577 Per Oral Pancreatoscopy With Intraductal Holmium Laser Lithotripsy for Treatment of Main Pancreatic Duct Calculi: A Multi-Center U.S. Experience

Abstract

Per Oral Pancreatoscopy With Intraductal Holmium Laser Lithotripsy for Treatment of Main Pancreatic Duct Calculi: A Multi-Center U.S. Experience Raj J. Shah*, Augustin R. Attwell, Isaac Raijman, Michel Kahaleh, Sandeep Patel University of Colorado Hospital, Aurora, CO; Weill Cornell University, New York, NY; University of Texas, San Antonio, San Antonio, TX; Digestive Associates of Houston, Houston, TX Background: Theoretical advantages of per oral pancreatoscopy (POP)-guided laser (LL) vs. electrohydraulic (EHL) lithotripsy of pancreatic duct (PD) stones is treating firmer calculi and reusing fibers; however, more precision is required. An advantage over ESWL is fragmenting and removing stones during the same procedure. We evaluated the technical success of LL for PD stones. Methods: Patients undergoing POP-LL at four U.S. centers were retrospectively identified. Opiate use, hospitalizations, pain scores, duct clearance, ESWL, and complications were recorded. Study definitions: Technical Success: complete or partial stone clearance. Clinical Success: greater than 50% reduction in opiate use, pain scores, or hospitalizations. Stone fragments were retrieved using baskets and balloons and strictures were dilated and stented. Follow-up was obtained by chart review and patient contact. Categorical variables are reported as medians. Results: Between October 2008 and November 2011, 28 patients [26M, 12F, age 51(17-74) years] underwent POP for PD stones with attempted LL using Spyglass. CP etiology: alcohol (N 14, 50%), idiopathic (N 7, 28%), other (N 7, 28%). Baseline parameters: pain requiring hospitalization (N 19, 68%), chronic opiate use (N 14, 50%), weight loss (N 11, 39%). Interventions preceding index POP-LL: ERCP [(22/28 (79%) had 1 (1-5)]; ESWL [9/28 (32%) had 2 (1-3)]; POP /EHL with failed or incomplete stone fragmentation [7/28 (25%) had 1 (1-3)]. At index POP, a median of 1 (1-5) stone 15mm (4-32mm)in size was located in the head (N 9, 25%) neck (N 3, 11%), body (N 9, 36%), tail (N 1, 4%%) or multiple sites (N 6, 21%). LL settings: 1-10J/5-10W using 200365nm probes and range of 2850-7763 pulses. Stricture dilation was performed in 21/28 (75%)patients and all were stented. Mild complications in 7/28 (25%) index POP-LL procedures. 100% follow-up for 11 (1-25) months. Additional interventions: 38 ERCPs [median 1 (1-6) per patient] and 11 POP (1-3 per pt) were performed to achieve 97% Technical Success with complete (24/28; 86%) and partial (3/28; 11%) clearance. Six patients are ongoing endotherapy for strictures (N 4), stones (N 1), or both (N 1). Clinical Success in 27/28 (96%) by improvement in pain (N 26), reduction in narcotics (N 25) or hospitalizations (N 19). No stone recurrence or surgery was observed. Conclusions: 1) When POP reaches the target stone, LL performed at expert centers results in a high rate of complete stone clearance and clinical improvement at nearly one year of follow-up. 2) POP-LL appears to have utility in cases where fragmentation with EHL is ineffective or incomplete. 3) Although ESWL was adjunctive in 1 of 3 patients with obstructing stones, ERCP-POP may be a preferred primary modality due to the ability to stent strictures and extract stone fragments at the same procedural session.