05 Jul

Pancreatic endoscopy is useful for the pain of chronic pancreatitis: DRAINAGE OF THE MAIN PANCREATIC DUCT

Endoscopic therapy, such as stone extraction and stenting of the main pancreatic duct with or without dilation, is usually performed in certain patients with chronic pancreatitis in an attempt to improve ductal drainage. It is offered as an alternative to surgery. Data from over 300 patients who have undergone pancreatic duct stenting for dominant strictures are summarized in Table 1. The rate of technical success was 99%, with a mean follow-up interval of approximately three years. Symptomatic improvement was reported in 66% of patients, the complication rate was roughly 20% and mortality occurred in 1% of cases.

It is important to understand that stenting may provide medium term relief of pain associated with strictures of the main pancreatic duct, but is not a definitive long term therapy. Moreover, this procedure can result in complications, including cholangitis, hemobilia and stent migration. Multiple stent changes are generally required over the patient’s lifetime, which is a considerable problem for patients with a benign condition. Endoscopic therapy has also been found to be potentially effective in treating the complications of chronic pancreatitis, such as jaundice from biliary strictures and pancreatic pseudocysts.

TABLE 1 Pancreatic duct stenting for dominant strictures

Author (year and reference) Attempted patents (n) Technical success* (n) Meanfollow-up(months) Improved patients§ (n) Major complications (n) Deaths (n)
McCarthy et al, 1988 (2) 5 5 14 4 2t 0
Grimm et al, 1989 (3) 63 55 19 31t 20t 1
Cremer et al, 1991 (4) 76 75 37 41 12 1
Kozarek et al, 1994 (5) NA 17 8 13 3 0
Binmoeller et al, 1995 (6) 93 84 39 61 6 0
Ponchon et al, 1995 (7) 28 23 26 12 10 0
Smits et al, 1995 (8) 51 49 34 40 8 0
Total 311t 99% 34t 66% 19%t 1%

*Refers to the number of patients for whom stenting was successful; fEstimate; *Does not include the study in which the number of patients attempted is not available; §Refers to the percentage of patients with technical success who enjoyed clinical benefit. NA Not available

Key point

The whole rationale for sphincterotomy and stenting is that it alleviates pain by decreasing pancreatic parenchymal pressure. I contend that this line of reasoning is flawed, given the poor results that are obtained with surgical decompression of the pancreatic duct. Find cheapest medications available online: buy ortho tri-cyclen online right now and see for yourself how little you could be paying for the treatment you need.

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