pancreas diseases : ENDOSCOPIC MANAGEMENT

Endoscopic techniques are used increasingly in the management of acute and chronic pancreatitis. In many instances surgery can be avoided by endoscopic intervention as in endoscopic drainage of pseudocysts. Other conditions that can be managed by endoscopy include biliary calculi in acute biliary pancreatitis, pancreatic duct disruptions, strictures or stones and treatment of potential causes of pancreatitis such as sphincter of Oddi dysfunction and pancreas divisum. Despite widespread use of these endoscopic techniques, there are few controlled studies comparing pancreatic endotherapy with either surgical intervention or medical treatment.

Management of patients with acute recurrent and chronic pancreatitis is hampered by our incomplete understanding of the pathogenesis of pancreatic inflammation and mechanism of pancreatic pain. The short term assessment of therapies is made more difficult due to the relapsing and remitting nature of pain in pancreatic disease. Therefore, a detailed understanding of the natural history of pancreatitis is required prior to undertaking endoscopic treatment of pancreatic diseases.

BILIARY PANCREATITIS

Gallstone disease is one of the most common causes of acute pancreatitis. Although most episodes are mild and resolve spontaneously, in some patients, severe pancreatitis with local and systemic complications develop and may lead to death in 10% to 15% patients.

A pathbreaking, randomized, controlled study by Neoptolemos and Carr-Locke[1] showed significantly lower complication (24% vs 61%) and mortality (4% vs 18%) rates and a shorter mean length of hospital stay (LOS; 9.5 vs 17 days) in patients with predicted severe pancreatitis who underwent ERCP with sphincterotomy and stone extraction within 72 hours compared with patients who received supportive medical management. Early ERCP had no beneficial effect on patients with mild pancreatitis. The mechanism by which patients with severe pancreatitis benefit from ERCP is unclear as ERCP cannot reverse the damage already done to the pancreas. It has been suggested that patients with severe pancreatitis have a high prevalence of residual common bile duct (CBD) stones which may lead to superimposed cholangitis or continue to irritate the pancreas. Endoscopic removal of these residual stones should benefit these patients.

Several other studies have shown different results. Fan et al[2] in a similar randomized trial from Hong Kong reported no significant difference in complication or mortality rate with respect to pancreatitis, but early ERCP did protect against cholangitis, which occurs in 9% to 10% of patients. In a German multicentre study[3] patients with biliary pancreatitis, excluding those with biliary obstruction or cholangitis, were randomized to ERCP within 72 hours or to noninvasive therapy. There was no significant difference in mortality or overall complication rate, but the ERCP group had more severe complications, especially respiratory failure. This study has been criticized because it excluded the patients most likely to benefit from endoscopic therapy, and because it was a multicentre study, not all hospitals had a high degree of experience in performing ERCP in acute settings.

Despite conflicting data, there is a strong consensus that patients who have predicted severe pancreatitis with evidence of a CBD stone or biliary obstruction benefit from urgent ERCP when performed by experienced operators. A meta-analysis[4] with pooled data showed a 34.6% relative risk reduction for complications and a 42.9% relative risk reduction for death in patients treated with urgent ERCP, sphincterotomy and stone extraction.

by R BAIJAL