Balancing benefits and risks of endotherapy in painless pancreatic stones: New horizons in chronic pancreatitis management

Chronic pancreatitis (CP) is a disease characterized by diffuse chronic changes in the pancreas, including fibrosis, cellular infiltration, and loss of pancreatic parenchyma.¹ Abdominal pain occurs in approximately 80% of CP cases, but painless cases also exist. Pancreatic duct (PD) stones typically develop during the course of CP, especially in the transition from the compensatory to the decompensatory phase. These stones can cause stagnation of pancreatic juice and increased intraductal pressure, leading to severe epigastric pain and abdominal tenderness.^{2, 3}

Current guidelines⁴ recommend treatment for cases when PD stones are associated with persistent pain or recurrent pancreatitis. In these cases, treatment aimed at alleviating pancreatic juice obstruction by removing stones is performed. In Japan, multicenter surveys report that the success rate of symptom resolution following PD stone treatment is extremely high, ranging from 90.9% to 98.5%, with minimal differences observed between treatment methods.⁵ Nonoperative methods, such as extracorporeal shock wave lithotripsy and endotherapy, are commonly used for cases involving stones in the main or accessory pancreatic ducts.⁶

On the other hand, follow-up is generally recommended for asymptomatic cases. However, in cases where pancreatic parenchymal atrophy is not observed and pancreatic juice obstruction due to PD stones is suspected, treatment may be given to aim at improving pancreatic function. Nonetheless, there is currently no established consensus on the treatment of painless PD stones.

In this issue of Digestive Endoscopy, Ikeura et al.⁷ focus on painless PD stones and discuss the potential benefits and risks of endoscopic treatment for this particular subgroup. This multicenter cohort study is notable for its robust methodology and large sample size, offering valuable insights into the natural history and management of painless CP. Achieving complete removal of PD stones was associated with a significant reduction in the risk of pancreatic parenchymal atrophy, a key surrogate marker for exocrine insufficiency. This underscores the potential role of endotherapy in preserving pancreatic function even in the absence of pain symptoms. The study highlights the adverse outcomes associated with incomplete stone removal, including an increased risk of glucose tolerance worsening and the onset of new pain episodes. These findings serve as a cautionary note, advocating for meticulous patient selection and technical precision in performing endotherapy. While patients who did not undergo endotherapy experienced significant pancreatic parenchymal loss during follow-up (70.8%), the absence of surgical interventions and low incidence of new pain (4.4%) in this group further emphasize the need to weigh the risks and benefits of active intervention in asymptomatic patients.

Current international guidelines recommend endotherapy primarily for symptomatic CP.^{4, 8-10} This study challenges these recommendations by providing evidence for its utility in preventing progressive pancreatic damage in patients with painless CP. The gap between guideline-based practice and real-world treatment patterns, as demonstrated in this study, calls for a nuanced approach that integrates patient-specific factors, such as the likelihood of complete stone clearance and baseline pancreatic health.

While the findings are compelling, the relatively low rate of complete stone clearance (31%) in the cohort underscores the technical challenges of endotherapy. To optimize outcomes, clinicians should prioritize patients who have a high likelihood of success, such as those presenting with a single PD stone or alcoholic CP. Additionally, careful consideration must be given to the potential for procedure-related complications and the patient burden associated with repeated interventions. Clear communication about the benefits and risks of endotherapy vs. conservative management is essential, and shared decision-making should be emphasized to align treatment plans with patient preferences and expectations.

This study's retrospective design and lack of direct functional assessments, such as endocrine and exocrine testing, highlight the need for prospective studies to further elucidate the long-term benefits of endotherapy. Additionally, exploring biomarkers of pancreatic function and refining techniques for complete stone clearance could enhance the therapeutic potential of endotherapy in CP management.

The findings of this study pave the way for a re-evaluation of treatment strategies in CP with painless PD stones. While endotherapy shows promise in preserving pancreatic parenchymal volume, its application must be judicious, taking into account individual patient profiles and the procedural success likelihood. As the evidence base grows, this study serves as a foundational step toward optimizing outcomes for patients with CP, bridging the gap between traditional guidelines and evolving clinical insights.

Authors declare no conflict of interest for this article.

None.