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.