**8.1 Treatment of the pain**

Although all therapeutic approaches for pancreatic pain is not very effective, endoscopic therapy is still one of the choices in patients whose pain is refractory to non-interventional therapy and who has remarkable anatomic alterations in their pancreas and/or in the surrounding tissue. There is no evidence for the use of the endoscopy in the mild disease or in painless CP [86–88]. Endoscopic therapy could be beneficial in patients with a symptomatic pancreatic duct obstruction in the pancreatic head or neck, together with an upstream duct dilatation, Plastic stents and fully covered self-expandable metal or biodegradable stents are safe and effective options for the relief of pancreatic outflow obstruction, and eventually of the pain [89–91]. Although celiac plexus (endoscopic or percutaneous) is still commonly used in clinical practice, the evidence for its efficacy of celiac plexus block in CP remains weak [92].

### **8.2 Treatment of the pancreatic duct stones**

Pancreatic stones are the result of the CP and they are usually getting calcified with progression of the disease [93]. Pancreatic ductal stones which cause symptoms such as pain by obstructing the flow of pancreatic juice, recurrent episodes of pancreatitis, or present with pseudocyst or fistula and other complications can be treated by endoscopic methods [94].

The location of the stone in the duct and its number is important for deciding endoscopic methods. Stones in the head and neck of the pancreas can be extracted with endoscopy, with or without stent replacement. However, endoscopic treatment is not suitable for stones, which already caused overt local complications or are located distally [85, 95, 96].

Pancreatic duct stones smaller than 5 mm are extracted by the ERCP, while extracorporeal shock wave lithotripsy (ESWL) is suggested for the clearance of radiopaque obstructive stones larger than 5 mm. Furthermore, recent studies suggest that performance of ESWL prior to the endoscopic attempt at stone extraction can provide more successful stone clearance [97–99].

### **8.3 Treatment of the pancreatic pseudocyst**

Pancreatic pseudocysts develop as a frequent complication between 20 and 40% of CP patients [100]. It is most prevalent in alcoholic CP, followed by idiopathic CP [101, 102]. Almost 40% of the pseudocyst, especially smaller ones can resolve within the 6 weeks after the attack. However, if it does not, the probability for a complication such as infection or rupture is 2/3 of all cases. Endoscopic drainage, which has a lower morbidity rate than surgery, is a successful treatment strategy for a symptomatic or complicated pseudocyst [103]. There are two main technics for the drainage of the pseudocyst: transmural or transpapillary drainage. Whereas transmural drainage can be applied to every pseudocyst, transpapillary drainage is feasible, only if the pseudocyst has a connection to major pancreatic duct [104]. It is recommended that EUS- guided access has higher technical success than the conventional approach [105]. Another important consideration when planning a pseudocyst drainage is the existence of pseudoaneurysms and portal hypertension. EUS guided drainage is recommended in case of portal hypertension as bleeding is common complication in these patients [106]. And since the mortality is very high due to ruptured aneurysms, embolization of the artery prior to the endoscopic intervention is recommended [107].

### **8.4 Treatment of the biliary strictures**

Biliary strictures are big obstacles during CP treatment. They are prevalent almost 46% of the CP patients. The symptoms include abdominal pain, jaundice, fever and the laboratory results show elevated serum alkaline phosphatase and/or bilirubin [108]. The endoscopic therapy is found to be long term effective only in 1/3 of the endoscopically treated patients. Therefore, endoscopic management is mostly used as transient therapy before the surgery [109, 110]. Studies suggest that placement of multiple plastic stents into the bile duct to treat bile duct obstruction in patients with chronic pancreatitis [111]. An important point about this clinical picture is absolute exclusion of the malignancy. It is essential to exchange the stents every 3 months to prevent the occlusion. However, this period is not such critical in multiple stents [111].

### **9. Surgical treatment**

When medical treatments fail, endoscopy and surgical resection, drainage procedures, or both can be used to relieve pain. These procedures are used to treat pancreatic ductal obstruction caused by stones, strictures, or both in order to relieve intraductal hypertension and thereby pain [112]. Whether surgical or endoscopic therapy should be offered first is controversial [2].

### *Current Approaches in Chronic Pancreatitis DOI: http://dx.doi.org/10.5772/intechopen.98214*

Despite weaknesses in the study design, two randomized controlled trials found that surgery offered greater long-term pain relief than endoscopy [95, 96, 113]. This effect may be explained by the fact that surgical treatment not only relieves ductal hypertension by allowing drainage, but also removes inflamed tissue that causes neural changes and pain [114, 115]. In another clinical trial, comparing the costeffectiveness of endoscopy and surgery, 38 CP patients were equally randomized and the mean number of ERCPs performed in the endoscopy group (6.3 vs. 0.4) was higher than in the surgery group [116].

Many patients prefer endoscopic therapy at first, in spite of the efficacy of surgery and frequent need for repeated procedures among people undergoing endoscopy because it is less invasive [112]. Patients with large inflammatory mass of the pancreatic head, distal pancreatic stenosis, and pancreatic head calcifications can be challenging to treat by endoscopy [85]. If endotherapy fails to provide immediate symptom relief without the need for repeated endoscopies, surgery should be considered by a multidisciplinary team [2]. Endoscopy is most frequently used as a therapeutic trial to determine patients most likely to benefit from surgery. While this approach is intuitive, the clinical evidence supporting this approach is not robust and more methods for predicting pain response are urgently required to prevent unhelpful interventions [117].

Surgery can be an effective first-line treatment for patients with CP who have large and multiple pancreatic stones or complicated strictures, an inflammatory mass of the head or a disease confined to the pancreatic tail [112]. Patients who are referred within 3–5 years of the onset of symptoms and have had less than four endoscopic procedures prior to surgery have better surgical outcomes [118].

The type of surgery is determined by the anatomy, the course of the disease, and local preferences [119]. The surgical approaches used to treat patients with CP are drainage options, resection options and neuroablative procedures [120]. Drainage options are cystojejunostomy, laterolateral pancreaticojejunostomy (Partington-Rochelle procedure) and caudal drainage (Puestow procedure). Resection options are pancreaticoduodenectomy (PD/Kausch-Whipple procedure) or pylorus preserving pancreaticoduodenectomy (PPPD/Traverso-Longmire-procedure), duodenum-preserving pancreatic head resection (DPPHR (Beger, Frey, Hamburg, Berne)), V-shaped excision, segmental resection and distal/total pancreatectomy. Neuroablative procedures are percutaneous radiofrequency ablation of the splanchnic nerves and thoracoscopic splanchnicectomy [120].

Total pancreatectomy accompanied by digestion of the pancreas, isolation of the islet cells and infusion into the patient's portal circulation is a radical surgical alternative that enables glucose homeostasis to be maintained without the need for immunosuppression of allogeneic islet transplantation [121]. Outside of the United States, total pancreatectomy with autoislet transplantation is still not widely available [2]. The primary indication for total pancreatectomy and islet auto transplantation is intractable pain that has a significant effect on quality of life (TPIAT) according to current clinical guidelines [122]. The procedure is successful in reducing or eliminating pain with a positive impact on quality of life [121–123]. However, severe pain persists in a large number of patients even after total pancreatectomy [124].
