When endoscopic therapy is used for the treatment of patients with painful chronic pancreatitis, extracorporeal shock wave lithotripsy (ESWL) can be proposed as a first-line approach when obstructive ductal stone(s) induce upstream dilation of the main pancreatic duct. Stone fragmentation by ESWL is followed by endoscopic ductal drainage using pancreatic sphincterotomy, fragmented stone(s) extraction, and pancreatic stenting in case of ductal stricture. After completion of endoscopic pancreatic ductal drainage, long-term clinical benefit can be expected for two thirds of the patients. Best clinical results are associated with absence or cessation of smoking and with early treatment in the course of chronic pancreatitis, while alcohol abuse increases the risks of diabetes, steatorrhea and mortality.
The complications of chronic pancreatitis are mainly the development of pseudocyst secondary to the downstream ductal obstruction, and biliary obstruction caused by fibrotic changes in the head of the pancreas. Successful endoscopic pseudocyst drainage is currently obtained in most patients, and carries a low complication rate. Biliary stenting is a safe and effective technique for the short-term treatment of symptomatic bile duct stricture due to chronic pancreatitis, but permanent resolution is obtained in only 25% of cases.
In conclusion, endoscopic management is now considered to be the preferred interventional treatment of chronic pancreatitis, for patients selected on the basis of the anatomical changes caused by the disease. This treatment is generally safe, minimally invasive, often effective for years, does not prevent further surgery, and can be repeated.
EtemadBWhitcombDCChronic pancreatitis: Diagnosis, classification and new genetic developments. Gastroenterology2001;120:682–707.
2.
KaranjiaNDReberHAThe cause and management of the pain of chronic pancreatitis. Gastroenterol Clin North Am1990;19:895–904.
3.
KasminFESiegelJHEndoscopic therapy for chronic pancreatitis. Surg Clin North Am2001;81:421–430.
4.
JakobsRBenzCLeonhardtASchillingDPereira-LimaJCRiemannJFPancreatic endoscopic sphincterotomy in patients with chronic pancreatitis: A single-center experience in 171 consecutive patients. Endoscopy2002;34:551–554.
5.
ShermanSLehmanGAHawesRHPonichTMillerLSCohenLBKortanPHaberGBPancreatic ductal stones: Frequency of successful endoscopic removal and improvement in symptoms. Gastrointest Endosc1991;37:511–517.
6.
DelhayeMVandermeerenABaizeMCremerMExtracorporeal shock wave lithotripsy of pancreatic calculi. Gastroenterology1992;102:610–62.
7.
BinmoellerKFJuePSeifertHNamWCIzbickiJSoehendraNEndoscopic pancreatic stent drainage in chronic pancreatitis and a dominant stricture: Long-term results. Endoscopy1995;27:638–644.
8.
MatosCMetensTDevièreJNicaiseNBraudePVan YperenGCremerMStruyvenJPancreatic duct: Morphology and functional evaluation with dynamic MR pancreatography after secretin stimulation. Radiology1997;203:435–141.
9.
DelhayeMMatosCDevièreJEndoscopic management of chronic pancreatitis. Gastrointest Endosc Clin N Am2003;13:717–742.
10.
RoschTDanielSScholzMHuibregsteKSmitsMSchneiderTEllCHaberGRiemannJFJakobsRHintzeRAdlerANeuhausHZavoralMZavadaFSchusdziarraVSoehendraNEndoscopic treatment of chronic pancreatitis: A multicenter study of 1000 patients with long-term follow-up. Endoscopy2002;34:765–771.
11.
DumonceauJMDevièreJLe MoineODelhayeMVandermeerenABaizeMVan GansbekeDCremerMEndoscopic pancreatic drainage in chronic pancreatitis associated with ductal stones: Long-term results. Gastrointest Endosc1996;43:547–555.
12.
SmitsMERauwsEAJTytgatGNJHuibregtseKEndoscopic treatment of pancreatic stones in patients with chronic pancreatitis. Gastrointest Endosc1996;43:556–560.
13.
FarnbacherMJSchoenCRabensteinTBenningerJHahnEGSchneiderHTPancreatic duct stones in chronic pancreatitis: Criteria for treatment intensity and success. Gastrointest Endosc2002;56:501–506.
14.
KozarekRABrandaburJJBallTJGluckMPattersonDJAttiaFFranceRTraversoWKoslowskiPGibbonsRPClinical outcomes in patients who undergo extracorporeal shock wave lithotripsy for chronic calcific pancreatitis. Gastrointest Endosc2002;56:496–500.
15.
BrandBKahlMSidhuSNamVCSriramPVJJaeckleSThonkeFSoehendraNProspective evaluation of morphology, function and quality of life after extracorporeal shockwave lithotripsy and endoscopic treatment of chronic calcific pancreatitis. Am J Gastroenterol2000;95:3428–3438.
16.
CostamagnaGGabbrielliAMultignaniMPerriVPandolfiMBoscainiMCrucittiFExtracorporeal shock wave lithotripsy of pancreatic stones in chronic pancreatitis: Immediate and medium-term results. Gastrointest Endosc1997;46:231–236.
17.
DelhayeMArvanitakisMVersetGCremerMDevièreJLong-term clinical outcome after endoscopic pancreatic ductal drainage for patients with painful chronic pancreatitis. Clin Gastroenterol Hepatol2004;2:1096–1106.
18.
CremerMDevièreJDelhayeMBaizeMVandermeerenAStenting in severe chronic pancreatitis: Results of medium-term follow-up in seventy-six patients. Endoscopy1991;23:171–176.
19.
AdamekHEJakobsRButtmannAAdamekMUSchneiderARJRiemannJFLong-term follow-up of patients with chronic pancreatitis and pancreatic stones treated with extracorporeal shock wave lithotripsy. Gut1999;45:402–05.
20.
DitePRuzickaMZborilVNovotnyIA prospective, randomized trial comparing endoscopic and surgical therapy for chronic pancreatitis. Endoscopy2003;35:553–558.
21.
PonchonTBoryRMHedeliusFRoubeinLDPaliardPNapoleonBChavaillonAEndoscopic stenting for pain relief in chronic pancreatitis: Results of a standardized protocol. Gastrointest Endosc1995;42:452–56.
22.
VitaleGCCothronKVitaleEARangnekarNZavaletaCMLarsonGMBinfordJHammondBRole of pancreatic duct stenting in the treatment of chronic pancreatitis. Surg Endosc2004;18:1431–1434.
23.
EleftheriadisNDinuFDelhayeMLe MoineOBaizeMVandermeerenAHookeyLDevièreJLong-term outcome after pancreatic stenting in severe chronic pancreatitis. Endoscopy2005;37:223–230.
24.
BoermaDVan GulikTMRauwsEAJObertopHGoumaDJOutcome of pancreaticojejunostomy after previous endoscopic stenting in patients with chronic pancreatitis. Eur J Surg2002;168:223–228.
AmmannRWMuellhauptBThe natural history of pain in alcoholic chronic pancreatitis. Gastroenterology1999;116:1132–1140.
27.
MalkaDHammelPSauvanetARufatPO'TooleDBardetPBelghitiJBernadesPRuszniewskiPLévyPRisk factors for diabetes mellitus in chronic pancreatitis. Gastroenterology2000;119:1324–1332.
28.
BeckinghamIJKrigeJEJBornmanPCTerblancheJEndoscopic management of pancreatic pseudocysts. Br J Surg1997;84:1638–1645.
29.
HowellDAEltonEParsonsWGEndoscopic management of pseudocysts of the pancreas. Gastrointest Endosc Clin N Am1998;8:143–162.
30.
BarthetMSahelJBodiou-BerteiCBernardJPEndoscopic transpapillary drainage of pancreatic pseudocysts. Gastrointest Endosc1995;42:208–213.
31.
BinmoellerKFSeifertHWalterASoehendraNTranspapillary and transmural drainage of pancreatic pseudocysts. Gastrointest Endosc1995;42:219–224.
32.
TelfordJJFarrellJJSaltzmanJRShieldsSJBanksPALichtensteinDRJohannesRSKelseyPBCarr-LockeDLPancreatic stent placement for duct disruption. Gastrointest Endosc2002;56:18–24.
33.
VaradarajuluSNooneTCTutuianRHawesRHCottonPBPredictors of outcome in pancreatic duct disruption managed by endoscopic transpapillary stent placement. Gastrointest Endosc2005;61:568–575.
34.
American Association for Gastrointestinal Endoscopy Guidelines: Endoscopic therapy of chronic pancreatitis. Gastrointest Endosc2000;52:843–848.
35.
GiovanniniMPesentiCHRollandALMoutardierVDelperoJREndoscopic ultrasound-guided drainage of pancreatic pseudocysts or pancreatic abscesses using a therapeutic echoendoscope. Endoscopy2001;33:473–477.
36.
SanchezCortes EMaalakALe MoineOBaizeMDelhayeMMatosCDevièreJEndoscopic cystenterostomy of non bulging pancreatic fluid collections. Gastrointest Endosc2002;56:380–386.
CatalanoMFLinderJDGeorgeSAlcocerEGeenenJETreatment of symptomatic distal common bile duct stenosis secondary to chronic pancreatitis: Comparison of single vs multiple simultaneous stents. Gastrointest Endosc2004;60:945–952.
39.
DevièreJDevaereSBaizeMCremerMEndoscopic biliary drainage in chronic pancreatitis. Gastrointest Endosc1990;36:96–100.
40.
SmitsMERauwsEAVan GulikTMGoumaDJTytgatGNHuibregtseKLong-term results of endoscopic stenting and surgical drainage for biliary stricture due to chronic pancreatitis. Br J Surg1996;83:764–768.
41.
VitaleGCReedDNNguyenCTLawhonJCLarsonGMEndoscopic treatment of distal bile duct stricture from chronic pancreatitis. Surg Endosc2000;14:227–231.
42.
FarnbacherMJRabensteinTEllCHahnEGSchneiderHTIs endoscopic drainage of common bile duct stenoses in chronic pancreatitis up-to-date? Am J Gastroenterol2000;95:1466–1471.
43.
KahlSZimmermannSGenzIGlasbrennerBProssMSchulzHUMcNamaraDSchmidtUMalfertheinerPRisk factors for failure of endoscopic stenting of biliary strictures in chronic pancreatitis: A prospective follow-up study. Am J Gastroenterol2003;98:2448–2453.
44.
CahenDLVan BerkelAMOskamDRauwsEAJWeverlingGJHuibregtseKBrunoMJLong-term results of endoscopic drainage of common bile duct strictures in chronic pancreatitis. Eur J Gastroenterol Hepatol2005;17:103–108.
45.
DevièreJCremerMBaizeMLoveJSugaiBVanderrmeerenAManagement of common bile duct stricture caused by chronic pancreatitis with metal mesh self expandable stents. Gut1994;35:122–126.
46.
Van BerkelAMCahenDLVan WesterlooDJRauwsEAJHuibregtseKBrunoMJSelf-expanding metal stents in benign biliary strictures due to chronic pancreatitis. Endoscopy2004;36:381–384.
47.
CottonPBRandomization is not the (only) answer: A plea for structured objective evaluation of endoscopic therapy. Endoscopy2000;32:402–405.
48.
BaronTHHarewoodGCMorganDEYatesMROutcome differences after endoscopic drainage of pancreatic necrosis, acute pancreatic pseudocyst, and chronic pancreatic pseudocysts. Gastrointest Endosc2002;56:7–17.
