Chronic Pancreatitis: Role of Endoscopic Procedures.

Long-term Results of Extracorporeal Shockwave Lithotripsy and Endoscopic Therapy for Pancreatic Stones

Purpose: Extracorporeal shock wave lithotripsy (ESWL) is an important tool for non-operative management of symptomatic pancreatic duct (PD) stones. Fragmentation of stones may permit endoscopic extraction at ERP thereby avoiding surgical intervention. First generation devices used water immersion and fluoroscopic targeting and became an integral adjunct in the non-operative management of painful chronic pancreatitis (CP). Second generation devices had self-contained water conducters and lower power profiles with ultrasound targeting but were ineffective for PD stones. LithoGold (Woodstock, GA) represents the third generation of ESWL with fluoroscopic targeting and a similar power profile to first generation devices. We aim to determine the safety and efficacy of this latest generation ESWL device on stone fragmentation and endoscopic management of painful CP. Methods: Retrospective chart review of all patients (pts) undergoing either first generation ESWL (fESWL) vs. LithoGold (LG) from 6/02 to 10/08 at UPMC. Outcomes included successful completion of ESWL, complications, clearance of the main PD at subsequent ERPs, improvement in symptoms, and number of pts ultimately requiring surgery. Results: 17 pts (8 fESWL, 9 LG) underwent therapy for symptomatic PD stones (mean age 54 years [range 40-76]; 11 males, 6 females). All pts underwent ERP prior to ESWL with placement of PD stent in 12/17. 8/8 successfully completed fESWL with mean of 1.9 treatments/pt (range 1-4) compared to 8/9 successfully completing LG with mean of 1.1 treatments/pt (range 1-2). A single failure occurred in the LG group due to interference of the spinal vertebrae with the shock wave despite oblique positioning of the pt. On average, 1150 shocks (range 800-2000) at 20 kV were administered with fESWL and 1670 shocks (range 1000-2750) at 24kV with LG. There were no complications in the fESWL group and only one case of transient hematuria in the LG group. Clearance of the PD at subsequent ERPs was reported in 7/8 (88%) pts with fESWL and 6/8 (75%) pts with LG. Initially, 7/8 (88%) pts in fESWL group and 6/8 (75%) pts in LG group reported symptom improvement after stone extraction. Ultimately, 3/8 (38%) in the fESWL group and 1/8 (13%) in the LG group required surgery. Conclusion: In our experience, LG is safe and effective with comparable results to fESWL for the treatment of symptomatic PD stones. The portability of the LG unit obviates the need for a specialized unit equipped with a water basin for fESWL. The disparity in surgical intervention may be attributed to longer follow-up in the fESWL group. Randomized studies are needed to determine the efficacy of third generation lithotriptors for treating PD stones.

Introduction: ERCP with SpyGlass® cholangioscopy and electrohydraulic lithotripsy (EHL) is an established treatment for large common bile duct stones. However, the role of SpyGlass® EHL in treating patients with pancreatic duct calculi has yet to be well studied. The current management of pancreatic duct stones consists of extracorporeal shock wave lithotripsy (ESWL) or surgical intervention. The purpose of this case series is to study the safety and efficacy of SpyGlass® EHL in patients with pancreatic duct calculi. Methods: In patients with chronic pancreatitis and pancreatic duct stones, we performed ERCP with SpyGlass® pancreatoscopy and EHL in an attempt to break the calculi into smaller fragments in order to relieve the pancreatic duct obstruction. Consecutive patients with pancreatic duct stones were included in the study. Pancreatic duct stents were placed following lithotripsy in all patients. The stents were later removed at a 4-6 week interval after the procedure. Results: ERCP with SpyGlass® EHL was performed in 7 patients with chronic pancreatitis and stones. Two patients were relieved of their obstruction after only 1 procedure. Four patients required 2 procedures, and 1 patient required 3 procedures. ERCP with SpyGlass® EHL was successful in relieving the main pancreatic duct obstruction in 5 patients. The remaining 2 patients were referred to a multidisciplinary pancreas team for ESWL therapy. However, both these patients ended up requiring surgery. One patient received Puestow’s procedure while the other received Berger’s operation. Two patients had pain following the ERCP and EHL treatment and required overnight hospitalization. One patient had mild pancreatitis. No other complications were reported. Conclusion: ERCP with EHL appears to be a safe and effective therapeutic procedure in the majority of patients with chronic pancreatitis and pancreatic duct calculi. Larger studies are needed to validate the results of our pilot study.

Response:

For chronic pancreatitis (CP) with pancreatolithiasis, extracorporeal shock wave lithotripsy (ESWL), endoscopic stenting with plastic stents, and the endoscopic clearance of stone fragments are recommended treatment strategies. However, when a main pancreatic duct (MPD) stricture exists, pancreatolithiasis often becomes recurrent and refractory. However, the combination of radiofrequency ablation and metallic stent placement has recently been performed to treat malignant biliary stricture. In this case, we used a similar treatment in a patient with MPD stricture and recurrent pancreatolithiasis for the first time. A 46-year-old man visited a nearby doctor for abdominal pain. An MPD stone that was approximately 10 mm in length was observed in the pancreatic body on CT, and dilation of the distal MPD was observed. Pancreatolithiasis was found to be recurrent due to an MPD stricture at the pancreatic body following ESWL and endoscopic plastic stent placement. Therefore, we performed endoscopic stone clearance with RFA and endoscopic metallic stent placement. Three months later, the metallic stent was removed. After that, the patient was followed up, and there was no recurrence. The combination of RFA and metallic stent placement can serve as a novel treatment for symptomatic CP with MPD stricture and recurrent and refractory pancreatolithiasis.

Introduction: Endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and balloon/basket extraction is the first line management for symptomatic pancreatic duct (PD) stones. The risk of stone extraction failure via ERCP increases with PD stones that are >10mm, impacted, multiple stones or in a complicated location [1]. With difficult PD stones, fragmentation prior to extraction may be required. Stone fragmentation can be accomplished through extracorporeal shock wave lithotripsy (ESWL), per-oral pancreatoscopy (POP) laser lithotripsy (LL) and POP- electrohydraulic lithotripsy (EHL). We report a case of difficult PD stones successfully managed by POP-LL holmium laser. Case Description/Methods: A 48-year-old man with advanced primary sclerosing cholangitis with percutaneous biliary drainage and chronic pancreatitis presented for recurrent jaundice, right upper quadrant and midepigastric abdominal pain and pruritus. ERCP revealed the ventral PD filled with numerous stones and was swept with a balloon and 1 stone was removed. Repeat ERCP was performed 2 weeks later with balloon extraction of a few small stones and debris from the PD. The ventral duct was then explored under pancreatoscopy using Spyglass, revealing multiple stones in the head and neck of the pancreas. Lithotripsy was then accomplished using a holmium laser. No immediate nor distant post-ERCP complications were encountered. A 1-week follow up revealed resolution of abdominal pain. Discussion: The patient in our case had recurrent abdominal pain caused by pancreatic duct stones resulting in pancreatic outflow obstruction. Both attempts using ERCP with balloon sweeping were unsuccessful in complete stone extraction leading to the use of POP Spyglass with laser lithotripsy for the management of the multiple remaining stones. Direct visualization of the PD with technology like Spyglass, has shown to reduce the risk of duct injury, allows the visualization of stones that may have been missed previously, and permits confirmation of clearance of the PD (Figure). As seen in this case, POP allowed for visualization of PD stones that could not be accessed through ERCP management and used in conjunction with laser lithotripsy, the PD stones were successfully and safely fragmented. POP-LL has been shown to successfully fragment difficult to manage PD stones, as evidenced in this case and other studies, and should be considered as a useful alternative in the management of numerous PD stones and/or multiple unsuccessful ERCP attempts.Figure 1.: Laser lithotripsy with holmium laser being applied through the catheter (red arrow) to the PD stone (White arrow).

Introduction. To evaluate the efficacy of combined endoscopic lithotomy and extracorporeal shock wave lithotripsy (ESWL), and additional electrohydraulic lithotripsy (EHL) as needed, for the treatment of pancreatic duct stones, we retrospectively evaluated 98 patients with chronic pancreatitis and pancreatic lithiasis. Methods. For the management of main pancreatic duct (MPD) stones in 98 patients, we performed combined endoscopic treatment (ET)/ESWL therapy as the first treatment option. When combined ET/ESWL was unsuccessful, EHL with the SpyGlass Direct Visualization system or X-ray guided EHL was performed. Outpatient ESWL was reserved as one of the final treatment options. Results. Fragmentation was successful in 80 (81.6%) patients as follows: combined ET/ESWL: 67 cases; SpyGlass EHL: 4 cases; X-ray guided EHL: 3 cases; and outpatient ESWL: 6 cases. Successful outcome was obtained by combined ET/ESWL in 67 of the 98 patients (74.5%), by EHL in 7 of 14 patients (7.1%), and by outpatient ESWL in 6 of 6 patients (6.1%). Negotiating the guidewire through a severe MPD stricture was significantly associated with a higher rate of stone fragmentation (P = 0.0003). Conclusions. In cases where combined ET/ESWL was not successful for stone clearance, EHL using the SpyGlass system or X-ray guided EHL was effective in cases where the guidewire could be negotiated through the MPD stricture and it increased the fragmentation rate.

Pancreatic duct stones are a common complication during the natural course of chronic pancreatitis and often contribute to additional pain and pancreatitis. Abdominal pain, one of the major symptoms of chronic pancreatitis, is believed to be caused in part by obstruction of the pancreatic duct system (by stones or strictures) resulting in increasing intraductal pressure and parenchymal ischemia. Pancreatic stones can be managed by surgery, endoscopy, or extracorporeal shock wave lithotripsy. In this review, updated management of pancreatic duct stones is discussed.

Background:Temporary stent placement is widely performed for pancreatic duct stenosis due to chronic pancreatitis. A fully covered self-expandable metal stent (FCSEMS) has a larger diameter, and therefore longer stent patency, and the effect of expansion of the main pancreatic duct stricture may be obtained. However, if stent migration upstream occurs, stent removal is extremely difficult. In addition, because of the diameter gap between the FCSEMS and the main pancreatic duct, stent-induced ductal change may occur. To prevent these adverse events, the technical feasibility, safety and efficacy of the placement of a novel 6 mm diameter FCSEMS with a long suture, to facilitate its removal in cases of stent migration upstream, were evaluated in a pilot study.Methods:Between December 2014 and August 2015, symptomatic chronic pancreatitis patients with abdominal pain and a main pancreatic head duct stricture were enrolled. Stent placement for main pancreatic duct stricture was performed under endoscopic retrograde cholangiopancreatography (ERCP) guidance and stent removal was performed within 6 months.Results:A total of 13 patients were retrospectively enrolled in this study. Metal stent insertion was successfully performed in all patients and clinical success was high (12/13, 92%). As adverse events, stent migration upstream was seen in two patients. Another 11 patients successfully underwent stent removal without any adverse events. During follow up (median 258 days), 2 patients still underwent pancreatic duct stenting because of continuing main pancreatic duct stricture.Conclusion:In conclusion, this novel FCSEMS is acceptable for stent placement in cases of chronic pancreatitis with a main pancreatic duct stricture.

<h3>Introduction</h3> Painful chronic pancreatitis is often associated with main duct obstruction due to stones. Approaches to management are challenging, including surgery, extracorporeal shock wave lithotripsy (ESWL), or endoscopic approaches. All have their limitations. Electrohydraulic lithotripsy (EHL) using Spyglass<b>™ </b>directed visualisation is highly effective for treating difficult bile duct stones, and is increasingly used in the UK. Here we report our early experience of Spyglass ™ pancreatoscopy and EHL for pancreatic duct stones. <h3>Method</h3> We retrospectively audited our unit’s use of Spyglass<b>™</b>EHL in the period February 2013–February 2015, with a focus on those patients undergoing pancreatic EHL. Indication, procedural details, and clinical outcome were assessed. <h3>Results</h3> Eighty-five procedures for Spyglass<b>™</b>and EHL for stones were performed, of which 5 (6%) were carried out for pancreatic stones in 4 patients (3 female, mean age 46 years ±16 years). All patients had painful chronic pancreatitis, with radiological evidence of a dilated pancreatic duct, and main duct stone disease within 2 cm of the ampulla. Surgical options had been considered in all cases. Prior to EHL all patients had undergone pancreatic sphincterotomy and pancreatic duct stenting. Stone fragmentation and duct decompression was achieved in 75% (3/4) of cases. One patient required two EHL procedures to achieve clearance. In the patient with failed clearance, pancreatoscopy revealed that the stone was not in the main duct, but in the adjacent parenchyme. There were no procedure related complications. All patients with successful EHL had pain relief/marked improvement at clinical review (mean follow up - 6.8 ± 5 months). <h3>Conclusion</h3> Pancreatoscopy with EHL may have a valuable role in treating obstructing pancreatic duct stones, possibly avoiding the need for surgery in some patients. However, careful patient selection is mandatory, and more studies are needed to better define treatment approaches. <h3>Disclosure of interest</h3> None Declared.

Endoscopic treatment of pancreatic duct stones using a 10F pancreatoscope and electrohydraulic lithotripsy

Endoscopic retrograde cholangiopancreatography (ERCP), which is the basic method of endoscopic treatment for pancreatic disease, was first reported in 1968 by McCune et al.,1 and was later spread worldwide by Oi2 and Takagi et al.3 Although subsequent advances in other modalities such as computed tomography and magnetic resonance imaging have reduced the use of ERCP for diagnostic imaging, ERCP-related procedures are increasingly used for therapeutic purposes. In this article, I review the use of endoscopic pancreatic sphincterotomy (EPST) and endoscopic pancreatic drainage as endoscopic treatments for pancreatic disease. Endoscopic pancreatic sphincterotomy is a procedure used to widen the pancreatic orifice by resecting the major and minor papillae. The procedure was first reported in 1983 by Inui et al.4 for the treatment of pancreatolithiasis, and was then popularized worldwide by Fuji et al.5 Fuji et al.5 reported that they successfully performed EPST in 10 of 13 patients with chronic pancreatitis, nine of whom exhibited an improvement in symptoms. Peroral pancreatoscopy was conducted in three of these patients, and calculi were removed with a basket catheter under direct visual observation in two patients. Pancreatic duct stenting was also conducted in three patients. The main indications and purpose of EPST are as follows (Table 1). Endoscopic extraction of pancreatic calculi Spontaneous delivery of pancreatic calcifications fragments following extracorporeal shock wave lithotripsy Decompression of increased pressure within the pancreatic duct Pancreatic stenting Endoscopic pancreatic sphincterotomy is performed to facilitate the insertion of devices for the endoscopic extraction of pancreatic calculi and prevent the basket from being impacted (Fig. 1). It may also be performed to enable the spontaneous delivery of pancreatic calcification fragments following extracorporeal shock wave lithotripsy. In chronic pancreatitis patients with pancreatic duct stricture, EPST is used (i) for pancreatic duct decompression by relieving a stricture in the pancreatic duct near the papillae, (ii) for large-diameter stent placement for main pancreatic duct stricture, and (iii) as a pretreatment for procedures such as the differential diagnosis of main pancreatic duct stricture as benign or malignant by peroral pancreatoscopy and electrohydraulic lithotripsy. In sphincter of Oddi dysfunction, endoscopic treatment may be required in patients with pain refractory to pharmacological and other medical treatments, or with abnormal hepatobiliary or pancreatic enzyme levels. In most cases, these are improved by endoscopic sphincterotomy (EST) alone, but EPST should also be considered in cases with main pancreatic duct dilation combined with elevated pancreatic enzymes or residual pancreatic pain following EST. Pancreas divisum is a congenital condition in which most of the pancreatic juices flow into the duodenum via the smaller orifice of the minor papilla, frequently causing recurrent acute pancreatitis. Such patients may respond to minor pancreatic sphincterotomy (Fig. 2). Even in the absence of pancreas divisum, minor pancreatic sphincterotomy may also dramatically improve the condition of patients in whom the pancreatic juices predominantly flow through the dorsal pancreatic duct and the minor papilla is undeveloped, such as those with ventral pancreatic duct obstruction/stricture or a calculus filling the ventral pancreatic duct. Endoscopic pancreatic sphincterotomy can be used as a precut method when deep biliary cannulation is difficult, by cutting from the pancreatic duct orifice in the direction of the bile duct orifice using a sphincterotome inserted into the main bile duct. In terms of pathophysiology and purpose, pancreatic drainage can be broadly divided into pancreatic duct drainage for chronic pancreatitis, prophylactic pancreatic duct drainage to prevent post-ERCP pancreatitis, and drainage of pancreatic fluid collection. In most cases, pancreatic fluid is drained by the less invasive method of endoscopic drainage, and either transpapillary drainage or endoscopic ultrasound (EUS)-guided transgastrointestinal drainage may be selected depending on the condition. Recently, attempts have also been made to perform EUS-guided pancreatic duct drainage in patients for whom the deep pancreatic duct cannot be accessed via the papilla. Many patients with chronic pancreatitis develop stricture of the pancreatic duct, which may cause chronic pain due to elevated pressure within the pancreatic duct as well as recurrent pancreatitis. Stricture may also be the cause of pancreatic calculus or pseudocyst formation. Endoscopic pancreatic duct drainage is effective in such symptomatic patients, and is indicated in the following cases, among others: (i) patients with a dilated distal pancreatic duct due to stricture and experiencing pain believed to be caused by elevated pressure within the pancreatic duct; (ii) patients with recurrent obstructive pancreatitis due to stricture; (iii) patients in whom stricture has resulted in pseudocyst formation causing some sort of symptoms; (iv) pancreatic abscess; (v) for the prevention of pancreatic calculus formation due to pancreatic fluid congestion and the prevention of recurrence following pancreatolithotripsy; and (vi) pancreatic fistula due to pancreatic duct disruption.6 Stent treatment for chronic pancreatitis was first reported by Fuji et al.,5 in which they described stent placement following EPST and the use of peroral pancreatoscopy to remove pancreatic calculi. Many subsequent reports have described high short-term response rates of 70–95%, but long-term recurrence-free rates of only approximately 50%.7 All previous randomized controlled trials comparing endoscopic and surgical treatments have demonstrated that surgical treatment is superior to endoscopic treatment. Dite et al.8 reported that the pain had completely disappeared at 5 years posttreatment in 37% of patients who underwent surgery, but only 14% of those treated endoscopically. Cahen et al.9 also found that the pain score at 2 years posttreatment was lower in patients treated surgically than in those treated endoscopically. Because endoscopic treatment is less invasive than surgical treatment, it is typically considered a first-line treatment, but taking the continuation of this treatment for approximately 1 year as one criterion, surgery must also be considered for patients in whom stent placement is ineffective and those whose abdominal pain recurs after treatment.10 A number of factors are believed to be involved in the etiology of post-ERCP pancreatitis, but pancreatic juice congestion as a result of duodenal papillary edema is considered to be a major factor. Prophylactic pancreatic duct stenting is one means of preventing this, particularly in high-risk groups (including women, patients with a history of post-ERCP pancreatitis, those in whom deep biliary cannulation is difficult, those undergoing multiple pancreatography or sphincterotomy, and patients with papillary dysfunction).11 One such procedure is the use of pancreatic spontaneous dislodgement stents, which are designed to dislodge spontaneously a few days after placement and are reportedly effective.12 In most cases, pancreatic fluid is drained by the less invasive method of endoscopic drainage, and either transpapillary drainage or EUS-guided transgastrointestinal drainage may be selected based on the condition. Transpapillary drainage is widely performed as an ERCP-associated procedure, but it is not always possible to place the drainage tube within the cyst. EUS-guided transgastrointestinal drainage enables the cyst to be approached directly, but as it can only be performed if the cyst is adhering to the gastrointestinal wall, its indications must be carefully considered. Walled-off necrosis (WON) develops when accumulated exudate or peripancreatic necrotic substances become encapsulated in the cavity of the bursa omentalis or elsewhere. Because the gastric serosa and the bursa omentalis essentially adhere to one other, if the WON is punctured transgastrically under EUS guidance there is little danger that its contents will leak into the abdominal cavity, and it is therefore a comparatively safe drainage procedure. It is also possible to create a large fistula between the stomach and the WON and insert the endoscope into the cavity of the bursa omentalis in order to perform a necrosectomy. Suspected communication between the bursa omentalis cavity and the pancreatic duct is an indication for transpapillary pancreatic duct drainage. In many cases, however, patients with necrotic substance accumulation do not improve with transpapillary drainage alone. In pancreatic pseudocyst (PPC), because the cyst wall and gastric wall are not typically in contact, when the cyst is punctured its contents may leak into the abdominal cavity, and EUS-guided transgastrointestinal drainage should only be undertaken with caution. Transpapillary drainage is indicated in the case of communication between the PPC and the main pancreatic duct, or of stricture of the main pancreatic duct on the papillary side of the PPC. In most patients with repeated exacerbations of chronic pancreatitis, the gastrointestinal wall and the cyst wall adhere to one other, making EUS-guided transgastrointestinal drainage feasible. Advances in endoscopic treatments for pancreatic disease have mainly involved EPST and pancreatic duct drainage, and EUS-guided treatment has also recently come into use, chiefly in high-volume centers. Endoscopic treatment is minimally invasive, and further advances are anticipated in the future. I thank Editage (www.editage.com) for English language editing. Author declares no conflict of interest for this article. None.

Tu1405 LONG TERM OUTCOMES OF ENDOTHERAPY USING A DEDICATED PANCREATIC BASKET CATHETER FOR PANCREATIC DUCT STONES

Pancreatic duct stones are sequela of chronic pancreatitis. They can cause pancreatic duct obstruction which is the most important cause of pain in chronic pancreatitis. Stone resolution has shown to improve pain. The goal of this review is to highlight recent endoscopic and surgical advancements in treatment of pancreatic duct stones. Stone fragmentation by extracorporeal shock wave lithotripsy has become first line and the mainstay of treatment for majority of patients with pancreatic duct stones. Introduction of digital video pancreatoscopy in the last few years with the capability of guided lithotripsy has provided a robust therapeutic option where extracorporeal shock wave lithotripsy is unsuccessful or unavailable. Historically, surgery has been considered a more reliable and durable option when feasible. However, it had not been compared with more effective endoscopic therapy. Lithotripsy (extracorporeal and pancreatoscopy guided) is evolving as a strong treatment modality for pancreatic stones.

Pilot Study of Dumbbell-Type Covered Self-Expandable Metal Stent Deployment for Benign Pancreatic Duct Stricture (with Videos)