**8. Pancreatic strictures**

Pancreatic strictures can be diagnosed radiologically by CT and MRI/MRCP with supplementation with Endoscopic Ultrasound, secretin-enhanced MRCP, pancreatic function tests especially in the early stages with limited structural changes [27]. ESGE recommends treating painful dominant main pancreatic duct (MPD) strictures with insertion of a single stent across the dominant MPD stricture for one uninterrupted year. Dominant pancreatic strictures are defined by presence of at least one of the following characteristics: upstream MPD dilatation ≥6mm in diameter, prevention of contrast medium outflow alongside a 6-Fr catheter inserted upstream from the stricture, or abdominal pain during continuous infusion of a naso-pancreatic catheter inserted upstream from the stricture with 1L saline for 12–24hours. Pancreatic duct stents decompress the MPD and persistently dilate the stricture relieving pain and may improve the exocrine pancreatic function [14]. Numerous studies have demonstrated pain relief [28]. In a meta-analysis involving 1498 patients, 88% had immediate pain relief and 67% had long-term pain relief with endotherapy for pancreatic strictures with a 7.85% complication rate [29].

Multiple side-by-side stents and self-expandable metal stents (SEMSs) can be used for refractory strictures. Fully covered SEMSs have been demonstrated to offer better pain relief results over the uncovered and partially covered types, though further

studies need to be conducted due to the associated potential complications [14]. Endoscopic ultrasonography can facilitate drainage of symptomatic MPD obstruction with failed trans-papillary approach with either the Rendezvous technique (puncturing the MPD through the gastric or duodenal wall and advancing a guidewire into the MPD to proceed with trans-papillary drainage) or through transmural drainage through a stent [14].

Malignancy should be ruled out before stent dilatation therapy.
