Martin L. Freeman, MD, Editor

Although great strides have been made in the diagnosis and management of pancreatic diseases, several important cautionary notes should be stressed. First, effective endoscopic management of pancreatic diseases requires substantial understanding of the disease processes in the pancreas, which is highly variable among endoscopists focused primarily on therapeutic endoscopy rather than the discipline of pancreatology. It is becoming increasingly clear that acute recurrent and chronic pancreatitis are the result of multifactorial predisposing factors, including genetics, environment, dietary, and toxic exposures as well as structural. Endoscopists tend to focus primarily on structural causes or consequences of disease. Thus education regarding diseases and management of the pancreas is highly desirable for practitioners and is ideally accomplished within organizations and institutions focused on pancreatic diseases rather than solely on therapeutic endoscopy.

Second, effective management of pancreatic disease requires a team approach with active cooperation among multiple specialties including specialized surgery, critical care, oncology, and diagnostic and interventional radiology. Probably no single entity exemplifies this more than management of necrotizing pancreatitis, for which morbidity and mortality is potentially very high, but endoscopic intervention is evolving as the procedure of choice in many circumstances, such as infected walled off necrosis. Before, during, and after pancreatic endoscopic interventions such as endoscopic necrosectomy, close cooperation with all of the above specialties is absolutely essential for good outcomes. Furthermore, the efficacy of endoscopic therapy of the pancreas is highly variable. The decision to pursue endoscopic therapy in the pancreas should be a multidisciplinary one, considering alternatives to endoscopic therapy. Once a decision to pursue endoscopic therapy has been made, it is essential to have a clear goal, an endpoint such that procedures such as ERCP with pancreatic stenting are not repeated excessively. Many pancreatic centers have seen patients with chronic pancreatitis who have undergone in excess of 50 ERCPs without substantial long-term improvement. There must be a plan for alternative treatment such as surgical or other management if and when endoscopic therapy fails to achieve the hoped goal. Particularly challenging is relief of chronic intractable pain associated with acute recurrent and chronic pancreatitis, which represent a continuum of diseases. Increasingly, new alternatives such as total pancreatectomy with islet autotransplantation are becoming feasible. If patients are appropriate for these alternative treatments, endoscopists should always question the value of embarking on long and expensive courses of endoscopic therapy. It is likely that reimbursement for such practices will eventually end.

Finally, the difficult question of who should be performing these advanced pancreatic endoscopic procedures? The demand for extreme technical expertise and performance of a high volume of these specialized procedures is probably greater than for any other area of gastrointestinal endoscopy. The potential for complications, sometimes severe or fatal, is enormous. There is probably no procedure in gastrointestinal endoscopy that carries a higher risk-to-benefit ratio. In fact, in some entities such as recurrent acute pancreatitis, due to a lack of randomized controlled trials, there are lingering questions as to whether there is any substantial benefit from commonly performed interventions such as minor papillotomy for pancreas divisum. As a result, it is recommended that the procedures discussed in this issue be performed only by highly specialized endoscopists at advanced medical centers, and with a deep understanding of the underlying disease processes they are addressing, and ideally with ongoing collection of data.

In this issue, I have had the privilege of including contributions from many of the world’s leaders in specific topics and procedures covering most of the spectrum of endoscopy in the diagnosis and treatment of pancreatic diseases. I am hopeful that readers will find this issue informative and instructive, with insights, analyses, tips, and tricks that will potentially improve their patients’ outcomes. I am very grateful to Dr Charles Lightdale for the opportunity to bring this issue to light.