Therapeutic pancreatic endoscopy.

In view of increasingly accurate noninvasive diagnostic imaging modalities for pancreatic diseases, endoscopic retrograde cholangiopancreatography (ERCP) should be mainly restricted to therapeutic indications. Acute pancreatitis is still the most common complication of ERCP. Prevention measures should focus in particular on well-defined risk groups. Temporary pancreatic duct drainage, preferably using small-diameter endoprostheses, can reduce the incidence of post-ERCP pancreatitis in at-risk individuals. By contrast, pharmacological prevention does not appear to be effective. ERCP in conjunction with sphincter of Oddi manometry frequently reveals the diagnosis of undetermined causes of acute recurrent pancreatitis. Endoscopic sphincterotomy (EST) is the treatment of choice in patients with sphincter of Oddi dysfunction or papillary stenosis. For these indications, dual pancreaticobiliary sphincterotomy promises a lower early morbidity and a better long-term outcome than biliary EST alone. In patients with pancreatic divisum, the cannulation rate of the dorsal duct can be improved by methylene blue staining and/or stimulation of the pancreatic secretion. Papillotomy of the minor papilla with short-term stenting appears to be an effective and safe approach for associated acute recurrent pancreatitis. Large-scale trials indicate that the majority of symptomatic patients with chronic pancreatitis can be well managed in the long term by endoscopic interventions. There is still a lack of prospective randomized controlled trials on endotherapy for chronic pancreatitis; however, they are also lacking for the surgical approach. Endoscopic and/or endosonographically guided drainage has become the treatment of choice for the majority of symptomatic pancreatic pseudocysts. Transmural debridement of pancreatic abscesses and infected necroses is still investigational, but appears to offer a minimally invasive alternative to surgery in selected cases. Pancreatic endotherapy is technically demanding and potentially hazardous; these interventions should be restricted to high-volume centers with options for an interdisciplinary team approach. Methods that have not yet been established should be evaluated in carefully designed prospective trials.