Endoscopy 2020; 52(02): 156
DOI: 10.1055/a-1027-7015
Letter to the editor
© Georg Thieme Verlag KG Stuttgart · New York

Reply to Liu et al.

Andrea Tringali
Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS and Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica del Sacro Cuore, Rome, Italy
,
Guido Costamagna
Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS and Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica del Sacro Cuore, Rome, Italy
› Author Affiliations
Further Information

Publication History

Publication Date:
28 January 2020 (online)

We wish to thank Dr. Liu and co-workers for their comments regarding our paper on the long-term results of multiple plastic stents for refractory pancreatic duct strictures in chronic pancreatitis [1]. In this study, we continued to apply a protocol [2] that we described 6 years before the first guidelines on the endoscopic treatment of chronic pancreatitis were published by the European Society of Gastrointestinal Endoscopy (ESGE) [3].

The recent ESGE guidelines suggest treating pancreatic duct strictures that are related to chronic pancreatitis with a single plastic stent for 1 year [4]; this is a weak recommendation with a low quality of evidence, meaning that the treatment is proposed on the basis of data from retrospective studies with a risk of bias and further research is required to have an important impact on the confidence in the estimate of effect. We inserted a single pancreatic plastic stent to identify patients with obstructive pancreatic pain who can benefit from stent therapy. According to our protocol, patients underwent insertion of multiple plastic stents after “at least two previous placements of a single pancreatic plastic stent for 3 months”, which means after a minimum of 6 months. This is slightly different to the proposal within the guideline, but we believe it is not improper.

The definition of “refractory” dominant pancreatic duct stricture is not well standardized; we proposed a radiological criterion (persistence of contrast medium in the body and tail for more than 5 minutes after stent removal), which is also objectifiable. We agree that symptoms (i. e. pain) are important indicators in the evaluation of chronic pancreatitis and its treatment outcome: the Kaplan–Meier curve (Fig. 3 in our paper) shows the symptom-free period during treatment with a single pancreatic stent and after removal of the multiple plastic stents.

In conclusion, we wish to clarify that our experience is not focused on adherence to guidelines on the management of chronic pancreatitis. In the era of evidence-based medicine, guidelines are a useful tool to provide the best treatment available to our patients, but guidelines are not “dogma” and continuous research is needed to improve the strength of recommendations.