further

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