Pancreatic endoscopic retrograde cholangiopancreatography (ERCP)

We review developments in five areas of therapeutic endoscopic retrograde cholangiopancreatography (ERCP) and management of pancreatic tumors during the period September 2005-August 2006. First, in the management of painful chronic pancreatitis, the use of multiple plastic stents for aggressive dilation of strictures located in the head of the pancreas has been put forward to resolve two significant issues associated with current techniques, i. e., the requirement for numerous ERCPs for stent exchange and the high relapse rate after stent removal. We then discuss the identification of protective factors against post-ERCP pancreatitis following pancreatic sphincterotomy. Next, bearing in mind the prospect of increasing use of neoadjuvant chemotherapy for resectable pancreatic ductal adenocarcinoma, new evidence supporting the systematic use of self-expandable metal biliary stents before cancer staging is presented and critically considered. A French study on the natural history of intraductal papillary mucinous neoplasms, which reinforces the current recommendation not to operate on all of these patients, is also discussed. Finally two centers with a high volume of cases have reported their experience with the drainage of pancreatic fluid collections with or without endosonography (EUS) guidance. It appears that EUS has extended the applicability of endoscopic drainage but, for collections amenable to conventional endoscopic techniques, it remains uncertain whether safety and effectiveness are improved when EUS guidance is used. Technical requisites for long-term success of drainage have been confirmed: multiple, double-pigtail stents should be inserted for a minimum of 6 weeks. It has also become evident that training in this technique is insufficient at many centers.