Pancreatoscopy-guided intracorporeal laser lithotripsy for difficult pancreatic duct stones: a case series with prospective follow-up (with video)

Abstract

Pancreatic stones develop in patients with chronic pancreatitis, with as many as 90% of alcoholic chronic pancreatitis patients bearing ductal stones during long-term follow-up. 1 Main pancreatic duct calculi can lead to an outflow obstruction with increased parenchymal pressure, upstream dilation (ie, toward the tail of the pancreas), and ischemia. Untreated stones can also trigger bouts of acute pancreatitis sometimes associated with life-threatening adverse events. Pain is the predominant symptom in most patients with obstructive chronic pancreatitis, often alleviated only by narcotics and inducing anorexia, malabsorption, and weight loss. It is only with main pancreatic duct decompression from impacted stones that such adverse events can be avoided. 2,3 Small stones can be extracted by using various endoscopic techniques during ERCP, such as pancreatic sphincterotomy with balloon or basket sweeping, pancreatic duct stricture dilation, or stent placement. Larger and impacted stones typically require lithotripsy or surgery. Endoscopic lithotripsy options include (1) mechanical lithotripsy, for which data are scarce but suggest that this procedure may carry an increased risk of adverse events when compared with lithotripsy for biliary stones 2 ; (2) extracorporeal shock wave lithotripsy (ESWL), which overcomes the problem of size by fragmenting calculi and reducing the stone burden, thus facilitating endoscopic duct clearance 3 ; (3) contact lithotripsy by using pancreatoscopy with a mother-baby endoscope system. 4 Directcontact lithotripsy of biliopancreatic stones can be achieved by means of electrohydraulic lithotripsy (EHL) or pulseddye laser, both of which must be done under direct vision. Scant clinical outcome data are available regarding the application of these methods for pancreatic duct stone fragmentation. 5 Our aim was to evaluate the endoscopic treatment at our center by intracorporeal laser lithotripsy (ILL) with a single-operator mini-endoscope (SpyGlass; Boston Scientific, Natick, Mass) during ERCP, for its performance, feasibility, and safety in the treatment of difficult main pancreatic duct stones.