ESGE recommends endoscopic therapy and extracorporeal shockwave lithotripsy as first-line treatment for painful uncomplicated chronic pancreatitis with obstructed main pancreatic duct, with specific guidance on stone management, stricture treatment, and pseudocyst drainage.
- ESWL is recommended for radiopaque obstructive main pancreatic duct stones larger than 5mm in the head or body of the pancreas, while ERCP is recommended for radiolucent stones or stones smaller than 5mm
- Clinical response to endoscopic therapy or ESWL should be evaluated at 6 to 8 weeks, with multidisciplinary discussion and consideration of surgery if response is unsatisfactory
- Predictive factors for good long-term outcome include absence of main pancreatic duct stricture, short disease duration, non-severe pain, cessation of smoking and alcohol, complete stone removal, and resolution of stricture with stenting
- Painful dominant main pancreatic duct strictures should be treated with a single 10-Fr plastic stent for one uninterrupted year if symptoms improve, with stent exchange based on symptoms or imaging at least every 6 months
- Endoscopic drainage is recommended over percutaneous or surgical treatment for uncomplicated chronic pancreatitis-related pseudocysts within endoscopic reach
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