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This clinical practice guideline from the American Society for Gastrointestinal Endoscopy (ASGE) provides an evidence-based approach for the role of endoscopy in the management of chronic pancreatitis (CP). This document was developed using the Grading of Recommendations Assessment, Development and Evaluation framework. The guideline addresses effectiveness of endoscopic therapies for the management of pain in CP, including celiac plexus block, endoscopic management of pancreatic duct (PD) stones and strictures, and adverse events such as benign biliary strictures (BBSs) and pseudocysts. In patients with painful CP and an obstructed PD, the ASGE suggests surgical evaluation in patients without contraindication to surgery before initiation of endoscopic management. In patients who have contraindications to surgery or who prefer a less-invasive approach, the ASGE suggests an endoscopic approach as the initial treatment over surgery, if complete ductal clearance is likely. When a decision is made to proceed with a celiac plexus block, the ASGE suggests an EUS-guided approach over a percutaneous approach. The ASGE suggests indications for when to consider ERCP alone or with pancreatoscopy and extracorporeal shock wave lithotripsy alone or followed by ERCP for treating obstructing PD stones based on size, location, and radiopacity. For the initial management of PD strictures, the ASGE suggests using a single plastic stent of the largest caliber that is feasible. For symptomatic BBSs caused by CP, the ASGE suggests the use of covered metal stents over multiple plastic stents. For symptomatic pseudocysts, the ASGE suggests endoscopic therapy over surgery. This document clearly outlines the process, analyses, and decision processes used to reach the final recommendations and represents the official ASGE recommendations on the above topics., Competing Interests: Disclosure The following authors disclosed financial relationships: S. G. Sheth: Consultant for Janssen Research & Development, LLC. J. D. Machicado: Consultant for Mauna Kea Technologies, Inc; food and beverage compensation from Mauna Kea Technologies, Inc and Boston Scientific Corporation. J. M. Chalhoub: Travel compensation from Olympus Corporation of the Americas;food and beverage compensation from Boston Scientific Corporation. C. Forsmark: Consultant for Nestle Healthcare Nutrition, Inc. N. C. Thosani: Consultant for Pentax of America, Inc, Boston Scientific Corporation, AbbVie Inc, and Ambu Inc; travel and food and beverage compensation from Pentax of America, Inc, Boston Scientific Corporation, and AbbVie Inc; speaker for AbbVie Inc. N. R. Thiruvengadam: Research support from Boston Scientific Corporation. S. Pawa: Consultant for Boston Scientific Corporation. S. Ngamruengphong: Consultant for Boston Scientific Corporation; food and beverage compensation from Medtronic, Inc, Boston Scientific Corporation, Pentax of America, Inc, and Ambu Inc. N. B. Marya: Consultant for Boston Scientific Corporation; food and beverage compensation from Boston Scientific Corporation and Apollo Endosurgery US Inc. D. R. Kohli: Research support from Olympus Corporation of the Americas. L. L. Fujii-Lau: Food and beverage compensation from Pfizer Inc. and AbbVie Inc. N. Forbes: Consultant for Boston Scientific Corporation, Pentax of America, Inc, AstraZeneca, and Pendopharm Inc; speaker for Pentax of America, Inc and Boston Scientific Corporation; research support from Pentax of America, Inc. S. E. Elhanafi: Food and beverage compensation from Medtronic, Inc, Nestle HealthCare Nutrition Inc, Ambu Inc, Salix Pharmaceuticals, Takeda Pharmaceuticals USA, Inc, and Merit Medical Systems Inc. N. Cosgrove: Consultant for Olympus Corporation of the Americas and Boston Scientific Corporation; food and beverage compensation from Boston Scientific Corporation and Ambu Inc. N. Coelho-Prabhu: Consultant for Boston Scientific Corporation and Alexion Pharma; research support from Cook Endoscopy and FujiFilm; food and beverage compensation from Olympus America Inc and Boston Scientific Corporation. S. K. Amateau: Consultant for Boston Scientific Corporation, Merit Medical, Olympus Corporation of the Americas, MTEndoscopy, US Endoscopy, Heraeus Medical Components, LLC, and Cook Medical LLC; travel compensation Boston Scientific Corporation; food and beverage compensation from Boston Scientific Corporation, Olympus Corporation of the Americas, and Cook Medical LLC; advisory board for Merit Medical. W. Abidi: Consultant for Ambu Inc, Apollo Endosurgery US Inc, and ConMed Corporation; food and beverage compensation from Ambu Inc, Apollo Endosurgery US Inc, ConMed Corporation, Olympus America Inc, AbbVie Inc, Boston Scientific Corporation, RedHill Biopharma Inc, and Salix Pharmaceuticals; research support from GI Dynamics. B. J. Qumseya: Consultant for Medtronic, Inc and Assertio Management, LLC; food and beverage compensation from Medtronic, Inc, Fujifilm Healthcare Americas Corporation, and Boston Scientific Corporation; speaker for Castle Biosciences. All other authors disclosed no financial relationships., (Copyright © 2024 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Objective: There is an unmet clinical need for effective, targeted interventions to prevent post-ERCP pancreatitis (PEP). We previously demonstrated that the serine-threonine phosphatase, calcineurin (Cn) is a critical mediator of PEP and that the FDA-approved calcineurin inhibitors, tacrolimus (Tac) or cyclosporine A, prevented PEP. Our recent observations in preclinical PEP models demonstrating that Cn deletion in both pancreatic and hematopoietic compartments is required for maximal pancreas protection, highlighted the need to target both systemic and pancreas-specific Cn signaling. We hypothesized that rectal administration of Tac would effectively mitigate PEP by ensuring systemic and pancreatic bioavailability of Tac. We have tested the efficacy of rectal Tac in a preclinical PEP model and in cerulein-induced experimental pancreatitis., Methods: C57BL/6 mice underwent ductal cannulation with saline infusion to simulate pressure-induced PEP or were given seven, hourly, cerulein injections to induce pancreatitis. To test the efficacy of rectal Tac in pancreatitis prevention, a rectal Tac suppository (1 mg/kg) was administered 10 min prior to cannulation or first cerulein injection. Histological and biochemical indicators of pancreatitis were evaluated post-treatment. Pharmacokinetic parameters of Tac in the blood after rectal delivery compared to intravenous and intragastric administration was evaluated., Results: Rectal Tac was effective in reducing pancreatic injury and inflammation in both PEP and cerulein models. Pharmacokinetic studies revealed that the rectal administration of Tac helped achieve optimal blood levels of Tac over an extended time compared to intravenous or intragastric delivery., Conclusion: Our results underscore the effectiveness and clinical utility of rectal Tac for PEP prophylaxis., Competing Interests: Declaration of competing interest S.Z.H is on the Scientific advisory board of ATIAS pharma., (Copyright © 2023. Published by Elsevier B.V.)

Life expectancy is rising, which is increasing the demand for endoscopic retrograde cholangiopancreatography (ERCP) in the elderly. Little data, particularly on complex procedures, has been reported. In this study, we compare the differences in the success and complications in ERCP between patients older and younger than 80 years old. We used a large endoscopic database reviewing the ERCPs performed and 30-day complications addressing age, degree of difficulty of procedures, and complications. A total of 2,606 patients underwent 3,924 ERCPs. Six hundred and twenty-eight were octogenarians undergoing 728 procedures. Mean age was 83.5 years in the octogenarian group and 59.0 years in the younger group. The endoscopic success rate was lower in octogenarians (96.9 vs. 98.3%, P = 0.004). Overall, complication rates between both groups was significantly less in older compared to younger patients (1.64 vs. 3.50%, P = 0.006). Complication and failure rates were higher as procedure complexity increased in all patients. ERCP in the elderly carries a high degree of success with low complication rates. Elderly patients carry similar risks of bleeding and perforation and a lower risk of pancreatitis.