Response to Liu et al.

We thank our colleagues for their interest on our study [1] and their critical appraisal, which gives us the opportunity to clarify some important issues.

As already acknowledged in the discussion of our paper, and relevant for any retrospective study, potential selection bias cannot be excluded. However, baseline Izbicki score did not differ among the three groups evaluated in our study.

In addition, our primary endpoint (successful endoscopic treatment) was strictly defined as “IS ≤ 10 at the end of the stenting period.” We would like to remind our colleagues that Izbicki score is a widely accepted score, frequently used in clinical trials, that takes into account not only the frequency and intensity of pain, but also the need for analgesic medication and the time of disease-related inability to work [2].

Furthermore, we believe that inclusion criteria are clearly stated in the definitions section of our study. More precisely, only patients with main pancreatic duct stenosis, based on morphological findings consisting of a stricture with upstream dilation (> 3.5 mm) demonstrated by magnetic resonance cholangiopancreatography or endoscopic retrograde cholangiopancreatography, were included. To the best of our knowledge a scale to stratify the degree of stenosis, as proposed by our colleagues, does not exist and a correlation between “degree of stricture” and severity of the disease has never been demonstrated in the literature.

Finally, we appreciate the reminder about the European Society of Gastrointestinal Endoscopy (ESGE) guidelines [3] – in which our center actively participated – as well as concurrent literature on management of chronic pancreatitis [4] [5]. However, we would like to emphasize that both studies from Rome [4] [5] deal with refractory (> 1 year of stenting) pancreatic duct strictures and not initial treatment of main pancreatic duct stenosis, which was the case in our study. Furthermore, both of the studies were conducted retrospectively – and not prospectively as inaccurately mentioned in the letter by Liu et al – from 1999 to 2018 in the same maturing cohort. Prospective studies with a large number of patients are difficult to conduct for this type of disease; therefore, even retrospective, well-conducted studies that focus on long-term outcome from such referral centers provide valuable information that allows us to evolve in the field of pancreatic endotherapy. Our retrospective study ends at 2012, when the first edition of the ESGE guidelines was published and single stenting was adopted as first-line treatment strategy in our center. Furthermore, we were focused on long-term outcomes, as reflected in our long median follow-up duration. We still hope that in the future we will have the opportunity to participate in a well-designed, prospective, multicenter study that will provide us with even more robust data for endoscopic management of patients with chronic pancreatitis.

Competing interests

The authors declare that they have no conflict of interest.

• References

• 1 Papalavrentios L, Musala C, Gkolfakis P. et al. Multiple stents are not superior to single stent insertion for pain relief in patients with chronic pancreatitis: a retrospective comparative study. Endosc Int Open 2019; 7: E1595-e1604
• 2 Izbicki JR, Bloechle C, Broering DC. et al. Extended drainage versus resection in surgery for chronic pancreatitis: a prospective randomized trial comparing the longitudinal pancreaticojejunostomy combined with local pancreatic head excision with the pylorus-preserving pancreatoduodenectomy. Ann Surg 1998; 228: 771-779
• 3 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
• 4 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
• 5 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; 51: 930-935

Publication History

Article published online:
23 March 2020