Sunil G Sheth et al., 2024: American Society for Gastrointestinal Endoscopy guideline on the role of endoscopy in the management of chronic pancreatitis: summary and recommendations

ASGE Standards of Practice Committee; Sunil G Sheth, Jorge D Machicado, Jean M Chalhoub, Christopher Forsmark, Nicholas Zyromski, Nirav C Thosani, Nikhil R Thiruvengadam, Wenly Ruan, Swati Pawa, Saowanee Ngamruengphong, Neil B Marya, Divyanshoo R Kohli, Larissa L Fujii-Lau, Nauzer Forbes, Sherif E Elhanafi, Madhav Desai, Natalie Cosgrove, Nayantara Coelho-Prabhu, Stuart K Amateau, Omeed Alipour, Wasif Abidi, Bashar J Qumseya; ASGE Standards of Practice Committee Chair
Gastrointest Endosc. 2024 Aug 8:S0016-5107(24)03249-8. doi: 10.1016/j.gie.2024.05.016

Abstract

This clinical practice guideline from the American Society for Gastrointestinal Endoscopy (ASGE) provides an evidence-based approach for the role of endoscopy in the management of chronic pancreatitis (CP). This document was developed using the Grading of Recommendations Assessment, Development and Evaluation framework. The guideline addresses effectiveness of endoscopic therapies for the management of pain in CP, including celiac plexus block, endoscopic management of pancreatic duct (PD) stones and strictures, and adverse events such as benign biliary strictures (BBSs) and pseudocysts. In patients with painful CP and an obstructed PD, the ASGE suggests surgical evaluation in patients without contraindication to surgery before initiation of endoscopic management. In patients who have contraindications to surgery or who prefer a less-invasive approach, the ASGE suggests an endoscopic approach as the initial treatment over surgery, if complete ductal clearance is likely. When a decision is made to proceed with a celiac plexus block, the ASGE suggests an EUS-guided approach over a percutaneous approach. The ASGE suggests indications for when to consider ERCP alone or with pancreatoscopy and extracorporeal shock wave lithotripsy alone or followed by ERCP for treating obstructing PD stones based on size, location, and radiopacity. For the initial management of PD strictures, the ASGE suggests using a single plastic stent of the largest caliber that is feasible. For symptomatic BBSs caused by CP, the ASGE suggests the use of covered metal stents over multiple plastic stents. For symptomatic pseudocysts, the ASGE suggests endoscopic therapy over surgery. This document clearly outlines the process, analyses, and decision processes used to reach the final recommendations and represents the official ASGE recommendations on the above topics.

Comment Peter Alken

“This clinical practice guideline from the American Society for Gastrointestinal Endoscopy (ASGE) provides an evidence-based approach for the role of endoscopy in the management of chronic pancreatitis (CP).” This announcement made in this first sentence of the abstract is not really substantiated in the text.
The guideline how to approach a wellknown medical problem is based on the experience described with 199 patients.
This is the “Summary of evidence”:
“We performed a systematic review and meta-analysis of studies in CP patients with main PD obstruction related to stone(s) and/or stricture(s). The search resulted in 6 studies including 4 randomized controlled trials (RCTs). We conducted a meta-analysis of RCTs, which included 3 of the 4 RCTs because 1 of the studies was with the same patient population but with a different follow-up period. These studies compared the outcomes of surgical intervention with endotherapy in 199 CP patients with an obstructed main PD. None of these studies included pancreatoscopy with lithotripsy in the endoscopic arm. In most of these studies, patients had pain that was nonresponsive to conservative management.”
6 key questions and answers are formulated and, based on the present review, all 6 are “Conditional recommendations” only because of low to moderate quality of evidence in 2, low quality in 2, very low to low quality in 1 and very low quality of evidence in 1.
At the end in the Section FUTURE DIRECTIONS 7 different topics are addressed. “More data are needed” is a standard term to describe the future in all 7 areas.
Guidelines can only summarize the evidence reported in the literature. Unfortunately, the low quality of medical publications is not limited to Gastroenterology (1-4).
1. Thompson E, et al. A Longitudinal Assessment of the Reporting Quality of Randomized Controlled Trials for Surgical Interventions to Treat Nephrolithiasis Over 16 Years (2002 to 2017). J Endourol. 2020 Apr;34(4):502-508. doi: 10.1089/end.2019.0649.
2. Ding M et al. Low Methodological Quality of Systematic Reviews Published in the Urological Literature (2016-2018). Urology. 2020 Apr;138:5-10. doi: 10.1016/j.urology.2020.01.004.
3 Dahm P. et al. Defining the publication source of high-quality evidence in urology: an analysis of EvidenceUpdates. BJU Int. 2016 Jun;117(6):861-6. doi: 10.1111/bju.13392.
4. Corbyons K et al. Methodological Quality of Systematic Reviews Published in the Urological Literature from 1998 to 2012. J Urol. 2015 Nov;194(5):1374-9. doi: 10.1016/j.juro.2015.05.085.

Peter Alken