Treatment for refractory pancreatic duct strictures should follow the guidelines

We read with interest the recently reported study on multiple plastic stenting for refractory pancreatic duct strictures in chronic pancreatitis [1]. The present study used methods that were identical to the previous study by Costamagna et al. [2], with only the number of patients and the follow-up time being different. However, we found some problems with this study, which was incompatible with the European Society of Gastrointestinal Endoscopy (ESGE) guidelines for endoscopic treatment of chronic pancreatitis that were published in 2012 and 2018 [3] [4], especially with regard to the treatment of dominant main pancreatic duct (MPD) strictures.

First, the management of patients in this study was improper. In the present study, patients were included if they had had at least two previous placements of a single pancreatic plastic stent for 3 months. However, according to guidelines, patients with painful dominant MPD strictures should first be treated by the insertion of a single 10-Fr plastic stent for an uninterrupted period of 1 year [3] [4] [5]. The stent can be exchanged if necessary, based on symptoms or signs of stent dysfunction on regular pancreatic imaging. We would question why patients at this institution underwent stent placement for only 3 months without symptoms or signs of stent dysfunction rather than the recommended 1 year of uninterrupted placement.

Second, the definition of refractory dominant stricture was inappropriate, being defined according to the persistence of contrast medium. Many factors can influence the outflow of contrast medium, including body position or the individualized structure of pancreas, which could therefore cause refractory dominant stricture to be misdiagnosed. Defining refractory dominant stricture simply by the persistence of contrast medium after stent removal was outdated. According to the guidelines, refractory MPD strictures are defined as symptomatic dominant strictures that persist or relapse after 1 year of single pancreatic stent placement [3] [4]. Symptoms, an important indicator of refractory MPD strictures, were also ignored in this study.

In conclusion, exploring methods to treat refractory pancreatic duct stricture is valuable, but in this particular study the management of patients did not follow the guidelines.

^* Equal first authors

• References

• 1 Tringali A, Bove V, Vadala di Prampero SF. et al. Long-term follow-up after multiple plastic stenting for refractory pancreatic duct strictures in chronic pancreatitis. Endoscopy 2019; DOI: 10.1055/a-0959-6163.
• 2 Costamagna G, Bulajic M, Tringali A. et al. Multiple stenting of refractory pancreatic duct strictures in severe chronic pancreatitis: long-term results. Endoscopy 2006; 38: 254-259
• 3 Dumonceau JM, Delhaye M, Tringali A. et al. Endoscopic treatment of chronic pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy 2012; 44: 784-800
• 4 Dumonceau JM, Delhaye M, Tringali A. et al. Endoscopic treatment of chronic pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Updated August 2018. Endoscopy 2019; 51: 179-193
• 5 Eleftherladis N, Dinu F, Delhaye M. et al. Long-term outcome after pancreatic stenting in severe chronic pancreatitis. Endoscopy 2005; 37: 223-230