Endoscopic management of pancreatic duct stricture in chronic pancreatitis

Main pancreatic duct strictures (MPDS) arise in chronic pancreatitis (CP) which result in persistent abdominal pain due to increased intraductal pressure and exocrine and endocrine insufficiency. The primary aim of endoscopic treatment is to decompress the MPD in order to reduce pain. Endoscopic management typically involves the insertion of a single plastic stent for 1 year if initial drainage is achieved. If MPDS recurs or persists after 1 year of single plastic stenting, the stricture is considered "refractory." Alternative treatments include surgical intervention, placement of multiple plastic stents (MPS), or, more recently, insertion of a covered self-expandable metal stent (SEMS). Surgery has demonstrated superior outcomes compared to endoscopic therapy, however, unfortunately, it is more invasive, and patients often refuse to undergo pancreatic surgery. The insertion of MPS has proven effective, feasible, and safe for maintaining stricture dilation and preventing pain recurrence, with a negligible reintervention rate. The temporary placement of fully covered SEMS has recently been evaluated to avoid more invasive surgical decompression, demonstrating promising results for rapid pain resolution although they are accompanied by a series of complications, as previously reported, thereby limiting their use in clinical practice. Conversely, the use of uncovered SEMSs has yielded disappointing outcomes due to tissue ingrowth, which complicates stent removal. A newly designed biodegradable non-covered SEMS was used to treat pancreatic duct strictures in patients with CP, although the use appears promising, further studies are required before firm conclusions can be drawn. This review summarizes the endoscopic approaches used to manage pain from MPDS in CP.