10
Endoscopic technique for the management of pancreatitis and its complications

https://doi.org/10.1016/S1521-6918(03)00077-5Get rights and content

Abstract

Therapeutic endoscopy is now increasingly used to treat gallstone pancreatitis, acute pancreatitis of other aetiologies, chronic pancreatitis and complications associated with acute or chronic pancreatitis.

This chapter is a brief review of the endoscopic interventions currently performed in patients with acute or chronic pancreatitis. These interventions include biliary and pancreatic endoscopic sphincterotomy at the major or minor papilla, stricture dilatation on the common bile duct or main pancreatic duct, stent placement in the biliary or pancreatic ducts, stone extraction with or without extracorporeal shock wave lithotripsy, and transmural or transpapillary drainage of pancreatic fluid collections.

As most of the studies reported were uncontrolled and retrospective, uncertainties persist with regard to the best approaches for treating the patients concerned.

Appropriate patient selection, adequate expertise, and a supporting multidisciplinary infrastructure are essential prerequisites of a high success rate in improving the clinical condition of these patients.

Section snippets

Gallstone-associated acute pancreatitis

In Western countries, gallstones account for about half the cases of AP. They often occur during middle age or later, and are more common in women.6

The pathogenesis of AP is due to the transient obstruction of the main pancreatic duct (MPD) and/or possible biliary reflux in the MPD.7., 8. There is experimental evidence that the severity of AP is proportional to the duration of pancreatic duct obstruction.8 This justifies the attempts to remove stones early in human gallstone pancreatitis.

The

Chronic pancreatitis

Chronic pancreatitis (CP) is a progressive disease for which there is no curative treatment. Therapeutic efforts have therefore concentrated on alleviating the severe pain associated with this condition.

Interventional endoscopy has been increasingly used to treat CP over the last 20 years, with clinical results comparable to those of conventional surgery.70., 71. However, unlike surgery, endoscopic therapy can be repeated in response to the recurrence of pain, and has a high clinical success

Summary

Thanks to the low invasiveness and safety of endoscopic therapy, it is now widely used as a first-line treatment for patients with acute or chronic pancreatitis.

In gallstone pancreatitis, the results of four randomized controlled studies in which endoscopic treatment was compared to conservative management indicate that the use of ERCP/ES should depend on the predicted severity of the disease and on its biliary symptoms.

In recurrent acute idiopathic pancreatitis, whether or not it is associated

References (112)

  • M. Delhaye et al.

    Pancreas divisum: congenital anatomic variant or anomaly? Contribution of endoscopic retrograde dorsal pancreatography

    Gastroenterology

    (1985)
  • C. Matos et al.

    Pancreas divisum: evaluation with secretin-enhanced magnetic resonance cholangiopancreatography

    Gastrointestinal Endoscopy

    (2001)
  • S.A. Cohen et al.

    Pancreas divisum. Endoscopic therapy

    Surgical Clinics of North America

    (2001)
  • L. Somogyi et al.

    Recurrent acute pancreatitis: An algorithmic approach to identification and elimination of inciting factors

    Gastroenterology

    (2001)
  • L. Heyries et al.

    Long-term results of endoscopic management of pancreas divisum with recurrent acute pancreatitis

    Gastrointestinal Endoscopy

    (2002)
  • G. Eisen et al.

    Santorinicele: new evidence for obstruction in pancreas divisum

    Gastrointestinal Endoscopy

    (1994)
  • G. Costamagna et al.

    Santorinicele and recurrent acute pancreatitis in pancreas divisum: diagnosis with dynamic secretin-stimulated magnetic resonance pancreatography and endoscopic treatment

    Gastrointestinal Endoscopy

    (2000)
  • M. Guelrud et al.

    Sphincter of Oddi dysfunction in children with recurrent pancreatitis and anomalous pancreaticobiliary union: an etiologic concept

    Gastrointestinal Endoscopy

    (1999)
  • M. Sugiyama et al.

    Pancreatic disorders associated with anomalous pancreaticobiliary junction

    Surgery

    (1999)
  • R. Samavedy et al.

    Endoscopic therapy in anomalous pancreatobiliary duct junction

    Gastrointestinal Endoscopy

    (1999)
  • F.L. Greene et al.

    Choledochocele and recurrent pancreatitis. Diagnosis and surgical management

    American Journal of Surgery

    (1985)
  • J.L. Frossard et al.

    Usefulness of endoscopic ultrasonography in patients with ‘idiopathic’ acute pancreatitis

    American Journal of Medicine

    (2000)
  • M.J. Levy et al.

    Idiopathic acute recurrent pancreatitis

    American Journal of Gastroenterology

    (2001)
  • P. Tarnasky et al.

    Pancreatic stenting prevents pancreatitis after biliary sphincterotomy in patients with sphincter of Oddi dysfunction

    Gastroenterology

    (1998)
  • T.H. Baron et al.

    Endoscopic therapy for organized pancreatic necrosis

    Gastroenterology

    (1996)
  • T.H. Baron et al.

    Outcome differences after endoscopic drainage of pancreatic necrosis, acute pancreatic pseudocysts, and chronic pancreatic pseudocyst

    Gastrointestinal Endoscopy

    (2002)
  • J.J. Telford et al.

    Pancreatic stent placement for duct disruption

    Gastrointestinal Endoscopy

    (2002)
  • G. Uomo et al.

    The incidence of main pancreatic duct disruption in severe biliary pancreatitis

    American Journal of Surgery

    (1998)
  • S.T. Lau et al.

    A pancreatic ductal leak should be sought to direct treatment in patients with acute pancreatitis

    American Journal of Surgery

    (2001)
  • J. Devière et al.

    Complete disruption of the main pancreatic duct: endoscopic management

    Gastrointestinal Endoscopy

    (1995)
  • J.J. Park et al.

    Definitive treatment of pancreatic abscess by endoscopic transmural drainage

    Gastrointestinal Endoscopy

    (2002)
  • E.L. Bradley

    Long-term results of pancreaticojejunostomy in patients with chronic pancreatitis

    American Journal of Surgery

    (1987)
  • M.J. Farnbacher et al.

    Pancreatic duct stones in chronic pancreatitis: criteria for treatment intensity and success

    Gastrointestinal Endoscopy

    (2002)
  • J.-M. Dumonceau et al.

    Endoscopic pancreatic drainage in chronic pancreatitis associated with ductal stones: long-term results

    Gastrointestinal Endoscopy

    (1996)
  • S. Sherman et al.

    Pancreatic ductal stones: frequency of successful endoscopic removal and improvement in symptoms

    Gastrointestinal Endoscopy

    (1991)
  • M. Delhaye et al.

    Extracorporeal shock wave lithotripsy of pancreatic calculi

    Gastroenterology

    (1992)
  • G. Costamagna et al.

    Extracorporeal shock wave lithotripsy of pancreatic stones in chronic pancreatitis: immediate and medium-term results

    Gastrointestinal Endoscopy

    (1997)
  • R.A. Kozarek et al.

    Clinical outcomes in patients who undergo extracorporeal shockwave lithotripsy for chronic pancreatitis

    Gastrointestinal Endoscopy

    (2002)
  • B. Brand et al.

    Prospective evaluation of morphology, function, and quality of life after extracorporeal shockwave lithotripsy and endoscopic treatment of chronic calcific pancreatitis

    American Journal of Gastroenterology

    (2000)
  • R.A. Kozarek et al.

    Endoscopic pancreatic duct sphincterotomy: indications, technique, and analysis of results

    Gastrointestinal Endoscopy

    (1994)
  • S.O. Ikenberry et al.

    The occlusion rate of pancreatic stents

    Gastrointestinal Endoscopy

    (1994)
  • T. Ponchon et al.

    Endoscopic stenting for pain relief in chronic pancreatitis: results of a standardized protocol

    Gastrointestinal Endoscoy

    (1995)
  • M.E. Smits et al.

    Long-term results of pancreatic stents in chronic pancreatitis

    Gastrointestinal Endoscopy

    (1995)
  • S. Lahoti et al.

    Endoscopic retrieval of proximally migrated biliary and pancreatic stents: experience of a large referral center

    Gastrointestinal Endoscopy

    (1998)
  • R.A. Kozarek

    Pancreatic stents can induce ductal changes consistent with chronic pancreatitis

    Gastrointestinal Endoscopy

    (1990)
  • C.S. Pitchumoni et al.

    Pancreatic pseudocysts. When and how should drainage be performed?

    Gastroenterology Clinics of North America

    (1999)
  • E. Bradley

    A clinically based classification system for acute pancreatitis

    Archives of Surgery

    (1993)
  • P.B. Cotton et al.

    International workshop on pancreatitis, cambridge, March 1993

  • United Kingdom guidelines for the management of acute pancreatitis

    Gut

    (1998)
  • S. Bank et al.

    Evaluation of factors that have reduced mortality from acute pancreatitis over the past 20 years

    Journal of Clinical Gastroenterology

    (2002)
  • Cited by (53)

    • Gallstone Pancreatitis. A Review

      2014, Surgical Clinics of North America
      Citation Excerpt :

      The goal of cholecystectomy is to prevent recurrence of GSP by removing the source of secondary gallstones. Although 1% to 2% of patients may recur even after cholecystectomy, the rate of recurrence in untreated patients with GSP is up to two-thirds of patients within 3 months of index presentation.72–75 Recurrent GSP may be graver than the initial presentation, as between 4% and 50% of cases are reported as severe, and mortality and morbidity is reported in up to 10% and 40%, respectively.13,76,77

    • Key Points

      2013, ERCP: Second Edition
    • Endoscopic biliopancreatic investigations and therapy

      2008, Best Practice and Research: Clinical Gastroenterology
      Citation Excerpt :

      In cases of mild ABP, the indications for ERCP with sphincterotomy are basically the following: presence of gallstones plus high operative risk, absence of gallstones or prior cholecystectomy, and pregnancy. ERCP is indicated for the evaluation and treatment of benign biliary strictures, especially postoperative biliary strictures,26,27 main duct strictures in primary sclerosing cholangitis,27,28 and – in selected cases – CBD strictures due to chronic pancreatitis.27,29–31 The endoscopic treatment of benign strictures includes mechanical or pneumatic dilations and the placement of plastic stents.

    View all citing articles on Scopus
    View full text