Endotherapy in Chronic Pancreatitis

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Endotherapy in Chronic Pancreatitis

• D Nageshwar Reddy MD,DM,FAMS,FRCP.
• Asian Institute of Gastroenterology
• Hyderabad

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Chronic Pancreatitis
Etiology of Pain
40 Neuro-Hormonal Ischemia CBD / DU Stenosis
60 Intra ductal Pressure
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Endoscopic therapy
Pain in Obstructive Chronic Pancreatitis
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Chronic pancreatitis

• Calculi 42
• Calculi Stricture 38
• Stricture 20

Reddy DN et al. Tropical Gastroenterol
2001 Cremer M et al. WCG 2002
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Chronic Pancreatitis

• Endoscopic Therapy

Primary Calculi Stricture
Complications Pseudocyst Fistula CBD
Stricture OG varices
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ERCP Classification (No 575)
(25)

• Type I

(72)
Type II
(84)
Type III
(174)
Type IV
(220)
Type V
Reddy DN, Asian Institute of Gastroenterology 1994
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Tropical Pancreatitis with Impacted Stone
8
Tropical Pancreatitis - Stone Extraction
9
Tropical Pancreatitis - Large Stone
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Criteria for Calculi Extraction

• Calculi distal duct
• Size lt 5 cm
• Absence of severe narrowing distally

Asian Institute of Gastroenterology 1996
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Pancreatic Calculi
ESWL Endotherapy
405
20 stenting
29 primary extraction
356 (88)
Partial clearance135 (38)
Complete clearance178 (50)
Non frag 43 (12)
Reddy DN, Rao GV et al Trop Gastroenterol 2000
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Pancreatic Calculi
ESWL Endotherapy
MPD Painclearance relief
Complete 178 170 Partial 135 102 None 43 0 272/356
(76)
Reddy DN, Rao GV et al Trop Gastroenterol 2000
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Pancreatic Calculi
ESWL Endotherapy
Complications 39/356 Pancreatitis 15 Infections 14
Bleeding 9 Perforation 1 All managed
conservatively
Reddy DN, Rao GV et al Trop Gastroenterol 2001
14
Post ESWL Follow up gt 4 yrs
n 88
4 yrs
72 Pain free
16 Significant symptoms
4Rec. calculi
12Rec. calculi
4No calculus
16/88 Rec. calculi after 4 yrs
Reddy DN et al J Gastroenterology, 2000
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Chronic Pancreatitis - Pancreatic Stent
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Multiple Pancreatic Stenting
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Chronic Pancreatitis - Stenting

• Single dominant stricture
• Distal stricture
• Dilated duct beyond
• No flow of contrast
• Negative for malignancy

Asian Institute of Gastroenterology 1996
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Pancreatic Stenting
102 patients
No relief 20
Relief of pain 82
68
1 yr removal of stent
29 No pain
30Pain Rec.
9 Rec. pain inbetween
14 Re-stenting
16Surgery
Reddy DN, Rao GV, Trop Gastroenterol 2001
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Endoscopic Stenting In Chronic Pancreatitis

• Clinical Trial Basis
• Acceptable Short-term Results
• ? Long-term role
• Pre-op assessment

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Chronic Pancreatitis Endotherapy
Contraindications

• Duodenal Stenosis
• Focal Lesion ?Carcinoma
• Type 5 CP
• Portal / Splenic Vein Thrombosis
• Nondilated Pancreatic Duct
• CBD Stenosis
• Lack of Expertise