From the Guidelines
The next step in managing pancreatitis with a dilated pancreatic duct is to consider surgical intervention, as it has been shown to be superior to endoscopic therapy for pain relief in patients with obstructive chronic pancreatitis.
Key Considerations
- The recent ESCAPE trial, a Dutch multicenter randomized trial, demonstrated higher complete or partial pain relief (58% vs 39%) in the early surgery group compared with the endotherapy group during 18 months of follow-up 1.
- Three randomized trials have suggested that early surgical intervention is superior to endoscopic therapy for pain relief in patients with obstructive chronic pancreatitis, with the overall data supporting early surgery over endoscopic decompression for the treatment of pain in obstructive chronic pancreatitis 1.
- Endoscopic retrograde cholangiopancreatography (ERCP) with stricture dilation and long-term stent placement can provide immediate pain relief and achieve enduring stricture remodeling and patency after long-term stent dwell, but may require serial ERCPs over the course of up to 12 months 1.
- The decision to proceed with surgical intervention should be carefully considered in the context of potential adverse events and the patient's individual circumstances.
Additional Options
- Endoscopic ultrasonography-guided pancreatic duct (EUS-PD) drainage may be considered in patients with pancreatic duct obstruction after failed ERCP or in patients with surgically altered anatomy or duodenal stenosis where ERCP is not possible 1.
- Minor papilla sphincterotomy, balloon dilation, or stent placement may be considered in patients with pancreas divisum and recurrent acute pancreatitis, but high-quality studies supporting endoscopic therapy in these patients are lacking 1.
From the Research
Management of Pancreatitis with a Dilated Pancreatic Duct
The next step in managing pancreatitis with a dilated pancreatic duct involves several options, including:
- Endoscopic stent therapy, which is a safe, minimally invasive, and effective procedure for patients experiencing pain attacks during chronic pancreatitis associated with a dilated pancreatic duct 2
- Endotherapy, including sphincterotomy, dilation, and stenting to provide drainage, which is considered the optimal first-line treatment modality 3
- Surgical intervention, such as longitudinal pancreaticojejunostomy, which is indicated in patients with a dilated duct and pain that requires narcotic analgesics for relief 4
- Pancreatic duct drainage, which is an effective method of dealing with many of the surgical complications of chronic pancreatitis without sacrificing pancreatic endocrine or exocrine function 5
Surgical Options
Surgical options for managing pancreatitis with a dilated pancreatic duct include:
- Laparoscopic lateral pancreaticojejunostomy, which is an effective surgical management for chronic pancreatitis with a dilated ductal system 6
- Modified Puestow's procedure, which has been adapted to a laparoscopic approach and is a technically demanding procedure primarily due to the need for extensive intra-corporeal suturing 6
- Endostapled anastomosis, which helps significantly reduce operative time without any corrosion of outcomes, especially in patients with wide ductal dilatation greater than 12 mm 6
Considerations
When considering the next step in managing pancreatitis with a dilated pancreatic duct, it is essential to:
- Evaluate the patient's symptoms, such as pain, weight loss, and steatorrhea, and assess the likelihood of malignancy 3
- Utilize high-quality imaging studies, such as CT, MRI/magnetic resonance cholangiopancreatography, or endoscopic ultrasound (EUS) scanning, to better define the ductal anatomy and detect any associated masses 3
- Consider the risk of malignancy and the need for tissue diagnosis, which may involve invasive procedures such as ERCP or EUS 3