Long-Term Outcome of Pancreatic Duct Stone Removal in Patients with Chronic Pancreatitis

Abstract

AIM: Determine the long-term outcome and clinical course after PD stone removal in pts with pain induced by chronic pancreatitis (CP) and PD obstruction. Improvement in pain has been previously reported after endoscopic stone removal and restoration of pancreatic drainage. METHODS: A retrospective review of all pts who had attempted stone removal from the PD (1991-2003) was done using a computer assisted data retrieval system. Pancreatic sphincterotomy was performed in all pts prior to stone removal. Attempts were made to remove MPD stones by balloon &/or basket/mechanical lithotripsy. If unsuccessful, PD stents were placed and the ERCP was repeated within 6-12 wks. If repeatedly unsuccessful, ESWL or EHL was used. Pain relief was assessed using an analog pain scale (0-10). Fisher's exact test was used to compare data. RESULTS: 78 pts (33 M, 45 F) with attempted PD stone removal were identified. The mean age was 54 yr (range 19-90). Etiology was determined to be: ETOH (24/78, 31%) idiopathic (38/78, 49%), divisum (9/78, 11%), hereditary (7/78, 9%). Stones were removed by: balloon &/or basket (54/78, 69%) and ESWL/EHL in addition to balloon &/or basket (24/78, 31%). Other characteristics of stones were: mean diameter 5.6 mm (range 2-18mm), single in 28 pts (36%) and multiple in 50 (64%). Complications were seen in 6% (5/78): bleeding (1), exacerbation of CP (4). Stricture of the MPD was seen in 69% (54/78) of pts. PD stents were placed in 92% (72/78) of pts to manage strictures and to facilitate stone removal. Mean number of stents used were 3.4 and they were exchanged on a regular basis. After multiple Rx interventions 30/78 (38%) had complete clearance of stones. Stone clearance was incomplete in 48/78 (62%). Average ERCPs needed in pts who had complete clearance of stones was 4.8. Four pts had pancreatic surgery during follow-up. Seven pts died during F/U. Among pts with complete ductal clearance, 27% (n=8) had no/partial relief of pain and 73% (n=22) had substantial relief. In pts with partial clearance 62% (n=30) had no/partial relief and 38% (n=18) had substantial relief. Analysis showed that substantial relief of pain was associated (p<0.01) with complete ductal clearance of stones. CONCLUSION: Substantial relief of pain in CP was significantly associated with complete stone clearance. Endoscopic attempts at removal of PD stones are worthwhile, although several ERCP sessions are required for complete stone clearance.