Dumonceau JM et al., 2019: Endoscopic treatment of chronic pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Updated August 2018
Dumonceau JM, Delhaye M, Tringali A, Arvanitakis M, Sanchez-Yague A, Vaysse T, Aithal GP, Anderloni A, Bruno M, Cantú P, Devière J, Domínguez-Muñoz JE, Lekkerkerker S, Poley JW, Ramchandani M, Reddy N, van Hooft JE. Gedyt Endoscopy Center, Buenos Aires, Argentina. Department of Gastroenterology Hepatopancreatology, and Digestive Oncology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium. Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Rome, Italy. Centre for Endoscopic Research, Therapeutics and Training (CERTT), Università Cattolica del Sacro Cuore, Rome, Italy. Gastroenterology and Hepatology, Hospital Costa del Sol, Marbella, Spain. Service de Gastroentérologie, University Hospital of Bicêtre, Assistance Publique-Hopitaux de Paris, Université Paris Sud, Le Kremlin Bicêtre, France. Nottingham Digestive Diseases Centre, NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, UK. Endoscopy Unit, IRCCS Istituto Clinico Humanitas, Rozzano, Milan, Italy. Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands. Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy. Gastroenterology Department, University Hospital of Santiago de Compostela, Santiago de Compostela, Spain.
ESGE suggests endoscopic therapy and/or extracorporeal shockwave lithotripsy (ESWL) as the first-line therapy for painful uncomplicated chronic pancreatitis (CP) with an obstructed main pancreatic duct (MPD) in the head/body of the pancreas. 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 and surgical options should be considered.Weak recommendation, low quality evidence.ESGE suggests, for the selection of patients for initial or continued endoscopic therapy and/or ESWL, taking into consideration predictive factors associated with a good long-term outcome. These include, at initial work-up, absence of MPD stricture, a short disease duration, non-severe pain, absence or cessation of cigarette smoking and of alcohol intake, and, after initial treatment, complete removal of obstructive pancreatic stones and resolution of pancreatic duct stricture with stenting.Weak recommendation, low quality evidence.ESGE recommends ESWL for the clearance of radiopaque obstructive MPD stones larger than 5 mm located in the head/body of the pancreas and endoscopic retrograde cholangiopancreatography (ERCP) for MPD stones that are radiolucent or smaller than 5 mm. Strong recommendation, moderate quality evidence.ESGE suggests restricting the use of endoscopic therapy after ESWL to patients with no spontaneous clearance of pancreatic stones after adequate fragmentation by ESWL.Weak recommendation, moderate quality evidence. ESGE suggests treating painful dominant MPD strictures with a single 10-Fr plastic stent for one uninterrupted year if symptoms improve after initial successful MPD drainage. The stent should be exchanged if necessary, based on symptoms or signs of stent dysfunction at regular pancreas imaging at least every 6 months. ESGE suggests consideration of surgery or multiple side-by-side plastic stents for symptomatic MPD strictures persisting beyond 1 year after the initial single plastic stenting, following multidisciplinary discussion. Weak recommendation, low quality evidence.ESGE recommends endoscopic drainage over percutaneous or surgical treatment for uncomplicated chronic pancreatitis (CP)-related pseudocysts that are within endoscopic reach.Strong recommendation, moderate quality evidence.ESGE recommends retrieval of transmural plastic stents at least 6 weeks after pancreatic pseudocyst regression if MPD disruption has been excluded, and long-term indwelling of transmural double-pigtail plastic stents in patients with disconnected pancreatic duct syndrome. Strong recommendation, low quality evidence. ESGE suggests the temporary insertion of multiple side-by-side plastic stents or of a fully covered self-expandable metal stent (FCSEMS) for treating CP-related benign biliary strictures. Weak recommendation, moderate quality evidence.ESGE recommends maintaining a registry of patients with biliary stents and recalling them for stent removal or exchange.Strong recommendation, low quality evidence.
Endoscopy. 2019 Feb;51(2):179-193. doi: 10.1055/a-0822-0832. Epub 2019 Jan 17.
Although chronic pancreatitis in no way is a urological disease the management of patients with pancreatic duct stones includes SWL as part of the recommendations in the recent guidelines issued by the European Society of Gastrointestinal Endoscopy (ESGE). For urologists who in most places of the world are responsible for the SWL service and SWL devices, it therefore is of value to briefly know something about the content of these guidelines. I therefore have summarized some of the points in the ESGE guideline document.
For patients with painful chronic pancreatitis and obstructive stone in the main pancreatic duct in the head or body of the pancreas endoscopic removal or SWL should be first-line treatment.
For stones in the main pancreatic duct with stone diameter > 5 mm, SWL is recommended as first line treatment provided the stones are radiopaque.
For radiolucent stones and if the stones are smaller than 5 mm, endoscopic treatment is recommended as the first line procedure. (Reviewer’s comment: The argument for not using SWL for small stones is not clear).
It was emphasized that the vast majority of pancreatic stones are calcified and accordingly radiopaque. (Reviewer’s comment: in most cases composed of calcium carbonate).
Interestingly the guidelines recommend restricted use of endoscopy after SWL with satisfactory disintegration but without clearance of stone fragments. However, when SWL did not result in adequate disintegration of the stone(s) the recommended approach is endoscopy.
The remaining parts of this guideline document deal with aspects beyond the urologist’s horizon or responsibility mentioned above.