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The decision to proceed to endoscopic treatment for chronic pancreatitis (CP) may be determined by several factors, including:

• If the patient has not achieved pain relief with medications
• If weight loss or malabsorption cannot be managed with medications
• If there is any underlying cause of chronic pancreatitis that can be corrected, such as stones
• If symptoms cause a significant impact on the quality of life of the patient

The goal of endoscopy is the decompression of the main pancreatic duct (ductal decompression) and enhancing the flow of pancreatic juice by:

• Enlarging the pancreatic or bile duct opening
• Removing stones from the pancreatic or bile duct
• Placing tubes or stents in the pancreatic duct to open ductal strictures
• Draining pseudocysts

There are various endoscopic procedures that may be performed, including:

• Endoscopic retrograde cholangiopancreatography (ERCP) which may be performed for:

  • removal of stones
  • management of strictures
  • drainage of pseudocysts

• Endoscopic pancreatic sphincterectomy which is performed at the location of the muscle where the common bile duct and the pancreatic duct enter the duodenum. It is effective for:

  • management of strictures
  • facilitating stent placement
  • reducing pancreatic duct pressure
  • stone removal

In general, strictures may be managed with ductal dilation and stenting. Ductal dilation is usually combined with stent placement since it is not effective when done alone. Typically, a balloon is used to dilate the stricture and then a stent is inserted to maintain the dilation. This results in the decompression of the pancreatic duct. Over time, stents can cause changes to pancreatic tissue and may need to be removed. Pain relief is achieved in up to 95% of patients over the short term. Some patients report prolonged relief even after removal of the stent.

Calcifications (stones in the pancreatic duct) obstruct the flow of pancreatic juices and are common in advanced or severe CP. Endoscopic removal of the stones typically follows extracorporeal shock wave lithotripsy (see below) so that the stones fragments can be extracted.

Although there is some controversy as to the long term efficacy of endoscopic treatment, a major advantage is that it is not as invasive as open surgery, there is a shorter recovery period, and it is associated with fewer complications. It is considered as an alternative to surgery and the success rate is between 60-80% by some estimates. Regression of pseudocysts following drainage is reported to occur in up to 85% of patients.

Extracorporeal Shock Wave Lithotripsy

Extracorporeal shock wave lithotripsy (ESWL) uses ultrasound waves to destroy calcifications and is used routinely in the treatment of kidney stones. It also may be effective as a treatment for patients with painful, calcific CP and those with main pancreatic duct dilatation due to obstruction from stones. The advantage of this treatment is that it does not require surgery or anesthesia and is not usually associated with complications.