Experimental evidence of beneficial effects of ductal decompression in chronic pancreatitis

Long-term outcome after 92 duodenum-preserving pancreatic head resections for chronic pancreatitis: comparison of Beger and Frey procedures

INTRODUCTION

Duodenum-preserving pancreatic head resection may be an alternative to pancreatoduodenectomy or drainage procedures for chronic pancreatitis. There are few studies directly comparing the long-term outcome after the operations described by Beger and Frey.

METHODS

One hundred thirteen patients underwent duodenum-preserving pancreatic head resection for complications of chronic pancreatitis. Follow-up was obtained in 92 patients (42 Beger, 50 Frey, median follow-up almost 5 years).

RESULTS

Overall/surgery-related perioperative morbidity was 30%/20% (Frey) and 40%/31% (Beger). In long-term follow-up (Frey vs Beger), 62% vs 50% were completely free of pain, but 6% vs 19% had pain at least once per week or daily, and 32% vs 31% experienced pain attacks at least once per year (n.s.). Diabetes mellitus occurred in 60% vs 57% (de novo 34% vs 17%). Rates of exocrine insufficiency were 76% vs. 74% (de novo 34% vs. 33%). Median gain in body weight was 2.5 vs 1.5 kg (n.s.), respectively. Four patients had clinically relevant biliary complications during follow-up requiring reintervention.

CONCLUSIONS

Our (nonrandomized) comparison of the long-term outcome after Frey and Beger procedures for chronic pancreatitis reveals a tendency for better pain control with the Frey operation. The functional outcomes were almost identical.

Endotherapy for pain in chronic pancreatitis

Pain is the most distressing symptom of chronic pancreatitis. Although the pathogenesis of pain is still poorly understood, an increase in intraductal pressure may be the dominant factor. The management of pain can involve medical, endoscopic, neurolytic, and surgical therapies. Endotherapy includes pancreatic sphincterotomy, extraction of stones, placement of stent, and dilatation of strictures, sometimes preceded or followed by extracorporeal shock-wave lithotripsy. Several studies have now shown that endotherapy provides partial or complete relief of pancreatic pain in a majority of patients with an acceptable frequency of early and late complications. Endotherapy should now graduate from an experimental form of treatment to a realistic treatment option in patients with chronic or relapsing pain, particularly in the setting of calcific chronic pancreatitis.

Endoscopic pancreatic duct stent placement for inflammatory pancreatic diseases

The role of endoscopic therapy in the management of pancreatic diseases is continuously evolving; at present most pathological conditions of the pancreas are successfully treated by endoscopic retrograde cholangio-pancreatography (ERCP) or endoscopic ultrasound (EUS), or both. Endoscopic placement of stents has played and still plays a major role in the treatment of chronic pancreatitis, pseudocysts, pancreas divisum, main pancreatic duct injuries, pancreatic fistulae, complications of acute pancreatitis, recurrent idiopathic pancreatitis, and in the prevention of post-ERCP pancreatitis. These stents are currently routinely placed to reduce intraductal hypertension, bypass obstructing stones, restore lumen patency in cases with dominant, symptomatic strictures, seal main pancreatic duct disruption, drain pseudocysts or fluid collections, treat symptomatic major or minor papilla sphincter stenosis, and prevent procedure-induced acute pancreatitis. The present review aims at updating and discussing techniques, indications, and results of endoscopic pancreatic duct stent placement in acute and chronic inflammatory diseases of the pancreas.

Endoscopic pancreatic duct stent placement for inflammatory pancreatic diseases

The role of endoscopic therapy in the management of pancreatic diseases is continuously evolving; at present most pathological conditions of the pancreas are successfully treated by endoscopic retrograde cholangio-pancreatography (ERCP) or endoscopic ultrasound (EUS), or both. Endoscopic placement of stents has played and still plays a major role in the treatment of chronic pancreatitis, pseudocysts, pancreas divisum, main pancreatic duct injuries, pancreatic fistulae, complications of acute pancreatitis, recurrent idiopathic pancreatitis, and in the prevention of post-ERCP pancreatitis. These stents are currently routinely placed to reduce intraductal hypertension, bypass obstructing stones, restore lumen patency in cases with dominant, symptomatic strictures, seal main pancreatic duct disruption, drain pseudocysts or fluid collections, treat symptomatic major or minor papilla sphincter stenosis, and prevent procedure-induced acute pancreatitis. The present review aims at updating and discussing techniques, indications, and results of endoscopic pancreatic duct stent placement in acute and chronic inflammatory diseases of the pancreas.

The role of endoscopy in the therapy of chronic pancreatitis

Almost all the therapeutic efforts in the treatment of chronic pancreatitis are directed towards pain control. Endoscopic techniques available for this purpose are endoscopic retrograde cholangiopancreatography (combined or not with extracorporeal shock wave lithotripsy) and endoscopic ultrasound. Pancreatic stones and strictures, pancreatic pseudocysts, and common bile duct strictures complicating chronic pancreatitis can be treated by endoscopy. The development of endoscopic ultrasound extended the possibilities in the treatment of pancreatic pseudocysts and main pancreatic duct drainage. Endoscopy is considered the first-line treatment in chronic pancreatitis and can be useful also as a 'bridge to surgery'. In fact the endoscopic approach to chronic pancreatitis can predict the response to surgical therapy as a definitive treatment. Medical, endoscopic and surgical methods for the management of chronic pancreatitis should all be considered in decision-making, and the best treatment should be chosen case by case and according to the local expertise.

Analysis of the effects of stent insertion and the factors related to stent retrieval in chronic pancreatitis accompanying main pancreatic duct obstruction

BACKGROUND/AIMS

Obstruction of the main pancreatic duct (MPD) has been considered one of the major causes for pain in chronic pancreatitis (CP). In this study, we evaluated the efficacy of MPD stenting in painful CP, and tried to determine a guideline for stent removal.

METHODS

Sixteen patients with painful CP who underwent MPD stenting were included. Follow up ERCP was performed 3 months after stenting in all patients. Stents were removed in patients who achieved pain relief, complete stone clearance, and decreased MPD diameter after 3 months.

RESULTS

Before stenting, ERCP showed MPD stricture in 11 cases, MPD dilatation by stone in 1 case, concomitant stricture and stone in 4 cases. After stenting, complete pain relief was achieved in 13 patients (81.3%) and partial pain relief was achieved in 3 patient (18.7%). There was no patient whose pain was not relieved. Stents were removed in 7 patients who achieved pain relief, complete stone clearance, and decreased MPD diameter after 3 months. Decrease of MPD diameter was significantly greater in patient who could remove stent than those who could not (72.9% vs. 127.9% of initial MPD diameter, p=0.008).

CONCLUSIONS

If partial or full pain relief is achieved after MPD stenting and follow up ERCP after 3 months shows decreased MPD diameter compared to the initial one, stent removal might be considered.

Outcomes after clearance of pancreatic stones with or without pancreatic stenting

BACKGROUND

Extracorporeal shockwave lithotripsy (ESWL) and endoscopic lithotripsy are useful for the fragmentation and extraction of pancreatic stones. However, pancreatic stones often recur, for which an adequate strategy is needed. Treatment for stricture of the main pancreatic duct (MPD) with a pancreatic stent after clearance of pancreatic stones may reduce the recurrence of pancreatic symptoms and stones.

METHODS

Forty patients with chronic pancreatitis with MPD stones were treated with ESWL in combination with endoscopic stone extraction. After clearance of the stones, a pancreatic stent was inserted when a stricture of MPD was observed on pancreatography. The stent was exchanged every 3 months and removed after a total of 1 year. We examined episodes of recurrent pain and pancreatitis in patients with and without stenting, as well as the MPD diameter, during follow-up.

RESULTS

MPD stricture was seen in 27 patients, and a stent was successfully inserted in 24 of them. Pancreatic symptoms recurred in five patients (21%) in the stenting group and in three patients (23%) in the control group during a mean follow-up period of 1.5 and 1.2 years, respectively. The diameter of the MPD, before, just after, and 1 year after treatment, was 7.6, 5.4, and 5.8 mm, respectively. It was significantly decreased after 1 year of follow-up, as well as just after stent removal, compared with before treatment (P < 0.05).

CONCLUSIONS

Additional stenting for MPD after extraction of pancreatic stones may reduce the risk of recurrence of pancreatic symptoms.

Pancreatic endoprostheses in chronic pancreatitis: criteria to predict stent occlusion

BACKGROUND

Good clinical results of main pancreatic duct (MPD) stent placement in chronic pancreatitis (CP) are clouded by early stent occlusion. The aim of this study was to increase knowledge about stent occlusion and its effects on clinical symptoms, and to define criteria that enable the prediction of clogging.

METHODS

A total of 100 pancreatic endoprostheses of 47 patients (32 men, 15 women; mean age, 53 years; standard deviation, 9 years) with CP were bench tested by simulating the pathophysiologically increased MPD pressure. The main study parameter was the reduction of water flow through clogged stents in comparison with native endoprostheses of identical type, length, and diameter. Major stent occlusion was defined as flow reduction by > or = 75%. The association between time to stent occlusion and stent- or patient-related variables was evaluated.

RESULTS

Occlusion took place in nearly all endoprostheses (97%). No significant association of occlusion with clinical or blood parameters was found. Multifactorial analysis proved 4 risk factors for major stent occlusion: (A) stent diameter > 8.5F, (B) stent length > 8 cm, (C) female gender, (D) exocrine pancreatic insufficiency that required regular oral enzyme supplementation. According to the relative risk, these factors were given the following scores: A, 3 points; B to D, 2 points. Stents in patients with a score sum > 5 showed a significantly higher risk of major stent occlusion within 90 days.

CONCLUSIONS

Stent clogging in CP seems to be an inevitable phenomenon. Because clinical and laboratory data do not reliably indicate clogging, stent removal or exchange should be performed in high-risk patients (score sum > 5) within 3 months.

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.

Composition of clogging material in pancreatic endoprostheses

BACKGROUND

Endoscopic management of chronic pancreatitis (CP), especially pancreatic stent placement, has made tremendous advances. However, good clinical results are hampered by rapid occlusion. The objective of this study was to understand mechanisms and materials that cause stent occlusion.

METHODS

The clogging material of 50 lyophilized pancreatic endoprostheses (length 8.5 cm, range 5-14 cm, diameter 7-11F) from patients with CP was completely removed and weighed. Protein solubilization was achieved at pH 8.0 by using sodium dodecyl sulfate (SDS) and 2-mercaptoethanol in the presence of proteasome inhibitors. Proteins were separated by using a SDS-polyacrylamide gel electrophoresis. Protein identification was performed by the Western blot technique, as well as by mass spectrometry. Insoluble components were examined by polarized light microscopy and after staining (periodic acid-Schiff [PAS]).

RESULTS

Clogging material was found in 49 prostheses, mainly at the duodenal flap (80%). More than a third of the prostheses contained visible calcium carbonate calculi. Light microscopy and PAS staining showed plant debris (80%), crystals (73.5%), and mucopolysaccharides (100%). The dry weight of clogging material (18 +/- 13 mg, range 3-72 mg) correlated significantly with the stent diameter ( p = 0.029) but not with any other stent- or patient-related criteria. Albumin, its degradation products, and lithostathine were identified as the main proteinaceous components.

CONCLUSIONS

Almost all pancreatic stents had clogging material, predominantly located at the duodenal flap, which contained plant material, mucopolysaccharides, and crystals, as well as visible calcium carbonate calculi. Albumin and lithostathine may play an important role in the development of stent occlusion.

Comparison of local resection of the head of the pancreas combined with longitudinal pancreaticojejunostomy (frey procedure) and duodenum-preserving resection of the pancreatic head (beger procedure)

The etiology of pain in chronic pancreatitis may be ductal hypertension, increased parenchymal pressure, or neural damage. It is difficult to assess the severity of pain in this patient population, a problem made more challenging by the frequency of narcotic dependency. Therapeutic interventions developed to relieve the pain of chronic pancreatitis include denervation of the pancreas, decompression of the main duct of the pancreas, resection of part or all of the diseased pancreas, and reduction of pancreatic secretion. Operative intervention for patients with chronic pain is indicated when severe pain, complications of pain, or potential malignancy are present. The operations that consistently provide long-lasting pain relief all have in common resection of all or a portion of the head of the pancreas. Adverse effects on exocrine and endocrine function, nutrition, and quality of life are related to the amount of pancreas resected. The ideal procedure should be easy to perform, have a low morbidity and mortality rate, provide long-lasting pain relief, and not augment endocrine and exocrine insufficiency. No single operation fulfills this ideal. The local resection of the head of the pancreas combined with longitudinal pancreaticojejunostomy (LR-LPJ) proposed by Frey and the duodenum-preserving resection of the head of the pancreas (DPHR) proposed by Beger are discussed. The conceptualization, development, and technique of LR-LPJ are discussed, and comparisons of patient outcomes are made with the outcomes of other procedures for chronic pancreatitis.

Endoscopic management of chronic pancreatitis

Endoscopic management of CP is generally safe, minimally invasive, and often effective for years, does not hinder further surgery, and can be repeated. It should be applied as a first-line approach to improving the clinical condition of patients with this chronic disease. The best results are obtained when endoscopic treatment is performed early in the course of CP. Proper patient selection, adequate expertise, and a supporting multidisciplinary infrastructure are essential. New technologies will continue to be developed and to extend the scope of therapeutic pancreatic endoscopy.

Endoscopic stent therapy in advanced chronic pancreatitis: relationships between ductal changes, clinical response, and stent patency

OBJECTIVE

Pancreatic duct stenting is now recognized as a treatment option for a number of pancreatic disorders. Although stent-induced ductal changes may result, there is little information regarding the frequency of these stent-induced changes in chronic pancreatitis and their relationship to stent occlusion and clinical response. Our objectives were to evaluate pancreatic ductal changes after endoscopic stenting in patients with preexisting radiographic evidence of chronic pancreatitis and to evaluate the relationships between ductal changes, pain response, and stent patency.

METHODS

Twenty-five consecutive patients had 40 stent placement episodes. Main pancreatic duct diameter, pancreatitis grade, preexisting obstructive lesions, and stent-induced strictures were recorded. Pain response and stent patency were correlated with main pancreatic duct caliber change using chi(2) analysis.

RESULTS

In 28 (70%) of 40 episodes, main pancreatic duct caliber increased or was unchanged after stenting; pain improved in 20 (71%) of 28. Pain improved in six (50%) of 12 patients with smaller ducts after stenting. Stent patency was documented upon retrieval in 34 episodes; most stents were occluded. Stent-induced strictures developed in 18% of 40 stent episodes.

CONCLUSIONS

Main pancreatic duct caliber after endoscopic stenting was not a good indicator of pain response or stent patency; main pancreatic duct was often larger, and even with stent occlusion, patients' symptoms were frequently improved. Stent-induced strictures were infrequent, compared with values previously reported in the literature.

Pancreatic Duct Strictures

The treatment of pancreatic duct strictures is based on an accurate assessment of the etiology of the disease, and then the degree of symptomatology. Our outline for therapy is as follows: Exclude a diagnosis of malignancy by using radiologic, endoscopic, histologic, and molecular biologic modalities. Once a benign stricture has been demonstrated, we favor a trial of endoscopic dilation and stent placement For the unresectable pancreatic neoplasm, in which an obstructive etiology for pain is suspected, a trial of endoscopic dilation and stent placement also should be considered. In benign pancreatic duct strictures complicated by biliary obstruction, and where the most durable treatment modality is sought, surgical intervention merits earlier consideration. Pancreatic duct stent placement should seldom be considered definitive therapy, and the risk of stent-induced duct injury must be weighed against potential therapeutic benefit.

Endoscopic treatment of the main pancreatic duct: correlations among morphology, manometry, and clinical follow-up

BACKGROUND AND AIM

During the course of chronic pancreatitis, the gradual increase in the main pancreatic duct pressure is the main pathophysiological factor responsible for pain, but up to now, the intra ductal pressure has never been measured during and after endoscopic stenting and correlated with clinical results. Pressure measurements of this kind could thus provide objective information about the useful duration of stenting period.

METHODS

Main pancreatic duct pressure was measured by performing endoscopic manometry on 13 chronic pancreatitis symptomatic patients (10 men, 3 women, mean age: 45.1+/-7.9 yr); clinical follow-up was carried out for a period of 29.0+/-16.1 mo. Before treatment, the main anatomical alteration present was a localized stenosis of the main pancreatic duct, i.e., one with a diameter of less than 2 mm (chronic pancreatitis alone), 10 cases; chronic pancreatitis associated with pancreas divisum, 3 cases). Stenosis was treated by endoscopic stenting: 7 F stent (7 cases) and 12 F stent (6 cases). The pressure was measured simultaneously in the duodenum (zero level) and within the main pancreatic duct, using an electronic device, The pancreatico-duodenal gradient was taken to be the difference between the pressure in the main pancreatic duct and the duodenum.

RESULTS

The endoscopic stenting induced a nonsignificant decrease in the intraductal pressure (p = 0.16). Among the 9 patients with a normal pressure at the end of the stenting and a successful anatomical outcome, 6 were painless during the follow-up period whereas 3 presented with recurrent pancreatic-type pain. The remaining 4 patients were symptom-free during the entire follow-up period, although the main pancreatic duct pressure was high at the end of the stenting and the stenosis was not completely cured.

CONCLUSION

The intraductal pressure at the end of the stenting period was perfectly correlated with the anatomical result, whether or not it was successful, but was not an accurate predictor of a favorable clinical outcome in patients with a poor anatomical result.

Radiologic investigations and pathologic results of experimental chronic pancreatitis in cats

RATIONALE AND OBJECTIVES

The purpose of this study was to evaluate a variety of methods to induce chronic pancreatitis and its radiologic expression by experimentally inducing this condition in cats.

MATERIALS AND METHODS

Chronic inflammatory and fibrosing pancreatitis was produced in cats by intraductal injection of 1.5 mL of 94% ethanol in one group or by a combination of intraductal and intraparenchymal injection of ethanol together with partial obstruction of the main pancreatic duct to 70% of its original lumen by fixation of a small catheter in the papilla. For comparison, other cats underwent total obstruction of the main pancreatic duct. All groups, as well as untreated control cats (n = 3), underwent repeat laparotomy to obtain biopsy specimens.

RESULTS

Cats with total obstruction showed progressing fibrosis with dilatation of ductules occasionally infiltrated with granulocytes. From 26 weeks on, acini and islets of Lnagerhans became atrophic. Radiographs showed progressive but diffuse dilatation of ducts, ductules, and side branches. Cats from the other two groups had interlobular inflammation and fibrosis with flattened and irregular ductular epithelium. Later, ductular proliferation occurred, interstitial inflammation subsided, and fibrosis increased. Radiographs showed very irregular ducts and ductules with stenosis and dilatation. From 26 weeks on, no substantial differences were observed between the cats who received only intraductal injection of ethanol and the cats who underwent the combination of procedures.

CONCLUSION

The histopathologic and radiographic alterations that evolved from damage to the ductal epithelium in the cat resembled the features of chronic pancreatitis in humans and differed from those caused by total obstruction of the main pancreatic duct in cats.

Endoscopic ductal drainage may avoid resective surgery in painful chronic pancreatitis without large ductal dilatation

CONCLUSION

Endoscopic stenting treatment, in cases of chronic pancreatitis unsuitable for decompressive surgery, appears to be safe and efficient. Perfect anatomical results are only obtained if large stents are used after balloon dilatation.

BACKGROUND

Decompressive surgery in cases of painful chronic pancreatitis is only feasible if the main pancreatic duct exceeds approx 8 mm over a sufficient length. When those anatomical changes are not present, surgery must be resective. This study evaluates the results of endoscopic stent drainage and decompression of painful chronic pancreatitis without large dilatation of the main pancreatic duct.

METHODS

Sixteen of our chronic pancreatitis patients were included in this study. They presented a mean of 5.3 episodes of pain in the 6 mo before treatment. Decompressive surgery was not possible because of a mean pancreatic duct diameter of 5.8 mm. Stents were 7F in eight patients and 12F in the other eight. They were left in the duct after endoscopic dilation for 9.5 +/- 1.0 mo.

RESULTS

During stenting we observed two early obstructions and seven episodes of pain. All cysts disappeared and stenosis of the duct disappeared anatomically in six cases, was improved in four, but persisted in six. During follow-up, two episodes of mild pain were recorded. No cysts reappeared. Complete disappearance of stenosis was only observed in patients whose pancreatic duct was equipped with a 12F stent (p < 0.02).

The acute abdomen in the critically ill patient

The critically ill patient with an acute abdomen represents a great challenge for the surgeon. The physiologic derangement that is associated with the critically ill state both fuels and is fueled by acute abdominal processes. Improvements in critical care and cardiopulmonary bypass technique have allowed for a group of patients to evolve that are susceptible to the complications of prolonged flow states. This article focuses on the abdominal consequences of support of the critically ill patient, as well as, the diagnostic and therapeutic options that are available to treat these patients.

Endoscopic treatment of pancreatic stones in patients with chronic pancreatitis

BACKGROUND

The aim of our study was to evaluate the long-term results of endoscopic pancreatic stone removal in patients with chronic pancreatitis.

METHODS

We retrospectively included 53 patients with chronic pancreatitis, in whom an attempt was made at endoscopic stone removal between 1984 and 1993. Patients presented with pain (30) or an exacerbation of pancreatitis (23). A sphincterotomy was performed in 41 patients. A nasopancreatic drain was left in situ for saline flushing in 6 patients. A pancreatic stent was inserted beyond the stones in 28 patients. Fragmentation of stones was performed by mechanical lithotripsy in 4 patients or by extracorporeal shock wave lithotripsy in 8 patients.

RESULTS

All patients had pancreatic stones (multiple 33, single 20) with proximal dilatation of the pancreatic duct. Median follow-up was 33 months (range 4 to 131). Stone removal was successful in 42 patients (79%) (complete 39, partial 3) with relief of symptoms in 38 of 42 (90%). The remaining 4 patients had pancreatic surgery. Stone removal failed in 11 patients and 3 of 11 patients had symptomatic improvement. The remaining 8 patients needed either pancreatic surgery (4) or continued conservative treatment (4). Thirteen of the 53 patients (25%) had recurrent stones, which could be removed endoscopically in 10 of 13. Procedure-related complications occurred in 5 of 53 patients (9%). Mortality was 0%. Seven of the 28 stented patients (25%) had stent-related complications.

CONCLUSIONS

Endoscopic treatment of pancreatic stones is a valid approach in patients with pancreatic lithiasis with an acceptable risk profile.

Chronic pancreatitis: diagnosis and treatment

Three-dimensional magnetic resonance cholangiopancreatography is currently the most exciting new imaging technique for chronic pancreatitis. Endoscopy-assisted duodenal intubation during the secretin-cholecystokinin test reduces intubation time in difficult cases. The NBT-para-amino benzoic acid test has been refined to enhance its discriminant power. The cholesteryl-[C13]octanoate breath test and the faecal elastase test are newer highly sensitive and specific tubeless tests. Pain in chronic pancreatitis continues to be a vexing therapeutic issue. Enzyme treatment continues despite criticism. Neurotensin is the new suspected mediator of the feedback mechanism, which is downregulated by enzyme therapy. Steroid ganglion block is an exciting therapeutic tool for pain relief. Endoscopic pancreatic sphincterotomy, Dormia basketing and pancreatic stenting in conjunction with extracorporeal shock wave lithotripsy should be performed early in chronic pancreatitis to prevent parenchymal atrophy with ensuing exocrine and endocrine pancreatic dysfunction. The modified Puestow's procedure preserves endocrine and exocrine pancreatic functions besides relieving pain. Closed loop insulin infusion allows superior management of pancreatic diabetes following near total pancreatectomy. The standardised incidence rate of pancreatic cancer is 16.5 in patients with alcoholic chronic pancreatitis and 100 for tropical chronic pancreatitis. Aggressive treatment protocols combining neo-adjuvant chemoradiation and intra-operative radiation with surgery are being used to improve the prognosis in this dismal complication of chronic pancreatitis.

Endoscopic management of recurrent and chronic pancreatitis

Endoscopic therapy is now being utilized in the setting of recurrent acute and chronic pancreatitis. This review analyzes the current state of the art of these new applications of endoscopy. Selection of appropriate candidates for the various treatment modalities appears important for optimal results of therapy. Patients with gallstone pancreatitis, pancreas divisum, obstructing main pancreatic duct stones, and bulging pseudocysts appear to be the best candidates for endoscopic therapy.

Polyethylene pancreatic duct stent-induced changes in the normal dog pancreas

This study was undertaken to evaluate the frequency, severity, and reversibility of stent-induced pancreatic ductal and parenchymal changes in the normal dog pancreas. Six adult mongrel dogs underwent duodenotomy and placement of 5F polyethylene pancreatic duct stents into the main pancreatic duct. After 8 weeks of stenting, the animals were randomly assigned to one of three groups: group I (n = 2), sacrifice; group II (n = 2), stent removal followed by sacrifice after an 8-week recovery period; group III (n = 2), the stent was exchanged and kept in place for an additional 8 weeks. In group III at 16 weeks the stent was removed, and the animals were allowed to recover for 8 weeks before sacrifice. Pancreatograms were obtained at each operation and were normal before stent placement. Gross and histologic evaluation was performed at the time of sacrifice. All stented animals developed radiographic, gross, and histologic abnormalities. Pancreatograms showed duct dilation in the stented region associated with a short stenosis at the mid to upstream segment of the stent. Group III animals had more advanced radiographic changes than group I and II animals. The radiographic findings were associated with gross evidence of fibrosis, which increased proportionately with the length of the stenting period. Group III animals developed moderate to severe pancreas atrophy. Histologic changes of obstructive pancreatitis were present in most experimental dogs. The results of this study suggest that pancreatic stenting may cause permanent damage in the normal dog pancreas. The cause of the damage appears to be related to stent occlusion, perhaps exacerbated by local stent-induced trauma.

Pancreatic blood flow in cats with chronic pancreatitis

Pancreatic blood flow and its relationship to pancreatic interstitial pressure were investigated in a model of chronic pancreatitis in cats using a hydrogen gas-clearance technique with an intraductal electrode. The intraductal technique correlated well with blood flow measurements made using gamma-labeled microspheres (r = 0.88, P less than 0.001). In control cats, the basal blood flow of 69.1 +/- 9.5 mL.min-1.100 g-1 increased by 25% to 86.2 +/- 11 mL.min-1.100 g-1 with secretory stimulation (P less than 0.05). Interstitial pressure was -0.02 +/- 0.3 mm Hg and did not change significantly with stimulation. In cats with chronic pancreatitis, basal interstitial pressure was 1.8 +/- 0.5 mm Hg and basal blood flow 39.9 +/- 4 mL.min-1.100 g-1 (P less than 0.05). Stimulation of the chronic pancreatitis gland increased the pressure to 3.0 +/- 0.4 mm Hg (P less than 0.01) and reduced flow 15% to 34.2 +/- 4 mL.min-1.100 g-1 (P less than 0.05). Papaverine increased blood flow in control and chronic pancreatitis cats without altering tissue pressure, suggesting that despite the reduced basal blood flow, the ability to increase blood flow was preserved in chronic pancreatitis. The increased interstitial pressure associated with secretion appeared to limit the gland's normal hyperemic response in this model of chronic pancreatitis.

Extracorporeal lithotripsy of pancreatic stones in patients with chronic pancreatitis and pain: a prospective follow up study

Extracorporeal shock wave lithotripsy of pancreatic duct stones (largest stone 12 (SD) 6 mm) was performed in 24 patients with abdominal pain and a dilated duct system (main pancreatic duct 10 (3) mm). The procedure was well tolerated in all but two patients, who had a mild pancreatitic attack immediately after lithotripsy. Disintegration of the stones was achieved in 21 patients. This allowed complete clearance of the duct system by an endoscopic approach in 10 (42%) patients and partial clearance in 7 (29%) patients. Within a mean follow up period of 24 (14) months half of the patients showed complete or considerable relief of pain and alleviation of symptoms was achieved in seven patients. Relief of pain occurred more often after complete ductal clearance. There were no fatalities within the follow up period. These findings underline the value of a combined non-surgical approach, using endoscopy and adjuvant shock wave lithotripsy to patients with large pancreatic calculi and pain attacks.