Endoscopic Therapy Of Chronic Pancreatitis Research Articles

A meta-analysis of the long-term outcomes following surgery or endoscopic therapy for chronic pancreatitis

PurposeRefractory abdominal pain is a cardinal symptom of chronic pancreatitis (CP). Management strategies revolve around pain mitigation and resolution. Emerging evidence from observational studies highlights that surgery may result in superior pain relief when compared to endoscopic therapy; however, its impact on long-term quality of life or functional outcome has yet to be determined.MethodsA search through MEDLINE, PubMed and Web of Science was performed for RCTs that compared endoscopic treatment with surgery for the management of CP. The main outcome measure was the impact on pain control. Secondary outcome measures were the effect on quality of life and the incidence rate of new onset exocrine and endocrine failure. Data was pooled for analysis using either an odds ratio (OR) or mean difference (MD) with a random effects model.ResultsThree RCTs were included with a total of 267 patients. Meta-analysis demonstrated that operative treatment was associated with a significantly higher rate of complete pain control (37%) when compared to endoscopic therapy (17%) [OR (95% confidence interval (CI)) 2.79 (1.53–5.08), p = 0.0008]. No difference was noted in the incidence of new onset endocrine or exocrine failure between treatment strategies.ConclusionSurgical management of CP results in a greater extent of complete pain relief during long-term follow-up. Further research is required to evaluate the impact of the time interval between diagnosis and intervention on exocrine function, combined with the effect of early up-front islet auto-transplantation in order to determine whether long-term endocrine function can be achieved.

2182 Endoscopic Challenges in a Patient With Ansa Pancreatica and Recurrent Pancreatitis

INTRODUCTION: Ansa pancreatica is a rare anatomical variation of the pancreatic duct where there is communication between the ventral pancreatic duct, which forms an ansa loop, and the accessory pancreatic duct. Its prevalence is estimated to be 1% in general population, and its presence can predispose to acute pancreatitis. We present an interesting and rare case of chronic pancreatitis with a pancreatic duct stricture in the setting of ansa pancreatica. CASE DESCRIPTION/METHODS: A 54-year-old female with a heterozygous CFTR mutation and a long-standing history of recurrent acute and now chronic pancreatitis. Two weeks after an episode of acute pancreatitis, a magnetic resonance cholangiopancreatography (MRCP) was performed showing a new stricture in the pancreatic duct near the genu, with pre-stenotic ductal dilation. Two prior endoscopic retrograde cholangiopancreatographies had been performed to attempt pancreatic duct endotherapy, but these were unsuccessful in achieving deep wire cannulation beyond the ansa loop. (image 1A-1B). The pancreatic duct in the genu of the pancreas was noted to have moderate stenosis on MRCP (image 1C). After a discussion with the patient, the decision was made to re-attempt endoscopic therapy. The ventral pancreatic duct was initially cannulated. The 0.025 inch angled guidewire was again unable to navigate the ansa loop and into the distal pancreas. Thereafter, we attempted dorsal pancreatic duct cannulation via the monir papilla. The guidewire was advanced successfully beyond the stricture and into the opacified body and tail (image 1D). The minor papilla and the stricture in the genu were dilated with a 7 Fr catheter dilator. After a minor papillotomy a 7 Fr by 8 cm plastic stent was placed into the dorsal pancreatic duct (image 1E, 2). The stent was removed 6 weeks later, and the duct remained patent. The patient has had no recurrence of acute pancreatitis to date. DISCUSSION: While the prevalence of ansa pancreatica is low, its presence can have great impact on the necessary approach for endoscopic therapy in chronic pancreatitis. In our case, the patient failed several ERCP attempts via ventral duct cannulation, and endoscopic therapy was successful only when cannulation of dorsal pancreatic duct was performed. In conclusion, in patients with chronic pancreatitis, recognition of ansa pancreatica, when present, is important to guide the endoscopic approach to treatment as minor papilla cannulation, a necessary skill for the interventional endoscopist, may be required.

Endoscopic therapy in chronic pancreatitis: current perspectives.

Endoscopic therapy in chronic pancreatitis (CP) aims to provide pain relief and to treat local complications, by using the decompression of the pancreatic duct and the drainage of pseudocysts and biliary strictures, respectively. This is the reason for using it as first-line therapy for painful uncomplicated CP. The clinical response has to be evaluated at 6–8 weeks, when surgery may be chosen. This article reviews the main possibilities of endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) therapies. Endotherapy for pancreatic ductal stones uses ultrasound wave lithotripsy and sometimes additional stone extractions. The treatment of pancreatic duct strictures consists of a single large stenting for 1 year. If the stricture persists, simultaneous multiple stents are applied. In case of unsuccessful ERCP, the EUS-guided drainage of the main pancreatic duct (MPD) or a rendezvous technique can solve the ductal strictures. EUS-guided celiac plexus block has limited efficiency in CP. The drainage of symptomatic or complicated pancreatic pseudocysts can be performed transpapillarily or transgastrically/transduodenally, preferably by EUS guidance. When the biliary stricture is symptomatic or progressive, multiple plastic stents are indicated. In conclusion, as in many fields of symptomatic treatment, endoscopy remains the first choice, either by using ERCP or EUS-guided procedures, after consideration of a multidisciplinary team with endoscopists, surgeons, and radiologists. However, what is crucial is establishing the right timing for surgery.

Su1713 Endoscopic Therapy in Chronic Pancreatitis: What Are the Factors Associated With Successful Response ?

Su1713 Endoscopic Therapy in Chronic Pancreatitis: What Are the Factors Associated With Successful Response ?

Su1435 Long Term Effectiveness After Endoscopic Therapy in Chronic Pancreatitis

The aim of this study was to investigate the frequency and risk factors of postERCP pancreatitis in patients who had undergone prophylactic pancreatic duct stenting. Patients and methods: Between July 2002 and January 2010, ERCPrelated procedures were performed in 9192 cases of pancreatobiliary diseases at seven institutions. From among them, 414 patients (246 men, 168 women; mean age, 68 yr; age range, 22-91 yr) at high risk of post-ERCP pancreatitis who had undergone prophylactic pancreatic duct stenting were included in this study. The stent used in the present study was a 5-Fr stent with a single duodenal pigtail, which is made of soft polyethylene and has no flange (Pit-stent: Cathex, Co., Ltd., Tokyo, Japan). The pancreatic duct stent was placed via the channel of the duodenoscope over a guidewire with the assistance of fluoroscopy at the end of the procedure. The frequency and risk factors of post-ERCP pancreatitis were investigated. Post-ERCP pancreatitis was defined based on the consensus criteria. Results: Therapeutic ERCP was performed in 52% of the patients. Indications for prophylactic pancreatic duct stenting were as follows: difficult cannulation of the bile duct, 192; pancreatic duct cytology/biopsy, 95; precut sphincterotomy, 40; pancreatic sphincterotomy, 29; female, 28; papillectomy, 25; sphincter of Oddi dysfunction, 12; history of pancreatitis, 10. Hyperamylasemia at 18-24 h after ERCP was observed in 64% (267 patients) of the patients. Pancreatitis occurred in 9.9% (41 patients: mild, 37; moderate, 2; severe, 2). Univariate analysis revealed intraductal papillary mucinous neoplasm (IPMN) of the pancreas to be the only significant risk factor for pancreatitis (OR 2.9, 95% CI 1.2, 7.1). Multivariate analysis also showed IPMN to be the only risk factor for pancreatitis (OR 3.1, 95% CI 1.2, 7.8). The mean diameter of the pancreatic head duct in patients with IPMN who developed post-ERCP pancreatitis was significantly smaller than that in those who did not develop pancreatitis (3.0 1 mm vs 4.7 2.6 mm, P 0.0037). Conclusions: Post-ERCP pancreatitis developed in 9.9% of the patients at high risk who had undergone prophylactic pancreatic duct stenting. Since the majority of cases of post-ERCP pancreatitis were mild, pancreatic duct stenting may contribute to lessening the severity of pancreatitis. Our results suggest that IPMN without a dilated pancreatic head duct is a possible risk factor for postERCP pancreatitis after prophylactic pancreatic duct stenting.

Endoscopic Therapy in Chronic Pancreatitis

Chronic pancreatitis (CP) is a debilitating disease that can result in chronic abdominal pain, malnutrition, and other related complications. The main aims of treatment are to control symptoms, prevent disease progression, and correct any complications. A multidisciplinary approach involving medical, endoscopic, and surgical therapy is important. Endoscopic therapy plays a specific role in carefully selected patients as primary interventional therapy when medical measures fail or in patients who are not suitable for surgery. Endoscopic therapy is also used as a bridge to surgery or as a means to assess the potential response to pancreatic surgery. This review addresses the role of endoscopic therapy in relief of obstruction of the pancreatic duct (PD) and bile du ct, closure of PD leaks, and drainage of pseudocysts in CP. The role of endoscopic ultrasound-guided celiac plexus block for pain in chronic pancreatitis is also discussed.

Long Period Endoscopic Therapy for Chronic Pancreatitis Necessitates Higher Medical Expense and Longer Hospital Stays as Compared to Surgery

The aim of this study was to compare the benefits between endoscopic treatment and surgical drainage of the pancreatic duct for patients with chronic pancreatitis. Forty seven patients were classified into endoscopic (n = 30) or surgical (n = 17) treatment groups. Patients receiving endoscopic treatment were further divided into 2 subgroups: short period group, patients who relieved from pancreatic stenting within 1 year, n = 17; long period group, patients who needed pancreatic drainage by serial endoscopic stenting for more than 1 year, n = 13. The medical records for these patients were retrospectively analyzed. The frequency of hospitalization for relapsing pancreatitis after treatment was about one half in the short period endoscopic treatment group compared to the surgery group while the medical expense, hospital stay and frequency of hospitalization were similar between these groups. On the other hand, patients in the long period endoscopic treatment group required longer hospital stays, more frequent hospitalizations and greater medical expense than the surgery group did. Therefore, patients who require endoscopic treatment for more than 1 year showed no benefits points compared to those who underwent.

Endoscopic therapy for chronic pancreatitis.

To summarize recent data on techniques, efficacy and complications of endoscopic management of chronic pancreatitis. Extracorporeal shock wave lithotripsy with or without endoscopic retrograde cholangiopancreatography is the first-line treatment for large painful obstructive pancreatic duct calculi. Use of preextracorporeal shock wave lithotripsy secretin could result in better stone clearance. The first-line treatment for dominant pancreatic duct strictures is placement of a single 10-Fr polyethylene stent with planned exchanges every 3 months until 1 year. Other endoscopic approaches that have shown good efficacy include placement of simultaneous multiple plastic stents and fully covered self-expanding metallic stents. Endoscopic options to treat chronic pancreatitis-associated benign biliary strictures include single and simultaneous multiple plastic stenting and fully covered self-expanding metallic stents. The European Society of Gastrointestinal Endoscopy recommends multiple plastic stenting for such strictures, although fully covered self-expanding metallic stents should be currently used under research settings. Endoscopic ultrasonography-guided cholangiopancreatography and pancreatobiliary drainage is an evolving option for chronic pancreatitis-related ductal obstruction after failed endoscopic retrograde cholangiopancreatography. Recent data have supported the safety and efficacy of endotherapy for chronic pancreatitis in children. Endotherapy is the first line of management in chronic pancreatitis with symptomatic pancreatobiliary ductal obstruction. Further studies are required in certain key areas such as use of fully covered self-expanding metallic stents for pancreatic ductal and biliary strictures and endoscopic ultrasonography-guided pancreatobiliary drainage after failed endoscopic retrograde cholangiopancreatography.

Endoscopic therapy for chronic pancreatitis: Technical success, clinical outcomes, and complications

Chronic pancreatitis (CP) can cause failure of both the exocrine and endocrine portions of the gland. Pain is the most recalcitrant clinical complaint in CP. Generally, conservative measures are first attempted to manage pain. These include cessation of alcohol use and smoking, enzyme replacement therapy, and finally, opioid analgesia. Endoscopy can be employed to treat the pain and complications due to CP. The results of the only two prospective randomized controlled trials suggest that surgery has a more durable effect than endoscopic therapy in controlling pain. Both trials suffer from severe limitations, however, and endoscopy remains the preferred approach for many patients because of its minimally invasive nature. Endoscopic ultrasound celiac plexus block has limited value in helping to control pain. More randomized trials are needed, along with further technologic innovation to improve the current treatment modalities. When considering interventional therapy for a patient with CP, a tailored and multidisciplinary therapeutic approach should be taken.

社会的要因からみた慢性膵炎に対する内視鏡治療の限界

社会的要因からみた慢性膵炎に対する内視鏡治療の限界

Multimodality Treatment of Chronic Pancreatitis: Can We Prevents Hospital Admission?

Background & Aims: Efficacy of endoscopic therapy for chronic pancreatitis (CP) has typically been evaluated by improvement in pain score. Unfortunately accurate evaluation of pain is difficult since most patients are already on pain medication when undergoing endoscopic therapy. Our aim is to determine the efficacy of multimodality treatment of chronic pancreatitis on the rate of hospitalization. Methods: 247 patients (174 male, mean age 51 ± 13 y/o) with CP associated with pain were endoscopically treated between December 2001 and November 2006 and followed prospectively. Therapy offered included ERCP with pancreatic duct stenting (PD stent), extracorporeal shock wave lithotripsy (ESWL), and celiac plexus block (CPB). Long term efficacy of therapy was based on the absence of recurrent admissions for abdominal pain or pancreatitis after therapy, excluding post-procedural admission. Multivariate analysis were effected on the following factors to assess prediction of successful treatment (Age (<55 versus ≥55 y/o), gender, etiology (alcoholic or not), PD stent (yes versus no), ESWL, CPB). Results: Therapy included a mean of 3.6 ± 2.9 ERCPs in 240 (97%) patients with 166 (67%) patients receiving a PD stent, 37 (15%) patients underwent a mean of 1.2 ± 0.7 ESWL (range 1-4) and 42 (17%) patients received a mean of 2.2 ± 2 CPB (range: 1-8). A total of 154 (62%) patients did not require further admission post therapy over a median period of three years (range:1-5). Multivariate logistic regression analysis identified only PD stent as a predictor of long term success (see table). Conclusions: Endoscopic treatment of chronic pancreatitis is efficacious in 62% of patients undergoing multimodality therapy. PD stent placement appears to be a predictor of success in preventing long -term hospitalization post therapy. Tabled 1Predictive factor of successful treatment Factors P value Odds ratio 95% CI Gender 0.970 1.01 0.53-1.93 Age 0.051 1.77 1.00-3.13 Etiology 0.292 0.72 0.38-1.33 PD stent 0.007 0.43 0.24-0.79 ESWL 0.807 0.91 0.44-1.90 CPB 0.293 0.68 0.33-1.40 Open table in a new tab

Extracorporeal shock wave lithotripsy for the treatment of pancreatic duct stones

The purpose of endoscopic therapy in chronic pancreatitis is to decompress the main pancreatic duct and to remove the obstacles that impede the ductal flow of pancreatic juice. The availability of extracorporeal shock wave lithotripsy (ESWL) has improved the results of endoscopic drainage of the main pancreatic duct and has also expanded the indications of endoscopic therapy for chronic pancreatitis. This article briefly reviews ESWL for pancreatic duct stones in patients with chronic pancreatitis, including our experience with ESWL. ESWL is an effective and safe procedure for endoscopically unremovable main pancreatic duct stones, and, in selected patients, ESWL alone may be effective.

Endoscopic therapy for chronic pancreatitis: An evidence-based review

In the setting of chronic pancreatitis, pancreatic ductal obstruction, and ductal leak, pseudocyst formation and biliary obstruction present many challenges for endoscopists. Although chronic pancreatitis has a variety of clinical manifestations, most commonly patients present with intermittent or chronic abdominal pain. Recent studies suggest stenting of pancreatic ductal strictures has a significant impact on reducing chronic pain. The removal of ductal calculi, presumably from relieving obstruction, also improves abdominal pain. When the site of leak is bypassed, ductal leaks may be cured by endoscopic stenting. Multiple plastic bile duct stents to treat chronic pancreatitis-associated bile duct stricture can delay the need for surgery. Although these endoscopic techniques have been beneficial for many patients, further study is warranted to better define their role in chronic pancreatitis compared with well-established surgical techniques.

Interventional endoscopic therapy in chronic pancreatitis including temporary stenting: A definitive treatment?

Objective. In the past 15 years there have been tremendous advances in endoscopic management of chronic pancreatitis (CP). However, the value of endoscopic pancreatic stenting is still debatable. Material and methods. In 98 patients suffering from symptomatic CP (84 M, 14 F, 49±12, age range 23–83 years) endotherapy including temporary stenting of the pancreatic duct was performed. After final stent removal, indicating the primary end-point of endotherapy, 96 patients were followed for 35±28 (8 days–111) months. All data were assessed retrospectively. Results. As well as other endoscopic procedures, a total of 358 prostheses were inserted in the pancreatic duct and left in place for 3±1 (1 day–11) months. Total stent treatment time was 10±10 (6 days–49) months. At 46±27 (4–111) months after limited endotherapy, 57 patients had no need for secondary intervention, two-thirds were even without further pain sensations. In 22 patients, surgical treatment and in 17 patients further endoscopic therapy became necessary, which was significantly correlated with continued alcohol consumption. Conclusions. Temporary stent placement as a part of interventional endoscopic therapy in CP shows a high rate of technical and long-term clinical success, with no need for secondary treatment in a remarkable number of patients. Continued cessation of alcohol consumption supports the treatment benefit significantly.

Dissection of a refractory pancreatic-duct stricture by using a pre-cutting needle-knife

Endoscopic deployment of a pancreatic stent may reduce the severity of abdominal pain for selected patients with chronic pancreatitis.1-3 However, the endoscopic therapy of chronic pancreatitis is sometimes difficult. When the stricture of the pancreatic duct is very severe and only the guidewire can pass across it, successful stent deployment is not possible. A Soehendra stent extractor (Wilson-Cook Medical Inc, Winston-Salem, NC) may be used for such a refractory stricture.4,5 In this report, we demonstrate the application of a pre-cutting needle-knife as an alternative to a Soehendra stent extractor to dissect a refractory stricture in the pancreatic duct of a patient with severe chronic pancreatitis, as well as the outcome of this procedure, in a 1.5-year follow-up.

Endoscopic Therapy for Chronic Pancreatitis

When endoscopic therapy is used for the treatment of patients with painful chronic pancreatitis, extracorporeal shock wave lithotripsy (ESWL) can be proposed as a first-line approach when obstructive ductal stone(s) induce upstream dilation of the main pancreatic duct. Stone fragmentation by ESWL is followed by endoscopic ductal drainage using pancreatic sphincterotomy, fragmented stone(s) extraction, and pancreatic stenting in case of ductal stricture. After completion of endoscopic pancreatic ductal drainage, long-term clinical benefit can be expected for two thirds of the patients. Best clinical results are associated with absence or cessation of smoking and with early treatment in the course of chronic pancreatitis, while alcohol abuse increases the risks of diabetes, steatorrhea and mortality. The complications of chronic pancreatitis are mainly the development of pseudocyst secondary to the downstream ductal obstruction, and biliary obstruction caused by fibrotic changes in the head of the pancreas. Successful endoscopic pseudocyst drainage is currently obtained in most patients, and carries a low complication rate. Biliary stenting is a safe and effective technique for the short-term treatment of symptomatic bile duct stricture due to chronic pancreatitis, but permanent resolution is obtained in only 25% of cases. In conclusion, endoscopic management is now considered to be the preferred interventional treatment of chronic pancreatitis, for patients selected on the basis of the anatomical changes caused by the disease. This treatment is generally safe, minimally invasive, often effective for years, does not prevent further surgery, and can be repeated.

Endoscopic Therapy for Chronic Pancreatitis

Endoscopic therapy for chronic pancreatitis is feasible and effective in selected patients. The management of pain and ductal obstruction is most effective if reversal of the obstructive process--stricture or stone--is successful and durable. Multiple endoscopic modalities are available, and new technologies will continue to advance the capabilities of therapeutic pancreatic endoscopists. Adjunctive treatments, such as ESWL, enhance the success of these techniques. These varied therapies, although attractive and theoretically sensible, have not been compared in a randomized, controlled fashion with standard surgical therapies. In this sense, they remain experimental. Nonetheless, these techniques are widely applied in advanced endoscopy centers worldwide, and uncontrolled individual series are expected to continue to expound on and demonstrate the effectiveness of these minimally invasive interventions until randomized, prospective studies become available.

Endoscopic therapy of chronic pancreatitis (CP) — Longterm follow-UP

Endoscopic therapy of chronic pancreatitis (CP) — Longterm follow-UP

Endoscopic therapy of chronic pancreatitis

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

7241 Endoscopic therapy in chronic pancreatitis through the minor papilla in non-divisum patients.

INTRODUCTION: A subset of patients with chronic pancreatitis (CP) have symptoms related to obstruction of the main pancreatic duct (MPD). Endoscopic decompression via stricture dilation or stone removal may alleviate symptoms. In patients with distal MPD obstruction and proximal dilation (Cremer IV), access to the MPD via the major papilla may be impossible. We describe 5 such cases in which endoscopic therapy was accomplished following access to the MPD through the minor papilla. METHODS:We reviewed 5 patients with CP undergoing ERCP for evaluation of recurrent pancreatitis (3) or chronic unremitting pain (2). There were 4 males, mean age 54yrs (range 34-81yrs). The etiology was ETOH in 4/5. On CT all had parenchymal calcifications, 4 had CBD dilation, 2 had PD dilation and 1 had PD calculi. RESULTS: After failed access to the MPD via the major papilla due to obstructing distal stricture (4) or stone (1), successful access to the Santorini's duct through the minor papilla revealed dilation of the MPD (5-20mm). Additionally 2 patients had free floating MPD stones. Endoscopic therapy included minor papilla sphincterotomy in 4, minor papilla push dilation (10fr) in 1, MPD stone extraction in 1 and minor papilla stent in 4. In addition 3 required biliary sphincterotomy and biliary stents. Excellent MPD drainage was observed in all patients. 4 had immediate complete symptom relief while 1 had partial relief. Repeat ERCP with minor papilla dilation and temporary stenting was performed in 2. In long term follow-up, surgery was performed in 2 (pylorus-preserving Whipple-1, Beger procedure-1) and recommended to a 3rd. The 2 remaining patients had durable symptom relief (1yr and 1.5yrs). CONCLUSIONS: In patients with CP and distal MPD obstruction, endoscopic therapy can be applied accessing the MPD through the minor papilla. As with endoscopic therapy for CP via the major papilla, short term pain relief can be expected and durable relief is seen in a subset.