Soft self-expandable metal stent to treat painful pancreatic duct strictures secondary to chronic pancreatitis: a prospective multicenter trial

A review on pancreatic duct stents: materials and emerging trends

Pancreatic duct strictures, which can arise from trauma, inflammation, or malignancy, often result in complications such as duct obstruction, pancreatic parenchymal hypertension, and ischemia. Endoscopic stenting is an effective therapeutic approach for managing these strictures. However, traditional plastic pancreatic duct stents fail to conform to the physiological curvature of the pancreas, while metal pancreatic duct stents with flared ends reduce migration but are associated with complications such as de novo strictures. Additionally, plastic and metal pancreatic duct stents require surgical removal. Whereas biodegradable pancreatic duct stents present a promising alternative due to their superior biocompatibility and ability to decompose into non-toxic materials, potentially eliminating the need for additional surgeries. Despite these advantages, biodegradable pancreatic duct stents remain in the experiment stage. This review assesses current materials of pancreatic duct stents, and emphasizes recent advancements in biodegradable options and emerging trends in clinical applications.

Management of Pancreatic Duct Strictures, Leaks, and Disconnected Pancreatic Duct Syndrome

Pancreatic duct (PD) strictures, leaks, and disconnected ducts are important morphologic consequences of inflammatory disease of the pancreas, resulting in abdominal pain, pancreatic ascites, pancreatic pleural effusion, and external pancreatic fistula. Traditionally, these PD complications were treated surgically, but a better understanding of their pathophysiology, along with advancement in endoscopic interventions, has transformed the therapy from morbid surgical interventions to minimally invasive, safe, and effective endoscopic treatment. This review discusses the current diagnostic and management strategies for PD strictures, leaks, and disconnected pancreatic ducts.

Endoscopic Retrograde Cholangiopancreatography: Pancreatic Endoscopy

The evolution of pancreatic endoscopic retrograde cholangiopancreatography (ERCP) has transformed from a diagnostic tool to now a primarily therapeutic modality. Mainly utilized within the spectrum of pancreatitis, pancreatic ERCP can help resolve pancreatic duct (PD) leaks, disruptions, and pancreatic fluid collections. In chronic pancreatitis, ERCP is effective for the treatment of PD strictures and stones with the improvement of pancreatoscopy greatly facilitating targeted therapy. Pancreatoscopy also allows for accurate mapping of main duct intraductal papillary mucinous neoplasms, which can help guide surgical resection.

Fully Covered Self-expandable Metallic Stents for Refractory Benign Pancreatic Duct Strictures: A Systematic Review and Meta-analysis

BACKGROUND

Endoscopic treatment of refractory pancreatic duct (PD) strictures includes the placement of multiple plastic stents. Recent studies have shown the benefit of fully covered self-expandable metal stents (FCSEMS). This systematic review analyzes the efficacy and safety of FCSEMS in PD strictures.

METHODS

A comprehensive search of all suitable studies was conducted using the databases of MEDLINE, EMBASE, and Scopus from inception to November 2022. The outcomes assessed were efficacy and safety of FCSEMS in PD strictures. Using a random-effects inverse-variance model, the pooled proportions were calculated.

RESULTS

A total of 22 studies with 439 patients were included in the analysis. The pooled stricture resolution rate was 91.6% (95% CI: 87.4-95.7), while the pooled pain resolution rate was 84.9% (95% CI: 77.7-92.1). The pooled incidences of stent-related adverse events, including acute pancreatitis, pain requiring stent removal, and de novo stricture, were 3.9% (95% CI: 1.2-6.7), 0.8% (95% CI: 0.0-2.1), and 3.3% (95% CI: 0.7-5.8). The pooled incidence of stent migration, stricture recurrence, and the need for restenting were 12.9% (95% CI: 6.7-19.1), 9.3% (95% CI: 4.7-13.8), and 12.3% (95% CI: 6.9-17.8), respectively.

CONCLUSIONS

FCSEMSs can be considered in carefully selected patients with benign PD strictures with high resolution rate and acceptable adverse event rate. De-novo structure formation appears to be a significant problem. Further studies may help to decide the role of FCSEMS in the algorithm.

American Society for Gastrointestinal Endoscopy guideline on the role of endoscopy in the management of chronic pancreatitis: summary and recommendations

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.

Progress in treatment of chronic pancreatitis: A review based on the ClinicalTrials.gov database

Chronic pancreatitis (CP) is a chronic progressive fibro-inflammatory disease of the pancreas caused by various etiologies, characterized by recurrent upper abdominal pain and pancreatic exocrine dysfunction. ClinicalTrials.gov is the most commonly used clinical trial database, including information of clinical trials which have been completed or are ongoing, or upcoming. Based on the ClinicalTrials.gov database, we retrieved all clinical studies registered before June 30, 2024, screened out recent clinical studies related to CP, and summarized and integrated highlights and directions of these studies from the perspectives of nutritional support, medication, endoscopy, etc., aiming to provide new ideas for the design of CP clinical studies in the future.

Fully Covered Self-expandable Metallic Stents for Refractory Benign Pancreatic Duct Strictures: A Systematic Review and Meta-analysis

Background:

Endoscopic treatment of refractory pancreatic duct (PD) strictures includes the placement of multiple plastic stents. Recent studies have shown the benefit of fully covered self-expandable metal stents (FCSEMS). This systematic review analyzes the efficacy and safety of FCSEMS in PD strictures.

Methods:

A comprehensive search of all suitable studies was conducted using the databases of MEDLINE, EMBASE, and Scopus from inception to November 2022. The outcomes assessed were efficacy and safety of FCSEMS in PD strictures. Using a random-effects inverse-variance model, the pooled proportions were calculated.

Results:

A total of 22 studies with 439 patients were included in the analysis. The pooled stricture resolution rate was 91.6% (95% CI: 87.4-95.7), while the pooled pain resolution rate was 84.9% (95% CI: 77.7-92.1). The pooled incidences of stent-related adverse events, including acute pancreatitis, pain requiring stent removal, and de novo stricture, were 3.9% (95% CI: 1.2-6.7), 0.8% (95% CI: 0.0-2.1), and 3.3% (95% CI: 0.7-5.8). The pooled incidence of stent migration, stricture recurrence, and the need for restenting were 12.9% (95% CI: 6.7-19.1), 9.3% (95% CI: 4.7-13.8), and 12.3% (95% CI: 6.9-17.8), respectively.

Conclusions:

FCSEMSs can be considered in carefully selected patients with benign PD strictures with high resolution rate and acceptable adverse event rate. De-novo structure formation appears to be a significant problem. Further studies may help to decide the role of FCSEMS in the algorithm.

Endoscopic Retrograde Cholangiopancreatography for Management of Chronic Pancreatitis

Management of symptomatic chronic pancreatitis (CP) has shifted its approach from surgical procedures to minimally invasive endoscopic procedures. Increased experience and advanced technology have led to the use of endoscopic retrograde cholangiopancreatography (ERCP) as a therapeutic tool to provide pain relief and treat CP complications including pancreatic stones, strictures, and distal biliary strictures, pseudocysts, and pancreatic duct fistulas. In this article the authors will discuss the use of ERCP for the management of CP, its complications, recent advancements, and techniques from the most up to date literature available.

Role of advanced endoscopy in the management of inflammatory digestive diseases (pancreas and biliary tract)

The progress of endoscopic diagnosis and treatment for inflammatory diseases of the biliary tract and pancreas have been remarkable. Endoscopic ultrasonography (EUS) and EUS-elastography are used for the diagnosis of early chronic pancreatitis and evaluation of endocrine and exocrine function in chronic pancreatitis. Notably, extracorporeal shock wave lithotripsy and electrohydraulic shock wave lithotripsy have improved the endoscopic stone removal rate in patients for whom pancreatic stone removal is difficult. Studies have reported the use of self-expanding metal stents for stent placement for pancreatic duct stenosis and EUS-guided pancreatic drainage for refractory pancreatic duct strictures. Furthermore, EUS-guided drainage using a double-pigtailed plastic stent has been performed for the management of symptomatic pancreatic fluid collection after acute pancreatitis. Recently, lumen-apposing metal stents have led to advances in the treatment of walled-off necrosis after acute pancreatitis. EUS-guided biliary drainage is an alternative to refractory endoscopic biliary drainage and percutaneous transhepatic biliary drainage for the treatment of acute cholangitis. The placement of an inside stent followed by switching to uncovered self-expanding metal stents in difficult-to-treat cases has been proposed for acute cholangitis by malignant biliary obstruction. Endoscopic transpapillary gallbladder drainage is an alternative to percutaneous transhepatic gallbladder drainage for severe and some cases of moderate acute cholecystitis. EUS-guided gallbladder drainage has been reported as an alternative to percutaneous transhepatic gallbladder drainage and endoscopic transpapillary gallbladder drainage. However, it is important to understand the advantages and disadvantages of each drainage method and select the optimal drainage method for each case.

Interventions for Pancreatitis-New Approaches, Knowledge Gaps, and Research Opportunities: Summary of a National Institute of Diabetes and Digestive and Kidney Diseases Workshop

ABSTRACT

There exists no cure for acute, recurrent acute or chronic pancreatitis and treatments to date have been focused on managing symptoms. A recent workshop held by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) focused on interventions that might disrupt or perhaps even reverse the natural course of this heterogenous disease, aiming to identify knowledge gaps and research opportunities that might inform future funding initiatives for NIDDK. The breadth and variety of identified active or planned clinical trials traverses the spectrum of the disease and was conceptually grouped for the workshop into behavioral, nutritional, pharmacologic and biologic, and mechanical interventions. Cognitive and other behavioral therapies are proven interventions for pain and addiction, but barriers exist to their use. Whilst a disease specific instrument quantifying pain is now validated, an equivalent is lacking for nutrition - and both face challenges in ease and frequency of administration. Multiple pharmacologic agents hold promise. Ongoing development of Patient Reported Outcome (PRO) measurements can satisfy Investigative New Drug (IND) regulatory assessments. Despite multiple randomized clinical trials demonstrating benefit, great uncertainty remains regarding patient selection, timing of intervention, and type of mechanical intervention (endoscopic versus surgery). Challenges and opportunities to establish beneficial interventions for patients were identified.

Management of chronic pancreatitis: recent advances and future prospects

As a progressive fibroinflammatory disease, chronic pancreatitis (CP) often manifests as recurrent bouts of abdominal pain with or without complications, causing a heavy burden of health care. In recent years, some meaningful insights into the management of CP have been obtained from randomized controlled trials, systematic reviews, and meta-analyses, which were of great importance. Based on this research, it is shown that there are various treatments for CP. Therefore, it is of great importance to choose a suitable strategy for patients with CP individually. Relevant evidence on the management of CP was summarized in this review, including nutrition supplements, medication, endoscopy, surgery, exploration of novel therapies as well as evaluation and prediction of treatment response.

[Interventional radiological and endoscopic technologies in diagnosis and treatment of chronic pancreatitis]

This review is devoted to internationally accepted diagnostic algorithms for complicated chronic pancreatitis (CP). In addition, the authors discuss interventional radiological and endoscopic diagnostic and therapeutic procedures, as well as their role in surgical approaches for this disease. Chronic pancreatitis is often diagnosed with severe symptoms following severe course of disease and complications. Imaging techniques, such as ultrasound, endoscopic ultrasound, CT, MRI/MR cholangiocreatography (MRCP), secretin-stimulated MRCP, are valuable to assess the pancreas in patients with initial manifestations of CP. Modern treatment of complicated CP includes transpapillary or transmural drainage of false cysts, shock wave lithotripsy and stenting for pancreatic duct strictures and/or stones, stenting for biliary hypertension, endovascular interventions for vascular complications and radical surgical treatment. Endoscopic methods are preferable regarding better short-term quality of life. Early surgical intervention (within 3 years after clinical manifestation) is effective to eliminate or significantly reduce pain and pancreatic insufficiency. Multidisciplinary team including surgeons, endoscopists and interventional radiologists should determine the most optimal diagnostic and treatment approach individually for each patient.

Quality of life after endoscopic procedures for chronic pancreatitis: A multicentre study

BACKGROUND

Chronic Pancreatitis (CP) causes morphological changes in the pancreatic tissue, leading to complications and pain, which may require endoscopic interventions.

OBJECTIVE

Our aim was to determine the frequency of endoscopic procedures (EP) in CP patients and to analyse pain and quality of life (QoL) in these patients after their EP.

METHODS

This study included 1327 CP patients from the Scandinavian Baltic Pancreatic Club (SBPC) database including four countries and eight centres. We analysed patients undergoing EPs and gathered information on the EP, pancreatic function, pain, disease and duration. The EORTC C-30 QoL questionnaire was gathered prospectively and multivariable analysis was conducted on independent parameters between the groups. The reference population had no interventions (n = 870).

RESULTS

260 CP patients (22%) underwent EPs, median one year (range 0-39 years) after CP diagnosis. 68% were males. The median age was 59 (20-90) years. Most common aetiological factors were alcohol in 65% and smoking in 71%. Extracorporeal shock wave lithotripsy (ESWL) was used in 6% of the CP population and in 21% of the EP group. Biliary duct stenting was performed on 37% and pancreatic stenting was performed on 56% of the patients. There was no difference in pain patterns between patients who had pancreatic stenting and the reference population. The EP group had slightly better QoL (p = 0.047), functioning and fewer symptoms than the reference population, in the multivariable analysis there was no interaction effect analysis between the groups. The pancreatic stent group had better QoL and the same amount of pain than the reference group. The patients who needed later surgery (23%) had more pain (p = 0.043) and fatigue (p = 0.021).

CONCLUSIONS

One in five of the CP patients underwent EP. These patients scored higher on QoL responses and had better symptom scores. CP patients who had pancreatic stenting performed had the same pain patterns as the reference population. Randomised prospective trials are needed to determine the effect of endoscopy procedures on CP patients.