Issa Y et al, 2017: Diagnosis and treatment in chronic pancreatitis: an international survey and case vignette study.
Issa Y, van Santvoort HC, Fockens P, Besselink MG, Bollen TL, Bruno MJ, Boermeester MA; Collaborators.
Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands.
Department of Surgery, St Antonius Hospital, Nieuwegein, The Netherlands.
Department of Gastroenterology, Academic Medical Center, Amsterdam, The Netherlands.
Department of Gastroenterology, Erasmus Medical Center, Rotterdam, The Netherlands.
Abstract
BACKGROUND: The aim of the study was to evaluate the current opinion and clinical decision-making process of international pancreatologists, and to systematically identify key study questions regarding the diagnosis and treatment of chronic pancreatitis (CP) for future research.
METHODS: An online survey, including questions regarding the diagnosis and treatment of CP and several controversial clinical case vignettes, was send by e-mail to members of various international pancreatic associations: IHPBA, APA, EPC, ESGE and DPSG.
RESULTS: A total of 288 pancreatologists, 56% surgeons and 44% gastroenterologists, from at least 47 countries, participated in the survey. About half (48%) of the specialists used a classification tool for the diagnosis of CP, including the Mayo Clinic (28%), Mannheim (25%), or Büchler (25%) tools. Overall, CT was the preferred imaging modality for evaluation of an enlarged pancreatic head (59%), pseudocyst (55%), calcifications (75%), and peripancreatic fat infiltration (68%). MRI was preferred for assessment of main pancreatic duct (MPD) abnormalities (60%). Total pancreatectomy with auto-islet transplantation was the preferred treatment in patients with parenchymal calcifications without MPD abnormalities and in patients with refractory pain despite maximal medical, endoscopic, and surgical treatment. In patients with an enlarged pancreatic head, 58% preferred initial surgery (PPPD) versus 42% initial endoscopy. In patients with a dilated MPD and intraductal stones 56% preferred initial endoscopic ± ESWL treatment and 29% preferred initial surgical treatment.
CONCLUSION: Worldwide, clinical decision-making in CP is largely based on local expertise, beliefs and disbeliefs. Further development of evidence-based guidelines based on well designed (randomized) studies is strongly encouraged.
HPB (Oxford). 2017 Nov;19(11):978-985. doi: 10.1016/j.hpb.2017.07.006. Epub 2017 Aug 15.
Comments 1
Although chronic pancreatitis does not belong to the urological speciality, it is worthwhile to consider some parts of the message in this article. There are certain points that should be known by urologists in their role as being responsible for the SWL-service.
The report is a summary of the outcome of a survey sent to pancreatologists of whom 288 had responded. Apart from the fact that a considerable variation in diagnostic and therapeutic principles became apparent the following aspects are of particular interest:
• SWL was used by 59% of gastroenterologists in the treatment of patients with chronic pancreatitis.
• In patient with dilated main pancreatic duct and intraductal stones, 42% used endoscopy (ERCP) and of them 42% combined ERCP with SWL.
• Interestingly half of the experts did not use SWL despite reports that total pain relief can be achieved in between 50 and 90% of the patients!
• The European Society of Gastrointestinal Endoscopy recommends SWL as first line treatment of patients with painful chronic pancreatitis when stones with a diameter ≥5 mm are obstructing the duct.
• Calcifications along the entire main pancreatic duct as well as isolated stones in the tail of pancreas were considered relative contraindications.