ERCP and Related Technologies: A Clinical Update

David L. Carr-Locke, MD, FRCP, FACG, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts.

Disclosures

May 22, 2000

In This Article

Chronic Pancreatitis

This session included presentations on endoscopic management of chronic pancreatitis from the Brussels group, a review of pancreatic stent therapy, and a surgeon's perspective on pancreatic endotherapy.

Jacques Deviere, MD,[95] introduced this section with a review of the indications for endotherapy in chronic pancreatitis. As he discussed, the indications include elective drainage of the pancreatic duct for relief of pain, complications such as fluid collections, and biliary stenosis. This technique is often combined with ESWL as the cornerstone of stone fragmentation, and he pointed out that there are almost no indications for diagnostic pancreatography since MRCP has become available. He further reported that he found that patients who had combination stricture and stone disease tended to have a good outcome in the long run if endotherapy was continued, and that the quality of life for such patients could be improved as a result.

Dr. Deviere also discussed the transgastric, transduodenal, and transpapillary methods of draining fluid collections associated with chronic pancreatitis as well as short-term use of biliary stents for stenosis. He concluded by stressing that the major advantage of endotherapy in the palliation of this disease is that it is repeatable without there being an associated increase in morbidity or mortality. Moreover, there is also no detrimental effect on endocrine or exocrine function and no risk to the potential success of subsequent surgery.

Dr. Carr-Locke stressed the importance of chronic pancreatitis as an underlying condition in almost all the common clinical presentations of pancreatitis. He also emphasized the surprisingly high mortality associated with a diagnosis of chronic pancreatitis (50% within 25 years of time of diagnosis). In addition, Dr. Carr-Locke reviewed the goals of palliative therapy: alleviation of pain, prevention of recurrent attacks of pancreatitis, and, if possible, improvement of exocrine insufficiency. He also focused on the pathogenetic mechanisms of pain in chronic pancreatitis, identifying ductal hypertension as the principal target of most interventional therapies. Dr. Carr-Locke stratified traditional surgical approaches into drainage procedures and/or resections, and indicated that at best there is only a 50% long-term success rate at 5 years or more. Small duct disease is even more difficult to manage, as Dr. Carr-Locke mentioned, because variations of head resections have been advocated.

As endotherapeutic approaches have been applied to pancreatic disease, good short- and medium-term successes have been reported using a range of techniques derived from biliary therapy. The treatment of pancreatic duct strictures has provided symptomatic improvement in 75% of patients, but very poor long-term resolution of such lesions. The endoscopic extraction of pancreatic duct stones, with and without ESWL, has provided clearance rates of up to 85% with symptomatic improvement in up to 95%. And, although stones recurred, these can again be treated endoscopically. Decompression therapy for diffuse ductal dilatation has had a variable outcome as well, and no randomized trials against surgery are available. Dr. Carr-Locke also reported some success in a special group of patients who had returned with pain or further pancreatitis after pancreatic surgery. He agreed with other investigators that long-term use of plastic stents for biliary stenosis in chronic pancreatitis has been disappointing.

He concluded by pointing out the risks of pancreatic duct manipulations -- which have more than a 20% risk of inducing acute pancreatitis -- and also addressed the ductal changes that could be induced by long-term stent therapy. Dr. Carr-Locke suggested a number of areas where prospective information requires collection and where randomized studies need to be established despite the tremendous difficulties and associated costs.

While Howard Reber, MD,[96] introduced himself as the 'token" surgeon for this section of the course, he was not averse to attempts at endoscopic therapy of these difficult conditions -- especially under appropriately controlled conditions and with appropriate collection of data.

He addressed the treatment of pancreas divisum and reported a 70% to 80% success rate in acute relapsing pancreatitis, regardless of whether patients were treated endoscopically or surgically. Dr. Reber did not advocate a trial of stent therapy in this setting to predict the long-term outcome of surgery and indicated he was concerned about the ductal and parenchymal changes that could take place with long-term use of stents in an otherwise normal duct. He expressed his view that in many patients who had undergone a series of endoscopic interventions before surgery, the results may have been perturbed because of the relative fibrosis induced in the head of the pancreas (although this has remained unproven). He further referred to the American Society of Gastrointestinal Endoscopy (ASGE) recommendation of using pancreatic duct stents in the very short term only, because of the potential for significant morbidity.

In the setting of chronic pancreatitis, Dr. Reber referred to his own group's work on an animal model. He also described subsequent human studies that confirmed the presence of ductal hypertension and the possible reduction effect on pancreatic blood flow through a compartment-like syndrome, which might be relieved by ductal decompression and/or incision of the parenchyma. He believed it was unlikely that endotherapy would provide a satisfactory long-term outcome in this heterogeneous disease, but offered that good short-term improvement could be a very realistic goal.

Lastly, Dr. Reber agreed that a number of issues remain to be resolved and subjected to scientific scrutiny, and shared his hope that the appropriate trials would be established in the near future.

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