Endoscopy 2006 – Update and Live Demonstration
Berlin, 04. – 05. Mai 2006
CHRONIC PANCREATITIS –
CONSERVATIVE TREATMENT,
ENDOSCOPY OR SURGERY?
J. F. Riemann
A. Rosenbaum
Medizinische Klinik C, Klinikum Ludwigshafen gGmbH
(Gastroenterologie, Hepatologie und Diabetologie)
CHRONIC PANCREATITIS
COURSE OF DISEASE
Prospective study over 20 years
N= 254; chronic pancreatitis (163 alcoholic CP, with calcifications in 145)
Follow-up 10,4 ys. (median)
¾ In 85% of pts. with calcifications continued improvement
after 4,5 ys. (median)
¾ In 47% of 163 pts. with alcoholic CP surgery necessary
¾ 50-60% of pts. with CP develop complications which
require endoscopic or surgical intervention
Med C
Ammann, Gastroenterology 1984
Ammann, Intern Med 2001
CHRONIC PANCREATITIS
PAIN
¾ Local inflammation of pancreatic tissue with
expression of neuropeptides (e .g. substance P)
¾ Elevation of pressure in pancreatic duct by stricture
¾ Pancreatic compartment syndrome
¾ Local compression by pseudocysts
¾ Extrapancreatic reasons:
–
Metereorism (steatorrhea)
–
Peptic ulcer
Med C
Di Sebastiano et al., Gut 2003
CHRONIC PANCREATITIS
COMPLICATIONS
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
+ Symptoms
Pancreatic duct strictures
=
Pancreatic stones
Endoscopic
Choledochal duct strictures
therapy
Pseudocysts
Inflammatory swelling of pancreatic head
Duodenal or colonic stenoses
Elevated pressure of portal vein
GI- bleeding
Exo- und endocrineous insufficiency
Cancer
Med C
CHRONIC PANCREATITIS
THERAPY - GOALS 1. Analgesia
2. Therapy of exocrine
insufficiency
3. Therapy of endocrine
insufficiency
Med C
Lankisch, Internist 2005
CHRONIC PANCREATITIS
MANAGEMENT
COMPLICATIONS
Interventional
endoscopy
Surgery
PAIN
Alcohol abstinence
Enzymes / Diet
Enzymes
Spasmolytics
Diet
Analgetics
Insulin
(NSAID etc.)
Surgery
Med C
MALDIGESTION
DIABETES
CHRONIC PANCREATITIS
PAIN MANAGEMENT
• Conservative
• Interventional
endoscopy
• Surgery
Med C
CHRONIC PANCREATITIS
PAIN – CONSERVATIVE TREATMENT • First: exclusion of treatable complications
•
•
•
•
Strict abstinence from alcohol
Analgetics (NSAID, non opioid)
Celiac block (CT- or EUS- guided)
Drug addiction must be avoided
Med C
CHRONIC PANCREATITIS
ENDOSCOPIC THERAPY - GUIDELINES
¾ Concerning the endoscopic therapy of chronic pancreatitis only
few randomized controlled prospective trials are available in
international literature
¾ No long-term results exist regarding the outcome of endotherapy
¾ Recommendations concerning therapy of strictures of the
pancreatic or choledochal duct and pseudocysts are based on
expert opinions and uncontrolled trials
DGVS-Leitlinien, Z Gastroenterol 1998
Med C
CHRONIC PANCREATITIS
Ludwigshafen - Registry
•
•
•
•
•
Retrospective and prospective (since 1998) registry
n=291 patients with chronic pancreatitis
Endoscopic therapy: n= 262 patients
Follow-up: Median 84 months (6-168 Months)
Hospital stays per patient (re-therapy): Median 4,2 (1-15)
Endoscopic intervention
N
Stenting of pancreatic duct
89
EST
191
Bile duct stenosis
60
Pseudocysts
38
Med C
ENDOSCOPIC THERAPY CP
SPHINCTEROTOMY
¾ Endosocpic sphincterotomy to pancreatic duct in
patients with chronic pancreatitis
own data (n=191)*
Success
187 (96,1 %)
Complications
Follow-up
Re-EST necessary
Med C
Ell (n=118)**
116 (98 %)
9 (4,7 %)
5 (4,2 %)
16-160 months
42 months
23 (12 %)
18 (15 %)
*Ludwigshafener Pankreatitisregister 2006
**Gastrointest Endosc 1998
ENDOSCOPIC THERAPY CP
PANCREATIC DUCT STRICTURE
¾ N = 89; men/women: 51/38; median age: 55,3 ys.
¾2,6 stents/patient; duration of stenting 254 days
¾Follow-up: 78 (9-164) months
clearly
moderately
improved (%) improved (%)
12 months
55
16
24 months
45
18
40 months
42
18
70 months
40
20
Med C
No further
stenting:
33 (38%)
Surgery:
21 (24%)
Own data, Ludwigshafener
Pankreatitisregister 2006
ENDOSCOPIC THERAPY CP
PANCREATIC DUCT STONES / ESWL
¾ Metaanalysis
¾ N = 588, 17 trials (1989-2002)
¾ Interventional endoscopic therapy plus
ESWL
¾ Follow-up: mean 20 mon. (6-72)
Results (Effect size*):
Stonefree
0,74
Improvement of pain
0,62
(*large effect: Effect size 0,5)
Med C
Guda et al.,
J Pancreas (Online) 2005
N = 80, F/U 40 Mon.
ENDOSCOPIC THERAPY CP
PANCREATIC DUCT STRICTURE/ LITERATURE
Results of
endoscopic
interventional
therapy
Med C
Author
n
Follow-up
(Months)
Clinically
improved
(%)
Cremer 1991
75
37
94
Binmoeller 1995
93
39
74
Smits 1995
49
34
82
Jakobs 1999
27
44
56
Rösch 2002
1018
59
86
Delhaye 2004
56
173
66
Gabrielli 2005
22
72
55
Farnbacher 2006
96
35
59
ENDOSCOPIC THERAPY CP
REFRACTORY PANCREATIC STRICTURE
•
•
•
•
•
Prospective trial
n=19;
Refractory stricture of pancreatic head
Multiple stenting of pancreatic duct
(median 3 stents)
Mean Follow-up: 38 months
Med C
Costamagna et al., Endoscopy 2006
ENDOSCOPIC THERAPY CP
ENDOTHERAPY VS. SURGERY
(mean follow-up: 4,9 Jahre)
Intensity
of pain
Endotherapy
OP
(n=758)
(n=238)
87%
79%
middle
10%
15%
strong
3%
3%
none
light
Med C
Rösch T et al., Endoscopy 2002
PANCREATIC DUCT STRICTURE
SURGERY VS. ENDOTHERAPY
N = 140
Prospective controlled (partly randomized) trial
Obstruction of pancreatic duct an pain
All
(N=140)
Analgesia
Weight
gain
Med C
Randomized
(N=72)
EI*
(%)
CI**
(%)
EI
(%)
CI
(%)
14,3
36,9
15
33,8
26,9
52,1
28,6
47,2
*endoscopic
intervention
(without ESWL)
**surgical
intervention
Dite et al., Endoscopy 2003
ENDOSCOPIC THERAPY CP
BILE DUCT STRICTURE / PLASTIC STENTS
¾ Long-term results of bile duct stenting in CP
Stent in situ /
improved n=11
¾ n=60, Follow-up: 86 months (mean)
(44 (4-120) Mon.)
No success
n=31 (52%)
Surgery /
improved n=13
(11,5 (1-45) Mon.)
Success
n=29 (48%)
Stent in situ /
death* n=7
*(not from cholangitis)
0
100 %
NB: Since 2001 programmed implantation of mulitple stents
(Medían 3,2 Stents/Pat.)
Success-rates rising!!
Med C
Eickhoff, 2006
ENDOSCOPIC THERAPY CP
BILE DUCT STENTS / RISK OF OCCLUSION
Retrospective trial (1996 – 1999)
N = 61 Pat. with CP
Risk factors for unsuccessful stenting of common bile duct
RR (95% CI)
p
Exocrine pancreatic insuff.
3,97 (1,2-13,2)
0,024
Endocrine pancreatic insuff.
1,12 (0,36- 3,5)
0,841
Calcifications of pancreatic head
17,3 (4,1-74)
<0,001
Swelling of pancreatic head
1,01 (0,29- 3,45)
0,992
Ongoing alcohol abuse
0,58 (0,31-1,09)
0,0882
Duration of illness
1,01 (0,91- 1,23)
0,83
Med C
Kahl et al., Am J Gastroenterol 2003
ENDOSCOPIC THERAPY CP
BILE DUCT STRICTURE / MULTIPLE STENTING
Autor
n
Draganov 2002
Catalano 2004
Pozsar 2004
9
12
29
Med C
Follow-up Removal of
(Mon.)
stricture (%)
48
44
46
100
12,1
60
ENDOSCOPIC THERAPY CP
BILE DUCT STRICTURE / METAL STENTS
Author
n
Techn.
success
Long-term Complicasuccess
tions
Follow
up
(months)
Deviere 1994
20
100%
90% (18)
10%
33
Van Westerloo
2000
15
100%
80% (12)
13%
14
Kahl 2003
3
100%
100% (3)
0%
18-57
Van Berkel
2004
13
100%
69% (9)
8%
50
Eickhoff 2006
8
100%
37,5% (3)
62%
12-64
Med C
Wallstent
ENDOSCOPIC THERAPY CP
PSEUDOCYSTS / LITERATURE
n
transpapillary/
transgastral/
transduodenal
Successrate
Complications
Relapse
Cremer 1989
33
0 / 11 / 22
96 %
6%
12 %
Sahel 1991
43
0 / 3 / 40
93 %
11 %
5%
Barthet 1995
30
30 / 0 / 0
77 %
13 %
10 %
Binmoeller
1995
53
29 / ? / ?
77 %
11 %
22 %
Cahen 2005
92
25 / 33 / 21
71 %
34%
5%
6 / 13 / 6
88 %
7%
12 %
Own data 2006 38
Med C
ENDOSCOPIC THERAPY CP
PSEUDOCYSTS - PROSPECTIVE TRIAL
Prospective trial
N = 99 patients with pancreatic pseudocysts
Comparison of short-term and long-term results:
Conventional vs. EUS-guided drainage
Follow-up: 6 months
Method
N
Short-term
success
Long-term
success
Complications
Conventional
53
94%
91%
18%
EUS-guided
46
93%
84%
19%
n.s.
n.s.
n.s.
Kahaleh et al., Endoscopy 2006
Med C
CHRONIC PANCREATITIS
SURGERY
¾ Severe chronic pancreatitis of head
With duodenal stricture
With extensive calcifications
¾ Multiple strictures of pancreatic duct / multiple stones
¾ Failure of conservative and interventional endoscopic
therapy (regarding pain, large pseudocysts, inner
Pankreas-Ca
fistulas, bleeding pseudoaneurysm)
¾ Suspected cancer
DGVS-Leitlinien, Z Gastroenterol 1998
Med C
Lankisch, Internist 2005
CONCLUSION
¾ More than half of all patients with CP require
interventional endoscopic therapy or surgery
because of complications
¾ Conservative treatment is fundamental but must
not lead to drug addiction
¾ Endoscopic therapy reduces pain caused by
strictures and pseudocysts
¾ Surgery is indicated if conventional and
endoscopic therapy fails
Med C
TEAM APPROACH
Adequate management ?
„TEAM “ of
gastroenterologist and surgeon
INDIVIDUAL THERAPY:
First step:
9 Endoscopic
therapy
Second step:
9 Surgery
Med C
Traverso, Bern, 2000