Stenting in severe chronic pancreatitis: results of medium-term follow-up in seventy-six patients

Between January 1985 and September 1989, 75 patients presenting with severe chronic pancreatitis with distal stricture and upstream dilatation underwent stenting of the main pancreatic duct (MPD) through the major papilla (n = 54) or minor papilla (n = 21) in order to drain the predominant duct through a 10 F plastic prosthesis. All patients had undergone biliary and pancreatic sphincterotomy with a few cases of complications, and the majority (84%) also ESWL in the period from October 1987 onwards without complications. Relief of pain (94%) occurred parallel to a decrease in the MPD diameter. In a mean follow-up period of 37 months improvement of the nutrition status and relief of pain was seen. Clogging of these large plastic stents was treated by replacement or by another endoscopic or surgical procedure. Complications were treated endoscopically. Further measures necessary due to failure of stenting consisted of laterolateral pancreatico-jejunostomy in 15% of patients and placement of self-expanding 18 F metal mesh stents in 29%. There was no mortality due to surgery. It is concluded that stenting of distal strictures in the MPD can lead to rapid resolution of pancreatic pain due to ductal hypertension and is the best means for determining the cause of pain, providing an alternative to surgery. Significant improvement of a stricture by prolonged stenting is however unusual, and such patients treated endoscopically require close follow-up with stent replacement approximately once a year.     

Multiple stenting of refractory pancreatic duct strictures in severe chronic pancreatitis: long-term results

BACKGROUND AND STUDY AIMS: Dominant pancreatic duct strictures located in the head of the pancreas in patients with severe chronic pancreatitis are often managed by endoscopic placement of a single plastic stent. Patients with refractory strictures after prolonged stenting require repeated stent replacement or surgical pancreaticojejunostomy. Placement of multiple plastic stents has proved effective in managing postoperative biliary strictures. The aim of this study was to investigate the feasibility, efficacy, and long-term results of multiple stenting of refractory pancreatic strictures in severe chronic pancreatitis. PATIENTS AND METHODS: 19 patients with severe chronic pancreatitis (16 men, three women; mean age 45 years) and with a single pancreatic stent through a refractory dominant stricture in the pancreatic head underwent the following protocol: (i) removal of the single pancreatic stent; (ii) balloon dilation of the stricture; (iii) insertion of the maximum number of stents allowed by the stricture tightness and the pancreatic duct diameter; and (iv) removal of stents after 6 to 12 months. RESULTS: The median number of stents placed through the major or minor papilla was 3, with diameters ranging from 8.5 to 11.5 Fr and length from 4 to 7 cm. Only one patient (5.5 %) had persistent stricture after multiple stenting. During a mean follow-up of 38 months after removal, 84 % of patients were asymptomatic, and 10.5 % had symptomatic stricture recurrence. No major complications were recorded. CONCLUSION: Endoscopic multiple stenting of dominant pancreatic duct strictures in chronic pancreatitis is a feasible and safe technique. Multiple pancreatic stenting is promising in obtaining persistent stricture dilation on long-term follow-up in the setting of severe chronic pancreatitis.     

Covered self-expanding metal stent use in the pancreatic duct: a case series

Plastic stents have been used in the pancreatic duct for a variety of indications. However, unlike in the bile duct, the use of covered self-expanding metal stents (CSEMSs) has been discouraged because multiple side branches drain into main pancreatic duct (MPD) and the ductal diameter is relatively small. This report aims to describe our experience using CSEMSs in the pancreatic duct in a series of nine patients, with special focus on adverse events. Indications were strictures (n = 5), intraductal mucinous neoplasm (IMPN; n = 1), pancreatic duct leak (n = 1), disconnected duct syndrome (n = 1), and severe acute pancreatitis/necrosis with disrupted duct (n = 1). Eight patients had symptomatic improvement, or radiological resolution of or improvement in their strictures, leaks, perforation, and necrosis. Two of these have indwelling CSEMSs for ongoing treatment. One patient (disconnected duct syndrome) was considered a treatment failure as the stent migrated and the patient underwent distal pancreatectomy for refractory pain. Two patients underwent pancreaticoduodenectomy for their malignancies after their CSEMSs had been in place for 43 and 49 days, respectively. Importantly no patients, including those with indwelling CSEMSs, developed stent-related acute pancreatitis with a median follow-up of 4 months. One patient developed post-procedure pain requiring hospitalization for 1 day. Median stent duration was 77 days. These observations suggest there is a potential role for the use of CSEMSs in the MPD in selected patients with pancreatic pathology.     

Long-term outcome after pancreatic stenting in severe chronic pancreatitis

BACKGROUND AND STUDY AIMS: Although it has been proved that pancreatic stenting is effective in the symptomatic management of severe chronic pancreatitis, long-term outcomes after stent removal have not been fully evaluated. PATIENTS AND METHODS: A total of 100 patients (75 men, 25 women; median age 49) with severe chronic pancreatitis and pancreatic duct strictures were successfully treated for pancreatic pain using polyethylene pancreatic stents and were followed up for at least 1 year after stent removal. The stents were exchanged "on demand" (in cases of recurrence of pain) and a definitive stent removal was attempted on the basis of clinical and endoscopic findings. Clinical variables were retrospectively assessed as potential predictors of re-stenting. RESULTS: The etiology of the chronic pancreatitis was alcoholic (77 %), idiopathic (18 %), or hereditary (5 %). Patients were followed up for a median period of 69 months (range 14 - 163 months) after study entry, including a median period of 27 months (range 12 - 126 months) after stent removal. The median duration of pancreatic stenting before stent removal was 23 months (range 2 - 134 months). After attempted definitive stent removal, 30 patients (30 %) required re-stenting within the first year of follow-up, at a median time of 5.5 months after stent removal (range 1 - 12 months), while in 70 patients (70 %) pain control remained adequate during that period. By the end of the follow-up period a total of 38 patients had required re-stenting and four ultimately underwent pancreaticojejunostomy. Pancreas divisum was the only factor significantly associated with a higher risk of re-stenting (P = 0.002). CONCLUSIONS: The majority (70 %) of patients with severe chronic pancreatitis who respond to pancreatic stenting maintain this response after definitive stent removal. However, a significantly higher re-stenting rate was observed in patients with chronic pancreatitis and pancreas divisum.     

Endoscopic treatment of chronic pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline

BACKGROUND AND AIMS: Clarification of the position of the European Society of Gastrointestinal Endoscopy (ESGE) regarding the interventional options available for treating patients with chronic pancreatitis. METHODS: Systematic literature search to answer explicit key questions with levels of evidence serving to determine recommendation grades. The ESGE funded development of the Guideline. SUMMARY OF SELECTED RECOMMENDATIONS: For treating painful uncomplicated chronic pancreatitis, the ESGE recommends extracorporeal shockwave lithotripsy/endoscopic retrograde cholangiopancreatography as the first-line interventional option. The clinical response should be evaluated at 6 - 8 weeks; if it appears unsatisfactory, the patient's case should be discussed again in a multidisciplinary team. Surgical options should be considered, in particular in patients with a predicted poor outcome following endoscopic therapy (Recommendation grade B). For treating chronic pancreatitis associated with radiopaque stones ≥ 5 mm that obstruct the main pancreatic duct, the ESGE recommends extracorporeal shockwave lithotripsy as a first step, combined or not with endoscopic extraction of stone fragments depending on the expertise of the center (Recommendation grade B). For treating chronic pancreatitis associated with a dominant stricture of the main pancreatic duct, the ESGE recommends inserting a single 10-Fr plastic stent, with stent exchange planned within 1 year (Recommendation grade C). In patients with ductal strictures persisting after 12 months of single plastic stenting, the ESGE recommends that available options (e. g., endoscopic placement of multiple pancreatic stents, surgery) be discussed in a multidisciplinary team (Recommendation grade D).For treating uncomplicated chronic pancreatic pseudocysts that are within endoscopic reach, the ESGE recommends endoscopic drainage as a first-line therapy (Recommendation grade A).For treating chronic pancreatitis-related biliary strictures, the choice between endoscopic and surgical therapy should rely on local expertise, patient co-morbidities and expected patient compliance with repeat endoscopic procedures (Recommendation grade D). If endoscopy is elected, the ESGE recommends temporary placement of multiple, side-by-side, plastic biliary stents (Recommendation grade A).     

胰管支架安置在胰管狭窄中的治疗作用

目的 采用胰管支架安置治疗胰管狭窄病例,以缓解胰管梗阻症状,同时对胰管支架的适应证及操作技术进行探讨.方法 对诊断明确的胰腺癌及慢性胰腺炎伴胰管狭窄的病例,先行内镜下逆行胰胆管造影及胰管腔内超声检查,确定狭窄长度及距乳头的距离,选择合适的胰管支架,在导丝的引导下,用推送器将支架送到目的部位,然后摄片定位.结果 该组18例安置顺利,支架都超过狭窄的远端,吸引后胰液外流,患者症状很快缓解.结论 胰管支架是治疗各种原因引起的胰管狭窄的有效的姑息治疗措施,对于胰管阻塞的病例能起到缓解症状、提高生活质量的目的,尤其是塑料胰管支架安置及取出较方便,并发症少.     

Endoscopic stenting and sphincterotomy of the minor papilla in symptomatic pancreas divisum: results and complications

Pancreas divisum has been postulated as a cause of acute pancreatitis and a chronic pain syndrome in a small subgroup of patients and can be treated with endoscopic dorsal pancreatic duct stent placement and minor papilla sphincterotomy. Twenty patients (9 with at least one attack of idiopathic pancreatitis, and 11 with severe pancreatic-type pain) were treated endoscopically. Dorsal duct stents were placed in 19 patients with subsequent needle knife sphincterotomy of the minor papilla over the stent. Clinical response was judged by comparison of symptoms (using a 0-to-l0 scale and the patient's overall assessment). The symptom score improved from 9.3 to 5.1 in the pancreatitis group and from 9.3 to 5.7 in the pain group. A good clinical response was observed in 3 of 7 patients in the pancreatitis group and in 6 of 11 in the pain group at a mean follow-up of 22 months. Complications of sphincterotomy were limited to pancreatitis in 6 patients (29%), 5 mild and 1 moderate according to published criteria. No patient required more than 4 days hospitalization. Two of 39 stents migrated into the pancreas, and another stent fractured and remained lodged in the pancreas. Eight of 9 patients evaluated demonstrated new morphologic duct changes on follow-up pancreatograms. Endoscopic stenting and sphincterotomy of the minor papilla are feasible and may be effective in some patients with pancreas divisum but carries a significant complication rate. The subjective improvement in patients with chronic pain warrants further controlled study.     

Prevention of pancreatitis in patients with idiopathic recurrent pancreatitis: a prospective nonblinded randomized study using endoscopic stents

BACKGROUND AND STUDY AIMS: Currently there is no available therapy to prevent attacks of acute pancreatitis in patients with idiopathic recurrent pancreatitis (IRP). This randomized, nonblinded prospective, controlled trial was undertaken to evaluate the effectiveness of pancreatic duct stents in preventing attacks of pancreatitis in IRP. PATIENTS AND METHODS: During a 5-year period 34 patients met the diagnostic criteria for IRP. Patients were randomly assigned to one of two groups; 19 patients (14 women, 5 men, mean age 44) to the pancreatic stent group; and 15 patients (10 women, five men, mean age 47) to the control group. The stent group received three stents over a period of 1 year and the control group had selective pancreatograms but no stent. Mean follow-up was 33 months (range 13-77) and 35 months (range 10-78) in the stent and control groups, respectively. Episodes of pancreatitis, frequency and intensity of pain requiring emergency room visits, and hospitalizations were recorded. RESULTS: Recurrence of pancreatitis occurred in eight out of 15 patients (53%) in the control group, but in only two our of 19 patients (11%) in the stent group (P<0.02). Two patients in the control group who had recurrences of pancreatitis crossed over to stent therapy and had no further pancreatitis thereafter. Six patients each, 32% and 40% in the stent and control groups respectively, continued to have pancreatic type pain. In the study period 17 stents were occluded and 14 migrated out. CONCLUSION: The results of this study suggest that pancreatic duct stenting may prevent recurrent attacks of pancreatitis in IRP patients. Intermittent pancreatic duct sphincter dysfunction or relative outlet obstruction may be the underlying cause for the recurrent attacks of pancreatitis.     

Chronic pancreatic pain successfully treated by endoscopic ultrasound-guided pancreaticogastrostomy using fully covered self-expandable metallic stent

One of the most common symptoms presenting in patients with chronic pancreatitis is pancreatic-type pain. Obstruction of the main pancreatic duct in chronic pancreatitis can be treated by a multitude of therapeutic approaches, ranging from pharmacologic, endoscopic and radiologic treatments to surgical interventions. When the conservative treatment approaches fail to resolve symptomatic cases, however, endoscopic retrograde pancreatography with pancreatic duct drainage is the preferred second approach, despite its well-recognized drawbacks. When the conventional transpapillary approach fails to achieve the necessary drainage, the patients may benefit from application of the less invasive endoscopic ultrasound (EUS)-guided pancreatic duct interventions. Here, we describe the case of a 42-year-old man who presented with severe abdominal pain that had lasted for 3 mo. Computed tomography scanning showed evidence of chronic obstructive pancreatitis with pancreatic duct stricture at genu. After conventional endoscopic retrograde pancreaticography failed to eliminate the symptoms, EUS-guided pancreaticogastrostomy (PGS) was applied using a fully covered, self-expandable, 10-mm diameter metallic stent. The treatment resolved the case and the patient experienced no adverse events. EUS-guided PGS with a regular biliary fully covered, self-expandable metallic stent effectively and safely treated pancreatic-type pain in chronic pancreatitis.     

内镜下诊断与治疗慢性胰腺炎17例

目的 探讨内镜下诊断和治疗慢性胰腺炎的价值。方法 对17例慢性胰腺炎均行内镜下逆行胰胆管造影术(ERCP)，并对部分胰管狭窄患者施行塑料支架放置引流术(ERPD)或鼻胰管引流术(ENPD)，对部分胰管内结石行内镜下胰管括约肌切开术(EPS)并行网篮取石。结果 有8例胰管狭窄者放置塑料支架，平均引流时间为276d。5例胰管结石中2例行EPS后网篮取出结石，3例行鼻胰管引流术后手术取出。结论 ERCP可作为有条件医院检查慢性胰腺炎的常规手段，是治疗部分慢性胰腺炎安全有效的方法。     

Removable fully covered self-expandable metal stents in the treatment of common bile duct strictures due to chronic pancreatitis: a case series

The aim of this study was to test the removability of fully covered self-expandable metal stents (FCSEMS) in patients with a benign common bile duct (CBD) stricture. A FCSEMS was inserted in six patients with a CBD stricture due to chronic pancreatitis who were considered to be unfit for surgery, and stent removal was attempted after predefined intervals of 4 and 6 months. FCSEMS were successfully placed in all patients (100 % placement success) and stent extraction was accomplished in four patients (66 % removal rate), all of whom achieved stricture resolution (66 % resolution rate). In one patient a recurrent stenosis developed after 6 months (recurrence rate 25 %). Proximal stent migration occurred in two patients. In conclusion, FCSEMS removal was possible in the majority of patients and results regarding stricture dilation were promising. Nevertheless, before FCSEMS can become an acceptable treatment option for benign CBD strictures, innovative stent design modifications are necessary and removability must be ascertained.     

全覆膜金属可回收支架在治疗食管顽固性良性狭窄中的应用价值

目的探讨全覆膜金属可回收支架治疗食管顽固性良性狭窄的安全性及疗效。方法回顾性分析行全覆膜金属可回收支架治疗的33例食管顽固性良性狭窄患者的临床资料,评价治疗的可行性、安全性及疗效。结果 33例患者共计放置可回收支架41支,其中8例患者行二次可回收支架置入,术后均有不同程度胸痛及异物感;术后并发支架移位11例(共计14支),移位发生率34.1%(14/41);其余22例患者(共计27支支架)均于术后4~8周顺利回收。术中及术后无明显出血、穿孔等并发症发生,无支架相关死亡病例。所有患者定期参加随访(12个月),其中12例成功解除梗阻,临床缓解率为36.4%(12/33)。结论全覆膜金属可回收支架用于治疗食管顽固性良性狭窄是安全可靠的,可使部分患者成功解除梗阻,但支架移位发生率高,有待于临床进一步研究解决。     

国产自膨式镍钛记忆合金食管支架的临床应用及疗效观察

目的：探讨国产自膨式镍钛记忆合金食管支架在食管、贲门良恶性狭窄及食管瘘中的临床应用并观察疗效。方法：收集我院2005年11月～2008年8月采用胃镜辅助置人镍钛记忆合金食管支架的患者108例,其中男90例,女18例,年龄37-88岁;包括食管癌性狭窄41例,贲门癌性狭窄5例,放疗后狭窄1例,肺癌压迫致食管狭窄1例,食管、贲门癌术后吻合口顽固性狭窄21例,食管癌术后复发致狭窄6例,食管瘘33例。结果：108例患者共置人食管支架116枚,一次性置人成功率100％,置入后患者吞咽梗阻的症状有不同程度的改善,呛咳的症状基本消失。结论：食管支架置人操作简单、安全,成功率高,是治疗食管良恶性狭窄及封堵瘘口的有效方法。     

Ultrasonography-guided endoscopic stent placement for malignant biliary obstruction: a preliminary report of four cases

We present a new combination of transabdominal ultrasound (US) and biliary endoscopy, with endoscopic stent placement carried out under US guidance. Four patients (two men, two women; average age 66.2 years) underwent US-guided stent placement for palliation of ampullary carcinoma (n = 3) or pancreatic cancer (n = 1). A guide wire and a guiding catheter were endoscopically introduced and identified, by US in the common bile duct across the stricture. Hydromer-coated polyurethane angled stents (10 Fr) were finally inserted over the guide wire/guiding catheter by a pusher tube system. Successful drainage, with substantial reduction in bilirubin level, was achieved in all patients (14.2 +/- 9.5 vs. 4.2 +/- 2.9 mg/dl at 1 week). The present case series shows that endoscopic stent placement performed under US guidance is safe and effective. Further studies of larger series, including more proximal strictures, are warranted.     

Prothèses biliaires et pancréatiques : indications,résultats et techniques

Biliary and pancreatic stents are used in several indications. Among them, the most frequent are benign and malignant biliary strictures andWirsung stenosis, most often in patients with chronic pancreatitis. Biliary fistula and big stones are other possible indications. Self-expandable metal stents are indicated in pancreatic cancers and common bile duct cancers, without restrictions in palliative situations and under certain conditions in pre-operative situation. Benign biliary strictures are currently treated by multiple plastic stents. Recent studies however suggest that self-expandable metal stents could be suitable in these cases, with same results as plastic stents. Wirsung strictures in patients with chronic pancreatitis can be treated by one or several plastic stents. A few studies suggest an equivalent efficiency of full-covered self-expandable metal stents. When retrograde endoscopic approach is not possible, the option of an endoscopic ultrasonography guided drainage could be considered.     

Abdominal actinomycosis: complication of endoscopic stenting in chronic pancreatitis?

Pancreatic endotherapy is frequently performed in patients with chronic pancreatitis and stenoses of the main pancreatic duct. In a patient with long-standing chronic pancreatitis and treatment with pancreatic stents, metastatic pancreatic head carcinoma was suspected because of infiltration of the neighboring organs and hepatic lesions. Ultrasound-guided aspiration of one liver lesion revealed grains typical for actinomycosis. In the light of this case, an extracted pancreatic stent was microbiologically investigated for actinomycetes in another patient who had a suspicious lesion of the pancreatic head. Microbiological examination of the extracted pancreatic stent revealed colonization by Actinomyces meyeri, Klebsiella oxytoca, and mixed cultures of anaerobic and saprophytic Gram-positive bacteria. In the following weeks, she developed a septic clinical picture with multiple abscesses of the liver. Actinomyces meyeri, Corynebacterium species, Candida and Enterococcae were cultivated in the aspirates. It seems possible, that treatment with pancreatic stents could have caused invasion of actinomycetes into the parenchyma of the pancreas, which was already harmed by the chronic inflammation, followed by the typical infiltrative growth and hematologic or biliary seeding into the liver.     

Floating pancreatic duct concrements in chronic pancreatitis. Pain relief by endoscopic removal

This report describes 3 patients with chronic relapsing pancreatitis, floating pancreatic duct concrements between 4 and 6 mm in diameter, moderate to advanced ductal changes, and repeated severe attacks of pain during acute relapses over a period of several months. Immediate relief of pain was achieved in all 3 patients by endoscopic papillotomy aimed at widening the main pancreatic duct and subsequent extraction or spontaneous passage of pancreatic duct concrements. On the basis of our experience with the patients presented here, endoscopic papillotomy widening the main pancreatic duct may be useful in some patients with chronic pancreatitis and floating pancreatic duct concrements.     

胰管结石19例的外科治疗

【目的】探讨胰管结石外科治疗方法。【方法】回顾性分析本院1984-2006年收治的19例胰管结石患者的临床资料。根据其病因和合并症的情况、胰管结石的分布以及胰管狭窄部位和程度采取不同的手术方式。【结果】19例中胰腺癌者8例,慢性胰腺炎者8例,不明原因者3例。临床表现为腹痛或上腹不适者15例,糖尿病者15例,消瘦者10例,脂肪泻者8例。全组患者胰管结石均经手术治愈。术后无残余结石,15例腹痛或腹部不适者均获不同程度的缓解,10消瘦者体重有所增加;4／15例糖尿病及5／8脂肪泻有所缓解。术后4例患者出现胰漏。并发胰腺癌者术后存活时间6～22个月。【结论】胰管结石一经确诊后应争取早日手术治疗,根据合并疾病的不同、胰管结石分布以及胰管狭窄情况具体选择。原则上应解除胰管狭窄,取尽胰管结石,建立通畅引流。     

短5Fr胰管支架在经内镜逆行胰胆管造影术困难胆管插管中的应用

目的探讨经内镜逆行胰胆管造影术(ERCP)在困难胆管插管病例中置入3 cm长5Fr胰管支架的临床应用价值。方法回顾性分析2012年1月-2015年10月在该科住院需行ERCP治疗的困难胆管插管131例患者的临床资料,根据术中是否预防性放置短5Fr胰管支架,将其随机分为胰管支架组66例和对照组65例。比较两组术后首次ERCP胆管插管成功率、术后腹痛情况、高淀粉酶血症、ERCP术后胰腺炎(PEP)及重症胰腺炎发生率。结果在胰管支架组中首次ERCP胆管插管成功率明显高于对照组;术后腹痛评分较对照组低;术后3 h和术后24 h血淀粉酶值均低于对照组;术后高淀粉酶血症、急性胰腺炎和重症胰腺炎发生率均低于对照组,差异均有统计学意义。采用3 cm长5Fr胰管支架置管成功率高,自发脱落率很高、并发症少,减少再次行内镜取出支架的概率。结论短5Fr胰管支架留置在内镜困难胆管插管中的运用是安全、有效的,既能提高胆管插管成功率、减轻患者术后腹痛程度,又能有效地降低PEP的发生率和严重程度。     

Treatment of pancreatic pseudocysts, pancreatic necrosis, and pancreatic duct leaks

Pancreatic pseudocysts arise as a complication of acute and chronic pancreatitis or pancreatic trauma (including postsurgical). Pancreatic necrosis occurs following severe pancreatitis and may evolve into an entity termed organized pancreatic necrosis that is endoscopically treatable. Pancreatic duct leaks are frequently seen in relation to pseudocysts and necrosis. Alternatively, pancreatic duct leaks may present with pleural effusions, ascites, or after pancreatic surgery or percutaneous drainage. Endoscopic treatment of pancreatic fluid collections and pancreatic duct leaks can be achieved using transpapillary and/or transmural stent placement.