Endoscopic Management of Paraduodenal Pancreatitis

Abstract

Background and Aims: Cystic dystrophy of the heterotopic pancreas and Groove pancreatitis are now described as paraduodenal pancreatitis (PP). It was recently suggested that most patients could be managed without surgery. The aim of this study was to review our experience in the endoscopic management of PP. Methods: Medical records of all patients with PP diagnosed by magnetic resonance (MRCP) or endoscopic ultrasonography (EUS) between 1995-2008 were retrospectively reviewed. Clinical features were recorded, as well as imaging procedures and findings. Treatment applied was noted, with emphasis on the endoscopic therapy. Response to the treatment and complications were evaluated, as well as success and survival rates. Results: Forty-three patients (95% men, 65% chronic alcoholic) were included. The median age at the onset of symptoms was 44 yr. Most frequent presenting symptom was abdominal pain (97%). MRCP was performed in 39 patients and EUS in 10 patients. Chronic pancreatitis was present in 74% of the cases. Cysts were demonstrated in 88% of the patients. Other findings included main pancreatic duct stenosis (72%), common bile duct stenosis (55%), and duodenal stenosis (51%). Thirty-nine patients underwent endoscopic treatment; cystenterostomy in 22 patients, pancreatic and/or biliary duct drainage (sphincterotomy and/or stenting) in 18 patients, and duodenal dilation in 4 patients. For the patients with available follow-up (n=34), the technical success was assessed by a decrease in the main pancreatic duct diameter, a decrease in the common bile duct diameter, and a reduction of the duodenal stenosis in 54%, 45%, and 63% of the cases respectively. Cyst size reduction was observed in 63% of the patients. Nineteen patients required repeated endoscopy and ten patients required surgery after the initial endoscopic management, mostly for suspected carcinoma. Histology, available in 22 patients, showed no malignancy. Complications occurred in 2 cases after endoscopic treatment, with no mortality. One patient died post-operatively, from sepsis. After a mean follow-up of 23 months, clinical success (complete or temporary disappearance of the symptoms) was achieved in 67% of the cases and overall survival rate was 90%. Conclusions: This is the largest series related to the endoscopic management of PP. MRCP was the pre-therapeutic imaging procedure of choice. Repeated endoscopic procedures were required in nearly half of the patients. However, no severe complication was observed and surgical treatment was restricted to 25% of the patients. Further evaluation is needed to evaluate the potential place of endoscopy as a first-line treatment strategy in PP.