Gedyt Endoscopy Center, Buenos Aires, Argentina.
Department of Gastroenterology Hepatopancreatology, and Digestive Oncology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium.
Endoscopy. 2019 Feb;51(2):179-193. doi: 10.1055/a-0822-0832. Epub 2019 Jan 17.
ESGE suggests endoscopic therapy and/or extracorporeal shockwave lithotripsy (ESWL) as the first-line therapy for painful uncomplicated chronic pancreatitis (CP) with an obstructed main pancreatic duct (MPD) in the head/body of the pancreas. The clinical response should be evaluated at 6 - 8 weeks; if it appears unsatisfactory, the patient's case should be discussed again in a multidisciplinary team and surgical options should be considered.Weak recommendation, low quality evidence.ESGE suggests, for the selection of patients for initial or continued endoscopic therapy and/or ESWL, taking into consideration predictive factors associated with a good long-term outcome. These include, at initial work-up, absence of MPD stricture, a short disease duration, non-severe pain, absence or cessation of cigarette smoking and of alcohol intake, and, after initial treatment, complete removal of obstructive pancreatic stones and resolution of pancreatic duct stricture with stenting.Weak recommendation, low quality evidence.ESGE recommends ESWL for the clearance of radiopaque obstructive MPD stones larger than 5 mm located in the head/body of the pancreas and endoscopic retrograde cholangiopancreatography (ERCP) for MPD stones that are radiolucent or smaller than 5 mm. Strong recommendation, moderate quality evidence.ESGE suggests restricting the use of endoscopic therapy after ESWL to patients with no spontaneous clearance of pancreatic stones after adequate fragmentation by ESWL.Weak recommendation, moderate quality evidence.ESGE suggests treating painful dominant MPD strictures with a single 10-Fr plastic stent for one uninterrupted year if symptoms improve after initial successful MPD drainage. The stent should be exchanged if necessary, based on symptoms or signs of stent dysfunction at regular pancreas imaging at least every 6 months. ESGE suggests consideration of surgery or multiple side-by-side plastic stents for symptomatic MPD strictures persisting beyond 1 year after the initial single plastic stenting, following multidisciplinary discussion. Weak recommendation, low quality evidence.ESGE recommends endoscopic drainage over percutaneous or surgical treatment for uncomplicated chronic pancreatitis (CP)-related pseudocysts that are within endoscopic reach.Strong recommendation, moderate quality evidence.ESGE recommends retrieval of transmural plastic stents at least 6 weeks after pancreatic pseudocyst regression if MPD disruption has been excluded, and long-term indwelling of transmural double-pigtail plastic stents in patients with disconnected pancreatic duct syndrome.Strong recommendation, low quality evidence.ESGE suggests the temporary insertion of multiple side-by-side plastic stents or of a fully covered self-expandable metal stent (FCSEMS) for treating CP-related benign biliary strictures.Weak recommendation, moderate quality evidence.ESGE recommends maintaining a registry of patients with biliary stents and recalling them for stent removal or exchange.Strong recommendation, low quality evidence.
ESGE 建议将内镜治疗和/或体外冲击波碎石术(ESWL)作为伴有胰头部/体部主胰管(MPD)阻塞的疼痛性慢性胰腺炎(CP)的一线治疗方法。应在 6-8 周时评估临床反应;如果效果不理想,应在多学科团队中再次讨论患者的情况,并考虑手术选择。弱推荐,低质量证据。ESGE 建议在选择初始或持续内镜治疗和/或 ESWL 的患者时,考虑与长期良好结局相关的预测因素。这些因素包括在初始检查时,MPD 无狭窄、疾病持续时间短、疼痛不严重、无吸烟和饮酒、在初始治疗后,完全清除阻塞性胰石和支架置入治疗胰管狭窄。弱推荐,低质量证据。ESGE 建议 ESWL 用于清除位于胰头部/体部的大于 5mm 的不透射线的阻塞性 MPD 结石,ERCP 用于清除不透射线或小于 5mm 的 MPD 结石。强推荐,中等质量证据。ESGE 建议将内镜治疗限制在 ESWL 后没有自发性清除胰石的患者中,这些患者在 ESWL 充分碎裂后没有自发性清除胰石。弱推荐,中等质量证据。ESGE 建议对于初始 MPD 引流后症状改善的疼痛性主胰管狭窄患者,在第一年使用 10Fr 塑料支架进行单一治疗。如果至少每 6 个月在胰腺成像时出现症状或支架功能障碍的迹象,应根据需要更换支架。ESGE 建议在初始单一塑料支架放置 1 年后,如果症状持续存在,多学科讨论后考虑手术或多个并排塑料支架。弱推荐,低质量证据。ESGE 建议对于内镜可及的与慢性胰腺炎(CP)相关的假性囊肿,应采用内镜引流而不是经皮或手术治疗。强推荐,中等质量证据。ESGE 建议如果排除 MPD 破裂,在胰腺假性囊肿消退后至少 6 周取出穿透性塑料支架,并对断开胰管综合征患者长期留置穿透性双猪尾塑料支架。强推荐,低质量证据。ESGE 建议对 CP 相关良性胆管狭窄采用多个并排塑料支架或全覆膜自膨式金属支架(FCSEMS)临时置入。弱推荐,中等质量证据。ESGE 建议维持胆道支架患者的登记册,并召回他们进行支架取出或更换。强推荐,低质量证据。
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