S0086 Impact of Image Quality on Single-Operator Pancreatoscopy-Guided Intraductal Lithotripsy for the Treatment of Main Pancreatic Duct Stones

Abstract

INTRODUCTION: For large pancreatic duct (PD) stones (≥5 mm), ERCP with single operator pancreatoscopy (SOP) guided electrohydraulic lithotripsy (EHL) is an emerging technique. The SOP systems have been refined with interval advances in image quality, evolving from a fiberoptic (f-SOP) to a digital (d-SOP) platform. The aim of this study is to report our center’s experience in terms of effectiveness and safety of SOP-EHL for the management of MPDS and assess for technical benefits from interval advances in image quality. METHODS: This is a retrospective series of patients who underwent SOP-EHL for the treatment of large MPDS from 9/2013 to 9/2019. Technical success was defined as complete or near complete stone clearance based on final pancreatogram. Clinical success was defined by improvement in pain or exocrine insufficiency (EPI) (cessation of enzyme supplementation after EHL). RESULTS: 18 patients underwent SOP-EHL including 8 with the f-SOP platform and 10 with the d-SOP platform. Baseline characteristics (Table 1) are similar between platforms. Symptoms prompting MPDS therapy included chronic pain (94.4%) and recurrent acute pancreatitis (5.6%). Number of large MPDS ranged from 1 to 4. Stone size ranged from 5 to 33 mm. Patients managed with the d-SOP platform were more likely to have a prior failed attempt at stone extraction (60% vs 12.5%, P = 0.040). Intraprocedural therapies and outcomes are included in table 2. Overall technical success was seen in 89%. Patients treated with d-SOP trended towards a higher rate of technical success (100% vs 75%, P = 0.094), fewer total shocks (1633 ± 1708 vs 5997 ± 6356, P = 0.057) and shorter procedure duration (80.2 ± 35.8 vs 132.0 ± 87.8 minutes, P = 0.107). Both technical failures with f-SOP went on to successful lithotripsy with ESWL. Exocrine insufficiency clinically resolved in 38.5%. Patients that experienced technical success had on average fewer lithotripsy sessions (1.3 ± 0.5 vs 3.5 ± 2.1, P < 0.001), fewer shocks (1909 ± 1592 vs 15498, P < 0.001), and a lower total procedure duration (85.8 ± 30.8 vs 243 ± 138.6, P < 0.001). On univariate analysis, no baseline characteristics were associated with technical failure. CONCLUSION: SOP-EHL is safe and effective for clearance of MPDS and impactful for CP symptoms. The d-SOP compared to f-SOP platform is associated with fewer total shocks and lower procedure time, likely due to improved optics. Our data suggests that improved imaging of MPDS with d-SOP enhances procedure efficiency and may equate to an increased rate of technical success.Table 1.: Baseline characteristics of patients with large main pancreatic ductal stones who underwent single operator pancreatoscopy (SOP) with electrohydraulic lithotripsyTable 2.: Outcomes in patients with large main pancreatic ductal stones who underwent single operator pancreatoscopy (SOP) with electrohydraulic lithotripsyFigure 1.: (A) Second generation digital single-operator pancreatoscopy (d-SOP) view of the main pancreatic duct stone, followed by (B) Electrohydraulic Lithotripsy (EHL) with stone fragmentation.