CP:Endotherapy or surgery.

1. Kurdistan Board GEH/GIT Surgery J Club 2022
Supervised by Professor Dr. Mohamed Alshekhani.

2. Introduction:
 Chronic pancreatitis (CP) is an inflammatory process characterized by
irreversible morphological changes in the pancreas.
 Pain is the predominant symptom observed during the course of CP.
 Pain is multifactorial:ductal hypertension from PD obstruction,
neuropathic causes &extrapancreatic comps as pseudocyst&distal bil obs.
 A sizeable % of CP are amenable to endoscopic treatment that includes:
 Decompression of PD with one or more plastic stents in those with stricture
 Fragmentation of PD calculi using extracorporeal shock wave lithotripsy.
 Nearly 2/3 achieve pain relief in the long term with endotherapy.
 Follow up of the suitability of endotherapy is paramount for best outcomes
 Predictors of poor response to endotherapy:multifocal dis, with multifocal
strictures or multiple calculi throughout the pancreas, or both.
 With emerging covered metal stents, the outcomes improve in refractory
PD strictures&CP-related distal biliary obst.
 EUS is a complementary for CP management&associated complications
like pseudocysts, refr pain& vascular complications.

10. Conclusion:
 Endotherapy for CP includes the management of pain, PD calculi,
strictures, &associated complications.
 Endotherapy IS only one prong in the management algorithm of CP &
should be integrated in lifestyle interventions like smoking&alcohol
cessation, pharm& nonpharmacological therapies.
 The first&foremost step is the assessment for suitability of endotherapy.
 Large PD calculi:by ESWL or pancreatoscopy-assisted lithotripsy.
 A step-up approach in cases with PD strictures that includes incremental
placement of MPS in cases with suboptimal response to a single stent.
 CP-related BS are esp refractory to endotherapy,so upfront use of MPS or
FCSEMS is recommended.
 It is imperative to comprehend the limitations of endotherapy.
 The suitability for endotherapy is not similar in all spectrum of CP& poor
responders should be referred for surgery early.
 With evidence of benefits of early surgery, a calculated decision should be
made based on the patient’s preferences, available resources& expertise