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Ito K, Takuma K, Okano N, Yamada Y, Saito M, Watanabe M, Igarashi Y, Matsuda T. Current status and future perspectives for endoscopic treatment of local complications in chronic pancreatitis. Dig Endosc 2025; 37:219-235. [PMID: 39364545 PMCID: PMC11884972 DOI: 10.1111/den.14926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 08/25/2024] [Indexed: 10/05/2024]
Abstract
Chronic pancreatitis is a progressive disease characterized by irregular fibrosis, cellular infiltration, and parenchymal loss within the pancreas. Chronic pancreatitis treatment includes lifestyle modifications based on disease etiology, dietary adjustments appropriate for each stage and condition, drug therapy, endoscopic treatments, and surgical treatments. Although surgical treatments of symptomatic chronic pancreatitis provide good pain relief, endoscopic therapies are recommended as the first-line treatment because they are minimally invasive. In recent years, endoscopic therapy has emerged as an alternative treatment method to surgery for managing local complications in patients with chronic pancreatitis. For pancreatic stone removal, a combination of extracorporeal shock wave lithotripsy and endoscopic extraction is used. For refractory pancreatic duct stones, intracorporeal fragmentation techniques, such as pancreatoscopy-guided electrohydraulic lithotripsy and laser lithotripsy, offer additional options. Interventional endoscopic ultrasound has become the primary treatment modality for pancreatic pseudocysts, except in the absence of disconnected pancreatic duct syndrome. This review focuses on the current status of endoscopic therapies for common local complications of chronic pancreatitis, including updated information in the past few years.
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Affiliation(s)
- Ken Ito
- Division of Gastroenterology and HepatologyDepartment of Internal MedicineToho University Omori Medical CenterTokyoJapan
| | - Kensuke Takuma
- Division of Gastroenterology and HepatologyDepartment of Internal MedicineToho University Ohashi Medical CenterTokyoJapan
| | - Naoki Okano
- Division of Gastroenterology and HepatologyDepartment of Internal MedicineToho University Ohashi Medical CenterTokyoJapan
| | - Yuto Yamada
- Division of Gastroenterology and HepatologyDepartment of Internal MedicineToho University Omori Medical CenterTokyoJapan
| | - Michihiro Saito
- Division of Gastroenterology and HepatologyDepartment of Internal MedicineToho University Omori Medical CenterTokyoJapan
| | - Manabu Watanabe
- Division of Gastroenterology and HepatologyDepartment of Internal MedicineToho University Omori Medical CenterTokyoJapan
| | - Yoshinori Igarashi
- Division of Gastroenterology and HepatologyDepartment of Internal MedicineToho University Ohashi Medical CenterTokyoJapan
| | - Takahisa Matsuda
- Division of Gastroenterology and HepatologyDepartment of Internal MedicineToho University Ohashi Medical CenterTokyoJapan
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Sheth SG, Machicado JD, Chhoda A, Chalhoub JM, Forsmark C, Zyromski N, Sadeghirad B, Morgan RL, Thosani NC, Thiruvengadam NR, Ruan W, Pawa S, Ngamruengphong S, Marya NB, Kohli DR, Fujii-Lau LL, Forbes N, Elhanafi SE, Desai M, Cosgrove N, Coelho-Prabhu N, Amateau SK, Alipour O, Abidi W, Qumseya BJ. American Society for Gastrointestinal Endoscopy guideline on the role of endoscopy in the management of chronic pancreatitis: methodology and review of evidence. Gastrointest Endosc 2025; 101:e1-e53. [PMID: 39243238 DOI: 10.1016/j.gie.2024.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2024] [Accepted: 05/29/2024] [Indexed: 09/09/2024]
Affiliation(s)
- Sunil G Sheth
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Jorge D Machicado
- Division of Gastroenterology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Ankit Chhoda
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Jean M Chalhoub
- Division of Gastroenterology and Hepatology, Staten Island University Hospital, Northwell Health, Staten Island, New York, USA
| | - Christopher Forsmark
- Division of Gastroenterology, Hepatology, and Nutrition, University of Florida, Gainesville, Florida, USA
| | - Nicholas Zyromski
- Department of Surgery, Indiana University, Indianapolis, Indiana, USA
| | - Behnam Sadeghirad
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada; Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
| | - Rebecca L Morgan
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada; School of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - Nirav C Thosani
- Center for Interventional Gastroenterology at UTHealth, McGovern Medical School, Houston, Texas, USA
| | - Nikhil R Thiruvengadam
- Department of Gastroenterology and Hepatology, Loma Linda University, Loma Linda, California, USA
| | - Wenly Ruan
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Swati Pawa
- Department of Gastroenterology, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - Saowanee Ngamruengphong
- Division of Gastroenterology and Hepatology, The Johns Hopkins University, Baltimore, Maryland, USA
| | - Neil B Marya
- Division of Gastroenterology, UMass Chan Medical School, Worcester, Massachusetts, USA
| | - Divyanshoo R Kohli
- Pancreas and Liver Clinic, Providence Sacred Heart Medical Center, Elon Floyd School of Medicine, Washington State University, Spokane, Washington, USA
| | | | - Nauzer Forbes
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Sherif E Elhanafi
- Division of Gastroenterology, Texas Tech University Health Sciences Center, El Paso, Texas, USA
| | - Madhav Desai
- Center for Interventional Gastroenterology at UTHealth, McGovern Medical School, Houston, Texas, USA
| | - Natalie Cosgrove
- Center for Interventional Endoscopy, AdventHealth, Orlando, Florida, USA
| | | | - Stuart K Amateau
- Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota Medical Center, Minneapolis, Minnesota, USA
| | - Omeed Alipour
- Division of Gastroenterology, University of Washington Medical Center, Seattle, Washington, USA
| | - Wasif Abidi
- Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, Texas, USA
| | - Bashar J Qumseya
- Division of Gastroenterology, Hepatology, and Nutrition, University of Florida, Gainesville, Florida, USA
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Sheth SG, Machicado JD, Chalhoub JM, Forsmark C, Zyromski N, Thosani NC, Thiruvengadam NR, Ruan W, Pawa S, Ngamruengphong S, Marya NB, Kohli DR, Fujii-Lau LL, Forbes N, Elhanafi SE, Desai M, Cosgrove N, Coelho-Prabhu N, Amateau SK, Alipour O, Abidi W, Qumseya BJ. American Society for Gastrointestinal Endoscopy guideline on the role of endoscopy in the management of chronic pancreatitis: summary and recommendations. Gastrointest Endosc 2024; 100:584-594. [PMID: 39115496 DOI: 10.1016/j.gie.2024.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2024] [Accepted: 05/29/2024] [Indexed: 10/20/2024]
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.
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Affiliation(s)
- Sunil G Sheth
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Jorge D Machicado
- Division of Gastroenterology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Jean M Chalhoub
- Division of Gastroenterology and Hepatology, Staten Island University Hospital, Northwell Health, Staten Island, New York, USA
| | - Christopher Forsmark
- Division of Gastroenterology, Hepatology, and Nutrition, University of Florida, Gainesville, Florida, USA
| | - Nicholas Zyromski
- Department of Surgery, Indiana University, Indianapolis, Indiana, USA
| | - Nirav C Thosani
- Center for Interventional Gastroenterology at UTHealth, McGovern Medical School, Houston, Texas, USA
| | - Nikhil R Thiruvengadam
- Department of Gastroenterology and Hepatology, Loma Linda University, Loma Linda, California, USA
| | - Wenly Ruan
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Swati Pawa
- Department of Gastroenterology, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - Saowanee Ngamruengphong
- Division of Gastroenterology and Hepatology, The Johns Hopkins University, Baltimore, Maryland, USA
| | - Neil B Marya
- Division of Gastroenterology, UMass Chan Medical School, Worcester, Massachusetts, USA
| | - Divyanshoo R Kohli
- Pancreas and Liver Clinic, Providence Sacred Heart Medical Center, Elon Floyd School of Medicine, Washington State University, Spokane, Washington, USA
| | | | - Nauzer Forbes
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Sherif E Elhanafi
- Division of Gastroenterology, Texas Tech University Health Sciences Center, El Paso, Texas, USA
| | - Madhav Desai
- Center for Interventional Gastroenterology at UTHealth, McGovern Medical School, Houston, Texas, USA
| | - Natalie Cosgrove
- Center for Interventional Endoscopy, AdventHealth, Orlando, Florida, USA
| | | | - Stuart K Amateau
- Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota Medical Center, Minneapolis, Minnesota, USA
| | - Omeed Alipour
- Division of Gastroenterology, University of Washington Medical Center, Seattle, Washington, USA
| | - Wasif Abidi
- Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, Texas, USA
| | - Bashar J Qumseya
- Division of Gastroenterology, Hepatology, and Nutrition, University of Florida, Gainesville, Florida, USA
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Bofill-Garcia A, Lupianez-Merly C. Endoscopic Retrograde Cholangiopancreatography for Management of Chronic Pancreatitis. Gastrointest Endosc Clin N Am 2024; 34:449-473. [PMID: 38796292 DOI: 10.1016/j.giec.2024.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2024]
Abstract
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.
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Affiliation(s)
- Aliana Bofill-Garcia
- Department of Gastroenterology and Hepatology, Mayo Clinic Rochester, 200 First Street Southwest, Rochester, MN 55905, USA.
| | - Camille Lupianez-Merly
- Department of Gastroenterology and Hepatology, Mayo Clinic Rochester, 200 First Street Southwest, Rochester, MN 55905, USA
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Kempeneers MA, Issa Y, Bruno MJ, van Santvoort HC, Besselink MG, Boermeester MA, Dijkgraaf MG. Cost-effectiveness of Early Surgery Versus Endoscopy-first Approach for Painful Chronic Pancreatitis in the ESCAPE Trial. Ann Surg 2023; 277:e878-e884. [PMID: 35129523 DOI: 10.1097/sla.0000000000005240] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Economic evaluation of early surgery compared to the endoscopy-first approach in CP. BACKGROUND In patients with painful CP and a dilated main pancreatic duct, early surgery, as compared with an endoscopy-first approach, leads to more pain reduction with fewer interventions. However, it is unknown if early surgery is more cost-effective than the endoscopy-first approach. METHODS The multicenter Dutch ESCAPE trial randomized patients with CP and a dilated main pancreatic duct between early surgery (surgery within 6 weeks) or the endoscopy-first approach in 30 centers (April 2011-September 2016). Healthcare utilization was prospectively recorded up to 18 months after randomization. Unit costs of resources were determined, and cost-effectiveness and cost-utility analyses were performed from societal and healthcare perspectives. Primary outcomes were the costs per unit decrease on the Izbicki pain score and per gained quality-adjusted life-year. RESULTS In total, 88 patients were included in the analysis, with 44 patients randomized to each group. Total costs were lower in the early surgery group but did not reach statistical significance (mean difference €-4,815 (95% bias-corrected and accelerated confidence interval €-13,113 to €3411; P = 0.25). Early surgery had a probability percentage of 88.4% of being more cost-effective than the endoscopy-first approach at a willingness-to-pay threshold of €0 per day per unit decrease on the Izbicki pain score. The probability percentage per additional gained quality-adjusted life-year was 75.7% at a willingness-to-pay threshold of €50,000. CONCLUSION In patients with painful CP and a dilated main pancreatic duct, early surgery was more cost-effective than the endoscopy-first approach.
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Affiliation(s)
- Marinus A Kempeneers
- Department of Surgery, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Yama Issa
- Department of Surgery, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
- Department of Surgery, Gelre Hospital, Apeldoorn, the Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, St Antonius Hospital, Nieuwegein, the Netherlands
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Marja A Boermeester
- Department of Surgery, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Marcel G Dijkgraaf
- Department of Epidemiology and Data Science, Amsterdam Public Health, Amsterdam UMC, University of Amsterdam, the Netherlands
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Shah BB, Rodge GA, Goenka U, Afzalpurkar S, Goenka MK. A prospective study of fully covered self-expandable metal stents for refractory benign pancreatic duct strictures. Clin Endosc 2022; 55:793-800. [PMID: 35368176 PMCID: PMC9726429 DOI: 10.5946/ce.2021.211] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 10/19/2021] [Accepted: 11/08/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND/AIMS Fully covered self-expanding metal stents (FCSEMSs) are a relatively novel option for treating painful main pancreatic duct refractory strictures in patients with chronic pancreatitis. Herein, we aimed to assess the efficacy, feasibility, and safety of FCSEMSs in this patient group. METHODS This prospective single-center study included patients who underwent endoscopic retrograde pancreatography with FCSEMS placement. The primary endpoints were the technical and clinical success rates. A reduction in visual analog scale pain score of >50% compared with that before stent placement was defined as clinical success. Secondary endpoints were resolution of pancreatic strictures on fluoroscopy during endoscopic retrograde pancreatography and the development of stent-related adverse events. RESULTS Thirty-six patients were included in the analysis. The technical success rate was 100% (n=36) and the clinical success rate was 86.1% (n=31). There was a significant increase in stricture diameter from 1.7 mm to 3.5 mm (p<0.001) after stent removal. The mean visual analog scale pain score showed statistically significant improvement. At 19 months of follow-up, 55.6% of the patients were asymptomatic. Stent migration (16.7%), intolerable abdominal pain (8.3%), development of de novo strictures (8.3%), and mild pancreatitis (2.8%) were the most common adverse events. CONCLUSION FCSEMS placement showed good technical and clinical success rates for achieving pain relief in patients with refractory main pancreatic duct strictures.
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Affiliation(s)
- Bhavik Bharat Shah
- Institute of Gastrosciences & Liver, Apollo Multispeciality Hospital, Kolkata, India
| | | | - Usha Goenka
- Department of Clinical Imaging and Interventional Radiology, Apollo Gleneagles Hospital, Kolkata, India
| | - Shivaraj Afzalpurkar
- Institute of Gastrosciences & Liver, Apollo Multispeciality Hospital, Kolkata, India
| | - Mahesh Kumar Goenka
- Institute of Gastrosciences & Liver, Apollo Multispeciality Hospital, Kolkata, India
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Kitano M, Gress TM, Garg PK, Itoi T, Irisawa A, Isayama H, Kanno A, Takase K, Levy M, Yasuda I, Lévy P, Isaji S, Fernandez-Del Castillo C, Drewes AM, Sheel ARG, Neoptolemos JP, Shimosegawa T, Boermeester M, Wilcox CM, Whitcomb DC. International consensus guidelines on interventional endoscopy in chronic pancreatitis. Recommendations from the working group for the international consensus guidelines for chronic pancreatitis in collaboration with the International Association of Pancreatology, the American Pancreatic Association, the Japan Pancreas Society, and European Pancreatic Club. Pancreatology 2020; 20:1045-1055. [PMID: 32792253 DOI: 10.1016/j.pan.2020.05.022] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 05/29/2020] [Accepted: 05/30/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVES This paper is part of the international consensus guidelines on chronic pancreatitis, presenting for interventional endoscopy. METHODS An international working group with experts on interventional endoscopy evaluated 26 statements generated from evidence on 9 clinically relevant questions. The Grading of Recommendations Assessment, Development, and Evaluation approach was used to evaluate the level of evidence. To determine the level of agreement, a nine-point Likert scale was used for voting on the statements. RESULTS Strong consensus was obtained for 15 statements relating to nine questions including the recommendation that endoscopic intervention should be offered to patients with persistent severe pain but not to those without pain. Endoscopic decompression of the pancreatic duct could be used for immediate pain relief, and then offered surgery if this fails or needs repeated endoscopy. Endoscopic drainage is preferred for portal-splenic vein thrombosis and pancreatic fistula. A plastic stent should be placed and replaced 2-3 months later after insertion. Endoscopic extraction is indicated for stone fragments remaining after ESWL. Interventional treatment should be performed for symptomatic/complicated pancreatic pseudocysts. Endoscopic treatment is recommended for bile duct obstruction and afterwards surgery if this fails or needs repeated endoscopy. Surgery may be offered if there is significant calcification and/or mass of the pancreatic head. Percutaneous endovascular treatment is preferred for hemosuccus pancreaticus. Surgical treatment is recommended for duodenal stenosis due to chronic pancreatitis. CONCLUSIONS This international expert consensus guideline provides evidenced-based statements concerning indications and key aspects for interventional endoscopy in the management of patients with chronic pancreatitis.
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Affiliation(s)
- Masayuki Kitano
- Second Department of Internal Medicine, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8509, Japan.
| | - Thomas M Gress
- Department of Gastroenterology, Endocrinology, Metabolism and Infectiology, University Hospital, Philipps-Universität Marburg, Marburg, Germany.
| | - Pramod K Garg
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India.
| | - Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan.
| | - Atsushi Irisawa
- Department of Gastroenterology, Dokkyo Medical University, Mibu, Tochigi, Japan.
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan.
| | - Atsushi Kanno
- Department of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan.
| | - Kei Takase
- Department of Diagnostic Radiology, Tohoku University Graduate School of Medicine, Sendai, Japan.
| | - Michael Levy
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA.
| | - Ichiro Yasuda
- Third Department of Internal Medicine, University of Toyama, Toyama, Japan.
| | - Phillipe Lévy
- Service de Pancréatologie-Gastroentérologie, Pôle des Maladies de l'Appareil Digestif, DHU UNITY, Hôpital Beaujon, APHP, Clichy Cedex, Université Paris 7, France.
| | - Shuiji Isaji
- Department of Surgery, Mie University Graduate School of Medicine, Tsu, Japan.
| | | | - Asbjørn M Drewes
- Centre for Pancreatic Diseases, Department of Gastroenterology, Aalborg University Hospital, Aalborg, Denmark.
| | - Andrea R G Sheel
- Department of Molecular and Clinical Cancer Medicine, Institute of Translational Medicine, University of Liverpool, Liverpool, UK.
| | - John P Neoptolemos
- Department of General Surgery, University of Heidelberg, Heidelberg, Germany.
| | - Tooru Shimosegawa
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan.
| | - Marja Boermeester
- Department of Surgery, Amsterdam University Medical Centers, location AMC, and Amsterdam Gastroenterology & Metabolism, Amsterdam, the Netherlands.
| | - C Mel Wilcox
- Division of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - David C Whitcomb
- Departments of Medicine, Cell Biology & Molecular Physiology and Human Genetics, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh and UPMC, Pittsburgh, PA, USA.
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Cost-effectiveness of benign Wirsung duct strictures treatment in chronic pancreatitis. Wideochir Inne Tech Maloinwazyjne 2018; 13:17-26. [PMID: 29643954 PMCID: PMC5890842 DOI: 10.5114/wiitm.2018.72578] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 10/29/2017] [Indexed: 01/22/2023] Open
Abstract
Introduction Chronic pancreatitis (CP) is an important problem for modern medicine, the healthcare system (Poland – NFZ) and the national insurance system (Poland – ZUS). The chronic nature of the disease, the lack of targeted treatment and the low mortality rate lead to an accumulation of patients who demand expensive treatment, both conservative and invasive. Rising costs in health care are forcing the need for a more cost-effective method of treatment. Aim The primary aim of this study was to perform a retrospective calculation of costs in both surgical and endoscopic treatment, hospital stay, healthcare, and public insurance of patients suffering from chronic pancreatitis. Parallel quality of life analysis was performed. It was possible to develop a cost-effective therapeutic algorithm for patients with an uncomplicated stricture of Wirsung’s duct within the Polish health care system. Results In Poland, the hospital costs of endoscopic treatment of patients with chronic pancreatitis were higher than those of the surgical treatment group despite both resulting in a similar life quality. Conclusions From a cost-effectiveness perspective, it was shown that surgical intervention is a more cost-effective therapy than endotherapy. Furthermore, patients with benign stricture of the main pancreatic duct in chronic pancreatitis should not be treated with endotherapy for longer than 12 months.
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Tantau A, Mandrutiu A, Leucuta DC, Ciobanu L, Tantau M. Prognostic factors of response to endoscopic treatment in painful chronic pancreatitis. World J Gastroenterol 2017; 23:6884-6893. [PMID: 29085231 PMCID: PMC5645621 DOI: 10.3748/wjg.v23.i37.6884] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Revised: 08/13/2017] [Accepted: 09/06/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate the endoscopic treatment efficacy and prognostic factors of long-term response to treatment for painful chronic pancreatitis. METHODS This retrospective analysis identified 168 patients with painful chronic pancreatitis hospitalized during January 2010-January 2015 in a Romanian tertiary referral center. Data on demographics, medical history, alcohol consumption, smoking habit, clinical parameters, type and number of endoscopic procedures and hospital admissions number were collected from the medical charts and analyzed. The absence or substantial reduction of pain (mild pain) at the end of the follow-up associated with the technical success of endotherapy was considered as clinical success. RESULTS Among the 168 patients with painful chronic pancreatitis admitted to our department during the study period, 39 (23.21%) had optimal response to the medical therapy. One hundred and twenty-nine patients required endoscopic treatment. The median follow-up period was 15 mo (range, 0-60 mo). Overall, technical success of endotherapy was achieved in 105 patients (81.39%). More than two-thirds of patients (82.78%) had substantial improvement of pain after the endoscopic treatment, including frequency and severity of the pain attacks. Patients younger than 40 years had significantly more successful endoscopic procedures (P = 0.041). Clinical success was higher in non-smoking patients (P = 0.003). The hospital admission rate was higher in patients with recognized alcohol consumption (P = 0.03) and in smokers (P = 0.027). The number and location of pancreatic stones and locations of strictures did not significantly influence the technical success (P > 0.05) or the clinical success (P > 0.05). CONCLUSION Younger age than 40 years can be considered an important factor positively influencing endoscopic treatment outcome in patients with painful chronic pancreatitis.
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Affiliation(s)
- Alina Tantau
- Department of Internal Medicine and Gastroenterology, “Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj-Napoca City, 400012 Cluj, Romania
- Department of Internal Medicine and Gastroenterology, 4th Medical Clinic, Cluj-Napoca City, 400015 Cluj, Romania
| | - Alina Mandrutiu
- Department of Gastroenterology, Gastroenterology and Hepatology Medical Center, Cluj-Napoca City, 400132 Cluj, Romania
| | - Daniel-Corneliu Leucuta
- Medical Informatics and Biostatistics Department, “Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj-Napoca City, 400012 Cluj, Romania
| | - Lidia Ciobanu
- Department of Internal Medicine and Gastroenterology, “Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj-Napoca City, 400012 Cluj, Romania
- Department of Internal Medicine and Gastroenterology, “Prof. Dr. Octavian Fodor“ Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca City, 400158 Cluj, Romania
| | - Marcel Tantau
- Department of Internal Medicine and Gastroenterology, “Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj-Napoca City, 400012 Cluj, Romania
- Department of Internal Medicine and Gastroenterology, “Prof. Dr. Octavian Fodor“ Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca City, 400158 Cluj, Romania
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Pylypchuk VI, Marino MV, Yavorskyy A. Chronic fibrous-degenerative pancreatitis with involvement of adjacent organs and their dysfunction: contemporary approaches to surgical treatment. Transl Gastroenterol Hepatol 2017; 1:48. [PMID: 28138615 DOI: 10.21037/tgh.2016.05.10] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Accepted: 05/18/2016] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Presently, there is no single opinion concerning the method preferable for surgical treatment of chronic pancreatitis (CP) with dysfunction of adjacent organs. METHODS Surgical treatment was applied to 144 patients with CP. In 54 (37.5%) patients, CP was complicated by dysfunction of adjacent organs. Particularly these were biliary hypertension (BH) in 36 (25%) patients and chronic duodenal obstruction (CDO) in 8 (5.5%) patients. In 5 (3.5%) patients, BH was combined with CDO, and another 5 (3.5%) patients had a combination of BH, CDO and venous hypertension (VH) of the portomesenteric area. In 24 patients with BH, we applied intraoperative monitoring of biliary pressure (IOM BP) in the process of performing duodenum-preserving pancreas resections. Frey's procedure was applied in 26 (48.1%) cases, where CP was complicated by the development of CDO, BH or CDO + BH. To correct BH, Frey's procedure was supplemented by application of hepatico-entero anastomosis (HEA) in 10 patients, pancreas lingual was excised; internal biliopancreatic anastomosis was applied in two patients. Beger's procedure was used in 2 (3.7%) patients, in which CP was complicated by BH + CDO + VH. Pancreaticoduodenal resection (PDR) according to Whipple was used in 5 (9.2%) cases. Longitudinal pancreatic-enteric anastomosis (LPEA) supplemented by HEA due to BH was applied to 8 (14.8%) patients. RESULTS The results of chronic treatment were traced in 23 (42.5%) patients throughout the period of 6 to 36 months. Life quality indicators appeared to be the best among the patients who underwent resection surgeries on the pancreas. CONCLUSIONS The method selected to treat surgically the patients with CP that involves adjacent organs and causes their dysfunction is duodenum-preserving resection surgeries on pancreas head, which in some cases should be supplemented by application of biliodigestive anastomosis or biliopancreatic diversion in the area of pancreas resection to eliminate the BH.
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Affiliation(s)
- Volodymyr Ivanovych Pylypchuk
- Department of surgery of the Institute of Postgraduate Education of the Ivano-Frankivsk National Medical University, Ivano-Frankivsk, Ukraine
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Park SM. [Recent Advances in Management of Chronic Pancreatitis]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2015; 66:144-9. [PMID: 26387696 DOI: 10.4166/kjg.2015.66.3.144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Treatment for chronic pancreatitis (CP) should be started early to prevent further pancreatic fibrosis and managed with a multidisciplinary approach to prevent complications and to maintain a good quality of life. The management strategies of CP can be divided into medical, endoscopic, and surgical treatment. The role of pancreatic enzymes and antioxidants for pain relief is not clearly defined, but their role in maintaining nutritional support by correcting exocrine insufficiency is well established. Endoscopic treatment is applied for resolution of pancreatic or bile duct strictures, clearance of pancreatic duct stones, and pseudocyst drainage. Endosonography-guided celiac plexus or celiac ganglia block for pain relief are known to be safe procedures but evidence for their effectiveness is still lacking. Surgery is commonly recommended when endoscopic therapy fails or there is suspicion of malignancy. New evidence-based guidelines for the management of CP are needed.
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Affiliation(s)
- Seon Mee Park
- Department of Internal Medicine, Chungbuk National University College of Medicine, Cheongju, Korea
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Ahmed Ali U, Pahlplatz JM, Nealon WH, van Goor H, Gooszen HG, Boermeester MA, Cochrane Upper GI and Pancreatic Diseases Group. Endoscopic or surgical intervention for painful obstructive chronic pancreatitis. Cochrane Database Syst Rev 2015; 2015:CD007884. [PMID: 25790326 PMCID: PMC10710281 DOI: 10.1002/14651858.cd007884.pub3] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Endoscopy and surgery are the treatment modalities of choice for patients with chronic pancreatitis and dilated pancreatic duct (obstructive chronic pancreatitis). Physicians face, without clear consensus, the choice between endoscopy or surgery for this group of patients. OBJECTIVES To assess and compare the effects and complications of surgical and endoscopic interventions in the management of pain for obstructive chronic pancreatitis. SEARCH METHODS We searched the following databases in The Cochrane Library: CENTRAL (2014, Issue 2), the Cochrane Database of Systematic Reviews (2014, Issue 2), and DARE (2014, Issue 2). We also searched the following databases up to 25 March 2014: MEDLINE (from 1950), Embase (from 1980), and the Conference Proceedings Citation Index - Science (CPCI-S) (from 1990). We performed a cross-reference search. Two review authors independently performed the selection of trials. SELECTION CRITERIA All randomised controlled trials (RCTs) of endoscopic or surgical interventions in obstructive chronic pancreatitis. We included trials comparing endoscopic versus surgical interventions as well as trials comparing either endoscopic or surgical interventions to conservative treatment (i.e. non-invasive treatment modalities). We included relevant trials irrespective of blinding, the number of participants randomised, and the language of the article. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by The Cochrane Collaboration. Two authors independently extracted data from the articles. We evaluated the methodological quality of the included trials and requested additional information from study authors in the case of missing data. MAIN RESULTS We identified three eligible trials. Two trials compared endoscopic intervention with surgical intervention and included a total of 111 participants: 55 in the endoscopic group and 56 in the surgical group. Compared with the endoscopic group, the surgical group had a higher proportion of participants with pain relief, both at middle/long-term follow-up (two to five years: risk ratio (RR) 1.62, 95% confidence interval (CI) 1.22 to 2.15) and long-term follow-up (≥ five years, RR 1.56, 95% CI 1.18 to 2.05). Surgical intervention resulted in improved quality of life and improved preservation of exocrine pancreatic function at middle/long-term follow-up (two to five years), but not at long-term follow-up (≥ 5 years). No differences were found in terms of major post-interventional complications or mortality, although the number of participants did not allow for this to be reliably evaluated. One trial, including 32 participants, compared surgical intervention with conservative treatment: 17 in the surgical group and 15 in the conservative group. The trial showed that surgical intervention resulted in a higher percentage of participants with pain relief and better preservation of pancreatic function. The trial had methodological limitations, and the number of participants was relatively small. AUTHORS' CONCLUSIONS For patients with obstructive chronic pancreatitis and dilated pancreatic duct, this review shows that surgery is superior to endoscopy in terms of pain relief. Morbidity and mortality seem not to differ between the two intervention modalities, but the small trials identified do not provide sufficient power to detect the small differences expected in this outcome.Regarding the comparison of surgical intervention versus conservative treatment, this review has shown that surgical intervention in an early stage of chronic pancreatitis is a promising approach in terms of pain relief and pancreatic function. Other trials need to confirm these results because of the methodological limitations and limited number of participants assessed in the present evidence.
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Affiliation(s)
- Usama Ahmed Ali
- University Medical Center UtrechtDepartment of SurgeryHeidelberglaan 100P.O. Box 85500UtrechtUtrechtNetherlands3508 GA
| | - Johanna M Pahlplatz
- University Medical Center UtrechtDepartment of SurgeryHeidelberglaan 100P.O. Box 85500UtrechtUtrechtNetherlands3508 GA
| | - Wiliam H Nealon
- Vanderbilt University Medical CenterDepartment of SurgeryD‐4314 Medical Center North1161 21st Avenue SouthNashvilleTennesseeUSA37232‐2730
| | - Harry van Goor
- Radboud University Nijmegen Medical CentreDepartment of SurgeryPO Box 9101NijmegenNetherlands6500 HB
| | - Hein G Gooszen
- Radboud University Nijmegen Medical CenterCentre of Evidence‐based SurgeryPO Box 9101Huispost 630, route 631NijmegenNetherlands6500 HB
| | - Marja A Boermeester
- University of AmsterdamDepartment of Surgery, Academic Medical CenterG4‐132.1Meibergdreef 9, Postbus 22660AmsterdamNoord‐HollandNetherlands1100 DD Amsterdam
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Abstract
This Review covers the latest developments in the treatment options for chronic pancreatitis. Pain is the most frequent and dominant symptom in patients with chronic pancreatitis, which ranges from severe disabling continuous pain to mild pain attacks and pain-free periods. Conventional treatment strategies and recent changes in the treatment of pain in patients with chronic pancreatitis are outlined. The different treatment options for pain consist of medical therapy, endoscopy or surgery. Their related merits and drawbacks are discussed. Finally, novel insights in the field of genetics and microbiota are summarized, and future perspectives are discussed.
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Kim YH, Jang SI, Rhee K, Lee DK. Endoscopic treatment of pancreatic calculi. Clin Endosc 2014; 47:227-35. [PMID: 24944986 PMCID: PMC4058540 DOI: 10.5946/ce.2014.47.3.227] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Revised: 05/07/2014] [Accepted: 05/13/2014] [Indexed: 12/16/2022] Open
Abstract
Chronic pancreatitis is a progressive inflammatory disease that destroys pancreatic parenchyma and alters ductal stricture, leading to ductal destruction and abdominal pain. Pancreatic duct stones (PDSs) are a common complication of chronic pancreatitis that requires treatment to relieve abdominal pain and improve pancreas function. Endoscopic therapy, extracorporeal shock wave lithotripsy (ESWL), and surgery are treatment modalities of PDSs, although lingering controversies have hindered a consensus recommendation. Many comparative studies have reported that surgery is the superior treatment because of reduced duration and frequency of hospitalization, cost, pain relief, and reintervention, while endoscopic therapy is effective and less invasive but cannot be used in all patients. Surgery is the treatment of choice when endoscopic therapy has failed, malignancy is suspected, or duodenal stricture is present. However, in patients with the appropriate indications or at high-risk for surgery, endoscopic therapy in combination with ESWL can be considered a first-line treatment. We expect that the development of advanced endoscopic techniques and equipment will expand the role of endoscopic treatment in PDS removal.
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Affiliation(s)
- Yong Hoon Kim
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Ill Jang
- Department of Internal Medicine, Hallym University Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Kwangwon Rhee
- Department of Internal Medicine, Godoil Hospital, Seoul, Korea
| | - Dong Ki Lee
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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Laramée P, Wonderling D, Cahen DL, Dijkgraaf MG, Gouma DJ, Bruno MJ, Pereira SP. Trial-based cost-effectiveness analysis comparing surgical and endoscopic drainage in patients with obstructive chronic pancreatitis. BMJ Open 2013; 3:e003676. [PMID: 24065699 PMCID: PMC3787408 DOI: 10.1136/bmjopen-2013-003676] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVE Published evidence indicates that surgical drainage of the pancreatic duct was more effective than endoscopic drainage for patients with chronic pancreatitis. This analysis assessed the cost-effectiveness of surgical versus endoscopic drainage in obstructive chronic pancreatitis. DESIGN This trial-based cost-utility analysis (ISRCTN04572410) was conducted from a UK National Health Service (NHS) perspective and during a 79-month time horizon. During the trial the details of the diagnostic and therapeutic procedures, and pancreatic insufficiency were collected. The resource use was varied in the sensitivity analysis based on a review of the literature. The health outcome was the Quality-Adjusted Life Year (QALY), generated using EQ-5D data collected during the trial. There were no pancreas-related deaths in the trial. All-cause mortality from the trial was incorporated into the QALY estimates in the sensitivity analysis. SETTING Hospital. PARTICIPANTS Patients with obstructive chronic pancreatitis. PRIMARY AND SECONDARY OUTCOME MEASURES Costs, QALYs and cost-effectiveness. RESULTS The result of the base-case analysis was that surgical drainage dominated endoscopic drainage, being both more effective and less costly. The sensitivity analysis varied mortality and resource use and showed that the surgical option remained dominant in all scenarios. The probability of cost-effectiveness for surgical drainage was 100% for the base case and 82% in the assessed most conservative case scenario. CONCLUSIONS In obstructive chronic pancreatitis, surgical drainage is highly cost-effective compared with endoscopic drainage from a UK NHS perspective.
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Affiliation(s)
- Philippe Laramée
- National Clinical Guideline Centre, Royal College of Physicians, London, UK
| | - David Wonderling
- National Clinical Guideline Centre, Royal College of Physicians, London, UK
| | - Djuna L Cahen
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Marcel G Dijkgraaf
- Clinical Research Unit, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Dirk J Gouma
- Department of Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Stephen P Pereira
- UCL Institute for Liver and Digestive Health, University College London, London, UK
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Abstract
Chronic pancreatitis (CP) is widely prevalent in Asian countries much more so in India and Japan. The phenotype of CP is somewhat similar to that reported from western countries. The prevalent types of CP are mainly idiopathic and alcohol related. Current evidence suggests that the term "tropical pancreatitis" used for idiopathic CP from India is a misnomer. Gallstones' association with CP reported from China remains controversial. There has been ample evidence that mutations in the SPNIK1 and CFTR genes are strongly associated with idiopathic CP in patients from different ethnic backgrounds. Oxidative stress is important in the pathophysiology and antioxidants have been shown to result in significant pain relief with CP. Home-made balanced diet is effective for treating malnutrition in patients with CP. Endoscopic therapy combined with ESWL may provide significant relief in patients with pancreatic ductal calculi/stricture. Surgery is quite effective in CP and may be better than endotherapy.
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Affiliation(s)
- Pramod Kumar Garg
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, 110029, India.
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