Endoscopic therapy of chronic pancreatitis

Abstract

Chronic pancreatitis is an inflammatory process characterized by destruction of pancreatic parenchyma and ductal structures with formation of fibrosis. Pain is the predominant symptom of chronic pancreatitis and its origin appears to be multifactorial. 1 Steer ML Waxman I Freedman S. Chronic pancreatitis. N Engl J Med. 1995; 332: 1482-1490 Crossref PubMed Scopus (585) Google Scholar , 2 Widdison AL Alvarez C Karanjia ND Reber HA. Experimental evidence of beneficial effects of ductal decompression in chronic pancreatitis. Endoscopy. 1991; 23: 151-154 Crossref PubMed Scopus (51) Google Scholar , 3 Karanjia ND Reber HA. The cause and management of the pain of chronic pancreatitis. Gastrointest Clin N Amer. 1990; 19: 895-904 PubMed Google Scholar , 4 Lo SK Lewis MPN Reber PU Patel A Sherman S Ashley SW Reber HA. In-vivo endoscopic trans-sphincteric measurement of pancreatic blood flow (PBF) in humans. Gastrointest Endosc. 1996; 43: 409A Abstract Full Text PDF Scopus (3) Google Scholar The multiplicity of causes of pain helps explain the mixed results achieved by current methods of therapy. Most therapeutic efforts in the treatment of chronic pancreatitis are directed toward control of symptoms. Medical therapies (dietary alterations, analgesics, nerve blocks, oral enzyme supplements, octreotide) are variably effective in relieving pain, 1 Steer ML Waxman I Freedman S. Chronic pancreatitis. N Engl J Med. 1995; 332: 1482-1490 Crossref PubMed Scopus (585) Google Scholar leaving surgical therapy as the main therapeutic option for patients who fail to improve with medical management. Early postoperative pain relief is seen in 80-90% of patients; however, pain recurs in 20-50% during long-term follow-up. 5 Bradley EL. Long-term results of pancreatojejunostomy in patients with chronic pancreatitis. Am J Surg. 1987; 153: 207-213 Abstract Full Text PDF PubMed Scopus (197) Google Scholar , 6 Malfertheiner P Buchler M. Indications for endoscopic or surgical therapy in chronic pancreatitis. Endoscopy. 1991; 23: 185-190 Crossref PubMed Scopus (26) Google Scholar Surgical drainage procedures are associated with a morbidity rate of 20-40% and an average mortality rate of 4%. 3 Karanjia ND Reber HA. The cause and management of the pain of chronic pancreatitis. Gastrointest Clin N Amer. 1990; 19: 895-904 PubMed Google Scholar While endoscopic therapy has revolutionized the approach to a variety of biliary tract disorders, it is only recently that the indications for therapeutic endoscopy have been expanded to include disorders of the pancreas. 7 Bedford RA Howerton DH Geenen JE. The current role of ERCP in the treatment of benign pancreatic disease. Endoscopy. 1994; 26: 113-119 Crossref PubMed Scopus (20) Google Scholar , 8 Kozarek RA Traverso LW. Endotherapy of chronic pancreatitis. Int J Pancreatol. 1996; 19: 93-102 PubMed Google Scholar , 9 Kaikaus RM Geenen JE. Current role of ERCP in the management of benign pancreatic disease. Endoscopy. 1996; 28: 131-137 Crossref Scopus (9) Google Scholar , 10 Sherman S Lehman GA. Endoscopic therapy of pancreatic disease. The Gastroenterologist. 1997; 5: 262-277 PubMed Google Scholar , 11 Kozarek RA Chronic pancreatitis in 1994: Is there a role for endoscopic treatment?. Endoscopy. 1994; 26: 625-628 Crossref PubMed Scopus (18) Google Scholar Although the endoscopic approach has not been compared directly to surgery, endoscopic drainage is appealing in that it may offer an alternative to surgical drainage procedures with generally less morbidity and mortality. Furthermore, endoscopic procedures do not preclude subsequent surgery, if necessary. Moreover, the outcome from reducing the intraductal pressure by endoscopic methods may be a predictor for the success of surgical drainage. 12 Huibregtse K Smits ME. Endoscopic management of diseases of the pancreas. Am J Gastroenterol. 1994; 89: S66-S77 PubMed Google Scholar