Chronic Calcific Pancreatitis Research Articles

Lateral Pancreaticojejunostomy in a Rare Case of Chronic Calcific Pancreatitis With Peripancreatic Pseudocyst in an 18-Year-Old Male: A Case Report

Lateral Pancreaticojejunostomy in a Rare Case of Chronic Calcific Pancreatitis With Peripancreatic Pseudocyst in an 18-Year-Old Male: A Case Report

Differences in Plasma Fatty Acid Composition Related to Chronic Pancreatitis: A Pilot Study.

Chronic pancreatitis (CP) is an inflammatory disease affecting the absorption of fat-soluble nutrients. Signaling in pancreatic cells that lead to inflammation may be influenced by fatty acids (FAs) through diet and de novo lipogenesis. Here, we investigated the relationship between plasma FA composition in CP with heterogeneity of etiology and complications of CP. Blood and clinical parameters were collected from subjects with CP (n = 47) and controls (n = 22). Plasma was analyzed for FA composition using gas chromatography and compared between controls and CP and within CP. Palmitic acid increased, and linoleic acid decreased in CP compared with controls. Correlations between age or body mass index and FAs are altered in CP compared with controls. Diabetes, pancreatic calcifications, and substance usage, but not exocrine pancreatic dysfunction, were associated with differences in oleic acid and linoleic acid relative abundance in CP. De novo lipogenesis index was increased in the plasma of subjects with CP compared with controls and in calcific CP compared with noncalcific CP. Fatty acids that are markers of de novo lipogenesis and linoleic acid are dysregulated in CP depending on the etiology or complication. These results enhance our understanding of CP and highlight potential pathways targeting FAs for treating CP.

Assessment of pancreatic ductal stone density on non-contrast computed tomography for predicting the outcome of extracorporeal shock wave lithotripsy.

Background and study aims The utility of stone density at non-contrast computed tomography (NCCT) for predicting the effectiveness of extracorporeal shock wave lithotripsy (ESWL) in chronic calcific pancreatitis (CCP) is relatively unexplored. Patients and methods This was a prospective observational study of patients with CCP. Hounsfield units (HU) were determined for the largest pancreatic ductal stone during pretreatment NCCT. All patients underwent ESWL until the largest stone was fragmented to <3mm, followed by endoscopic retrograde cholangiopancreatography (ERCP) for stone extraction. The predictive factors following ESWL for successful stone extraction were studied and the receiver operating characteristic (ROC) curve determined the HU optimal cut-point. Results Eighty-two patients with a median (interquartile range) age of 36 years (range, 29-55); majority male 45 (54.9%), were included. Idiopathic CCP was noted in 78 patients (95.1%). The median stone density (SD) was 1095 HU (range, 860.7-1260.7) and the number of ESWL sessions was 2 (range, 2-3). Complete stone removal at index ERCP was achieved in 55 patients (67.1%). Those with partial clearance (n=27) needed a repeat ERCP, which was successful in 26 (96.3%); one patient (3.7%) underwent surgery. There was a significant, positive correlation between number of ESWL sessions and SD (r=0.797; P <0.001). On bivariate analysis, SD and the number of ESWL sessions revealed a significant association with complete ductal clearance. The optimal cut-point for complete stone removal by the ROC curve was 1106.5 HU (Youden index 0.726), with a sensitivity of 93% and a specificity of 80%. Conclusions The SD is a significant predictor of ESWL success followed by ductal clearance at ERCP, and <1106.5 HU is a predictor of good candidates for ESWL therapy.

Utility of Contrast-Enhanced Computed Tomography for Differentiating Pancreatic Ductal Adenocarcinoma from Inflammatory Mass in Chronic Calcific Pancreatitis

Abstract Objective The aim of this study was to identify the most useful contrast-enhanced computed tomography (CECT) features for differentiating pancreatic ductal adenocarcinoma (PDAC) from mass-forming chronic pancreatitis (MFCP) in chronic calcific pancreatitis (CCP). Methods In total, 101 patients with CCP and focal pancreatic mass formed the study group. Sixteen qualitative and four quantitative parameters were analyzed. Qualitative parameters included size, site, margin, intralesional hypodensity, collateral duct sign, abrupt pancreatic duct (PD) cutoff, upstream PD dilatation, distal pancreatic atrophy, double duct sign, enhancement pattern, contrast attenuation, peripancreatic inflammation, vascular involvement, regional nodes, and metastasis. Quantitative parameters included duct-to-body ratio, common bile duct (CBD) diameter, main pancreatic duct (MPD) diameter, and carcinoembryonic antigen 19-9 (CA19-9). Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were calculated for prediction of PDAC. A receiver operating characteristic (ROC) curve analysis was performed and the area under ROC curve (AUROC) was calculated to determine diagnostic accuracy to assess the optimal cutoff. Results PDAC was confirmed in 48 patients and MFCP in 53 patients. A duct-to-body ratio greater than 0.48 had 95.5% sensitivity, 83.3% specificity, 80.8% PPV, 96.2% NPV, and 88.5% accuracy for predicting PDAC. A CBD diameter cutoff ≥9.5 mm had an accuracy of 75% (p &lt; 0.019) and an MPD cutoff ≥6.25 mm had an accuracy of 67.8% (p = 0.008) for predicting PDAC. On binary logistic regression, the duct-to-body ratio was found to be the significant independent factor associated with malignancy. Conclusion A duct-to-body ratio greater than 0.48, intralesional hypodensity, and abrupt duct cutoff are the most helpful computed tomography (CT) features for distinguishing PDAC from MFCP in CCP. On binary logistic regression, the duct-to-body ratio was found to be a significant independent factor. Interspersed normal parenchyma was observed as a very specific sign of MFCP. Intraparenchymal hypodensity has high specificity, but further validation is needed.

Chronic Calcific Pancreatitis in a Child- Clinical Presentation, Diagnosis and Management

Context Chronic Pancreatitis is a rare, but important disease in children and adolescents with negative impact on quality of life. It is necessary to recognise this condition as one of the differential diagnosis of recurrent epigastric pain and bringing together a multidisciplinary team for effective diagnosis and management. Case Report A 16 year old male child with history of recurrent pain abdomen was diagnosed with chronic calcific pancreatitis with severe exocrine insufficiency with pain with duct centeric disease cause idiopathic, without any family history for which Puestow’s procedure was performed. Conclusion Successful treatment of chronic pancreatitis reduces the risk of life threatening exacerbations, allows the patient to have significant improvements in life quality, alleviating daily symptoms that may have been present for years.

Recurrent upper gastrointestinal bleeding in chronic pancreatitis since childhood: a case report

Chronic pancreatitis is a progressive inflammatory disease of the pancreas. Causes of gastrointestinal (GI) bleeding in chronic pancreatitis are bleeding into the pseudocyst, pseudoaneurysm of peripancreatic vessels, and thrombosis of portal vein and splenic vein. We are presenting a rare case presentation of recurrent GI bleed in chronic pancreatitis since childhood and its management. A seventeen-year-old female patient presented with recurrent attacks of upper abdominal pain, hematemesis, bleeding per rectum, and melena since 1 month of age. She was diagnosed with a case of chronic calcific pancreatitis with pseudoaneurysm of common hepatic artery, and portal vein thrombosis with splenomegaly at the age of 2 years. She underwent angioembolization of the common hepatic artery pseudoaneurysm at the age of 2 years. However, she continued to have recurrent episodes of upper GI bleeding which required multiple hospital admissions and blood transfusions in the past. Contrast-enhanced computed tomography of abdomen was suggestive of chronic calcific pancreatitis with status post coil embolization of common hepatic, gastroduodenal, and proper hepatic arteries. She underwent modified Frey’s procedure in view of recurrent symptoms. Currently, the patient is doing well after 18 months of follow-up, with no further episodes of GI bleed. Angioembolization or surgical ligation of pseudoaneurysm of involved vessels in chronic pancreatitis can control GI bleed. However, in cases where the source of bleeding is not localized by imaging/ endoscopy, drainage of pseudocyst or local resection of pancreatic tissue can reduce inflammation in and around the pancreas and prevent further GI bleed in chronic pancreatitis.

Chronic Calcific Pancreatitis and Its Association With Secondary Diabetes Mellitus

Chronic Calcific Pancreatitis and Its Association With Secondary Diabetes Mellitus

Clinical Profile, Etiology and Role of Endotherapy in Chronic Calcific Pancreatitis: An Experience from North India.

Background: In recent years, we have witnessed an evolving landscape in the management of chronic pancreatitis (CP). Endoscopy plays a pivotal role in CP management. Because the management of CP is problematic, we aimed to review and evaluate the role of endoscopy in the management of CP. Methods: This study was carried out in patients with painful chronic calcific pancreatitis who were admitted to the Department of Gastroenterology at the Sher-I-Kashmir Institute of Medical Sciences (SKIMS), Srinagar. This was an observational prospective study. We included 67 patients with painful chronic calcific pancreatitis and pancreatic duct abnormalities (stones, strictures, or ductal variations) in our study. These patients had to access exocrine and endocrine status before any therapeutic measures. All the patients underwent endoscopic retrograde cholangiopancreatography (ERCP) as a therapeutic measure. After ERCP, the patients were followed up for 2 years to assess improvement in pain (visual analog scale score reduction), endocrine status (HBA1C reduction), or exocrine status (Fecal elastase reduction). Results: 67 patients were included in the study. Among them males were 32 (47.8%), females were 35(52.5%) and the age distribution studied were as in the age group of 15-30 years, patients were 23 (34.3%), in 30-45 years, there was 20 (29.9%), in age group of 45-60 year, patients were 20 (29.9%), and in the age group of 60-75 years, the patients were 4 (6%). Etiology was sought in all patients; alcohol-related CP was seen in three patients (4.5%), genetic in 11 (16.4%), IgG4 in one (1.5%), pancreatic divisum in 6 (9.0%), hyperparathyroidism in on1e (1.5%), and idiopathic in 45 (67.2%). All patients underwent ERCP for their symptoms to reduce ductal pressure, which is postulated as one of the hypotheses for pain in CP. Pancreatic duct (PD) clearance was attempted in all patients (complete in 42 [62.7%], partial in 17 [25.4%], and failed in 8 [11.9%]). These patients were followed for a period of two years after endotherapy, and the important predictors for pain reduction were single PD stones, disease in the head and body, and non-stricturing disease. Conclusion: Endotherapy offers a high rate of success in selected patients, clearance being better in distal disease and CP without PD strictures, suggesting early disease usually gets cleared very easily.

Chronic Calcific Pancreatitis Presented with Secondary Diabetes and Diabetic Ketoacidosis: A Case Report

Chronic Calcific Pancreatitis Presented with Secondary Diabetes and Diabetic Ketoacidosis: A Case Report

1262-P: Circulating Lysophosphatidic Acid Levels Suggest a Metabolic Pathway in T3cDM and Distinguish It from T2DM

Introduction: Diabetes associated with chronic pancreatitis (T3cDM) has distinct clinical features. We investigated metabolomics signature to distinguish T3cDM from T2DM. Methods: Study participants (n=200); treatment naïve nonalcoholic calcific chronic pancreatitis [CP] patients (n=106, age 34.4±11.1 years, BMI 20.9±2.8), T2DM patients (n=68, age 46±10.7 years BMI 27.0±5.8), healthy controls (n=26, age 31.0±5.3 years, BMI 25.0±2.8) were recruited prospectively. OGTT was performed to define diabetes (ADA criteria) with 60% CP patients being normoglycemic, 19% having prediabetes and 21% with diabetes. Metabolomics was done on fasting plasma samples using liquid chromatography/mass spectrometry and quantifications were measured on tandem mass spectrometry. Student’s t-test, PLS-DA, ROCs were used to compare and compute to assess the performance of identified metabolites in distinguishing diabetes subtypes (T3cDM and T2DM). Regression analysis was employed to develop a prediction model. Results: A total of 5493 and 4104 metabolites were detected in T3cDM and T2DM respectively. Untargeted metabolome profiling identified significant differences in fatty acid conjugates in CP. Fatty acid conjugates were 28% in normoglycemic CP, 60% in prediabetic CP, 13% in T3cDM as compared to 42% in controls. Among them, 57 fatty acid conjugates showed increased peak intensities. Comparison of absolute quantifications identified higher lysophosphatidic acid (LPA) in T3cDM 40.50±6.55, T2DM 21.65 ± 1.75; p=0.01 in comparison to controls 16.20±3.4 ng/ml. Sensitivity and specificity for LPA were 81.8%, 78.6% with AUC 80% (p&amp;lt;0.0001), 95% CI (70.6-87.8). Prediction model (null and full model p&amp;lt;0.0001) and its performance (Hosmer-Lemeshow test p=0.9) indicated high accuracy (AUC 87%; 95% CI, 77.8-92.7). Conclusion: Increased Lysophosphatidic acid levels implicate glycerolipid pathway in the pathogenesis of T3cDM and can be used to distinguish T3cDM from T2DM. Disclosure V. Ketavarapu: None. M. Aslam: None. R. Talukdar: None. R. Amanchy: None. P. Sripadi: None. A.C. Powers: None. K. Narayan: None. K.C. Coate: None. L.R. Staimez: None. R. Jagannathan: None. N. D: None. M. Sasikala: None. Funding Science and Engineering Research Board, India Project (CRG/2019/005125)

A Diagnosis of Irritable Bowel Syndrome Using Rome IV Criteria and Limited Investigations is Durable in Secondary Care

Irritable bowel syndrome (IBS) is a positive diagnosis, made using symptom-based criteria and limited, judicious, investigation. However, this may lead to uncertainty on the part of clinicians regarding potential for a missed diagnosis of organic gastrointestinal disease. Few studies have examined durability of a diagnosis of IBS, and none have used the current gold standard to diagnose IBS, the Rome IV criteria. We collected complete symptom data from 373 well-characterized adults meeting Rome IV criteria for IBS referred to a single UK clinic between September 2016 and March 2020. All patients underwent relatively standardized work-up to exclude relevant organic disease before diagnosis. We followed these individuals up to December 2022, assessing rates of rereferral, reinvestigation, and missed organic gastrointestinal disease. During a mean follow-up of 4.2 years per patient (total follow-up in all patients, 1565 years), 62 (16.6%) patients were rereferred. Of these, 35 (56.5%) were rereferred for IBS and 27 (43.5%) for other gastrointestinal symptoms. Among the 35 rereferred with IBS this was caused by a change in symptoms in only 5 (14.3%). Reinvestigation was undertaken in 21 (60.0%) of 35 rereferred with IBS and 22 (81.5%) of 27 rereferred with other symptoms (P= .12). Only 4 (9.3% of those reinvestigated and 1.1% of the entire cohort) new cases of relevant organic disease, which may have been responsible for IBS symptoms at baseline, were identified (1 case of chronic calcific pancreatitis among those rereferred with IBS and 1 case each of inflammatory bowel disease-unclassified, moderate bile acid diarrhea, and small bowel obstruction among those rereferred with other gastrointestinal symptoms). Despite rereferral for gastrointestinal symptoms among 1 in 6 patients overall, with almost 10% rereferred with ongoing IBS symptoms, and substantial reinvestigation rates, missed organic gastrointestinal disease occurred in only 1%. A diagnosis of Rome IV IBS after limited investigation is safe and durable.

Clinical profile and outcome of newly diagnosed children with chronic pancreatitis presenting at a tertiary care hospital in Dakshina Kannada

Background: Acute recurrent pancreatitis (ARP) and chronic pancreatitis (CP) are poorly understood conditions of childhood. Aetiology of CP in children is different from adults, very limited studies are available in pediatric population; hence this study was conducted. Methods: This was a hospital record based retrospective study performed in the department of pediatrics, at Yenepoya medical college hospital, Mangalore. Children from 1 month to 16 years of age were included in this study. Demographic data, clinical details, laboratory parameters, imaging results, and treatment data were collected. The data was tabulated and examined in SPSS software v.24 for analysis. Results: Sixteen children with newly diagnosed CP were included in the study. The median age of children diagnosed with CP was 12 years. Pain abdomen as presenting complaint was observed in all the children diagnosed with CP. All children were residents of Karnataka state. Calcific CP was seen in almost 50% of children. There was no history of tapioca consumption in any child diagnosed with CP. In more than 90% of the children, the aetiology was idiopathic. Conclusions: CP is common amongst children from Karnataka, India. Calcific pancreatitis is a common form of presentation and constituted nearly half of children with newly diagnosed CP in our study. Growth failure and steatorrhea are common complications in children with CP. Aetiology in majority of children with CP in our study was idiopathic, and not related to tapioca consumption. Genetic studies to determine the genetic predisposition for CP in children may play a significant role in future.

Prurigo Nodularis in Fibrocalculous Pancreatic Diabetes (FCPD)

Fibrocalculous Pancreatic Diabetes (FCPD) is a secondary form of diabetes mellitus due to chronic nonalcoholic calcific pancreatitis. Prurigo nodularis is seen in various dermatological diseases, but also seen in hematological and metabolic diseases (such as solid tumors, lymphoma, diabetes mellitus).

A rare pancreatic tumor mimicking chronic calcified pancreatitis.

A 48-year-old woman was admitted for severe upper abdominal pain, with impressive dilation and multiple high-density stones in the main pancreatic duct (PD). The patient was diagnosed with “chronic pancreatitis” and a therapeutic endoscopic retrograde cholangiopancreatography (ERCP) was planned.

A rare case of recurrent hyperparathyroidism

Abstract A 58 year old man presented to our hospital three years ago with history of upper abdominal pain, recurrent vomiting and dehydration. On evaluation, pancreatitis with mass in the head of pancreas was diagnosed. Fine needle aspiration from pancreatic head mass was suggestive of low-grade adenocarcinoma. Whipple's procedure was planned and the surgical gastroenterology team did open pylorus resecting pancreatoduodenectomy and feeding jejunostomy for him in October 2016. But the biopsy was reported as chronic calcific pancreatitis. On workup, hypercalcemia (12.5 mg/dl) was noted and hyperparathyroidism due to right inferior parathyroid adenoma was diagnosed as PTH levels were elevated (iPTH-474 pg/ml). He had a slippage of the jejunostomy tube and was readmitted. Right inferior parathyroidectomy was done by the surgical oncologist along with the repair of slipped feeding jejunostomy tube by the surgical gastroenterology team in the same sitting in March 2017. Biopsy was reported as right inferior parathyroid adenoma. Post-surgery, he had hungry bone syndrome which stabilized after one month. After 6 months, he started noticing a small nodule in the right side of the neck which progressively increased in size from a small nodule to a size of 1*1 cm over a duration of one year, associated with multiple small nodules superiorly. He also complained of weight loss, constipation, generalized weakness, and bone pains. Hypercalcemia was noted and iPTH level was again elevated (564.7 pg/ml). He was admitted for evaluation for recurrence of parathyroid adenoma/ parathyroid carcinoma/ parathyromatosis. Ultrasonography of the neck showed a 4*3 mm hypoechoic lesion with internal vascularity noted posterior to right lobe of thyroid and medial to great vessels, and multiple heterogenous hypoechoic well-defined lesions noted in the subcutaneous plane on the right side of the neck, few noted along surface of right strap muscle and sternocleidomastoid muscle. FNAC of the subcutaneous nodule was suggestive of parathyroid adenoma. Parathyroid scan showed multiple MIBI-avid nodule seen anterior and lateral to inferior pole of thyroid gland. He was operated in February 2019 and five nodules were removed. Biopsy was suggestive of parathyroid carcinoma. After the surgery, his symptoms improved but Calcium(13mg/dl) and iPTH (453 pg/ml) levels were elevated at 3 months follow up. Biopsy was suggestive of parathyroid carcinoma. But in view of the previous surgery, earlier biopsy report of adenoma and no metastasis, he was diagnosed to have parathyromatosis. A follow up CT revealed residual nodules in the neck. A repeat surgery was done in August 2019 to remove the nodules as the patient complained of persistent generalized malaise and bone pains. Following surgery, his iPTH levels remained elevated (iPTH pre-op-492.4 pg/ml; post-op- 444.4 pg/ml). His symptoms improved mildly. He was started on medical management for hypercalcemia with Cinacalcet. Figure 1. Image of the neck of the patient showing multiple nodules.

Пациент с хроническим калькулезным панкреатитом: задача со многими неизвестными

Aim. To describe a clinical case of a patient with diabetes mellitus in the outcome of chronic calcific pancreatitis. Key points. Chronic pancreatitis is a multifaceted disease complicating a great number of body systems work. Currently, the problem of post-pancreatitis diabetes mellitus is receiving more and more attention precisely because simultaneous decrease of the endo- and exocrine functions of the pancreas without timely correction is accompanied by concomitant metabolic disorders that lead to different complaints, hiding the underlying cause. In addition to the familiar to endocrinologists’ problem of correcting hyperglycemia, there is also the problem of exocrine pancreatic insufficiency and vitamin-mineral-protein deficiency. Our patient’s dysfunction of the pancreas was reflected in the appearance of secondary hyperparathyroidism with the formation of osteoporosis, decreased growth, and a pathological fracture. The presented clinical case demonstrates the variety and scale of complications that develop in a patient with chronic calculous pancreatitis. Conclusion. Careful history taking and a comprehensive examination of a patient with a long story of chronic alcoholic pancreatitis should contribute to the timely diagnosis and correction of diseases that develop due to a progressive loss of endo- and exocrine pancreatic function. Keywords: chronic calcific pancreatitis, pancreatic elastase, exocrine pancreatic insufficiency, secondary hyperparathyroidism, osteoporosis, diabetes mellitus.

PHPT with Pancreatitis: Atypical Presentation of PHPT.

Primary hyperparathyroidism (PHPT) is rarely associated with the occurrence of acute or chronic pancreatitis, requiring complex perioperative management. This study aimed to assess the prevalence and disease characteristics of pancreatitis in PHPT. This study is a clinicopathological analysis of the medical records of patients who were diagnosed with PHPT with pancreatitis between 1989 and 2021 in the Endocrine Surgery department, SGPGI, Lucknow. Out of 548 PHPT cases, 44 (8.03%) were found to be associated with pancreatitis. The mean age was 33.57 years (15-65 years); 5 were ≤20 years, while 26 were ≤30 years of age. There were 27 males and 17 females. Twenty-one cases were of acute (11 acute, nine recurrent acute, one acute on chronic), whereas 23 were of chronic pancreatitis (six chronic calcific pancreatitis). The major clinical presentation of PHPT with pancreatitis was abdominal pain (65.91%). The mean number of attacks per patient in recurrent acute pancreatitis was two. Mean PTH levels were 68.19 pmol/L. The mean tumor size (in the largest dimension) was 2.79 ± 1.4 cm while the mean tumor weight was 4.91 g. Nephrolithiasis was associated with 25 cases. An association with multiple endocrine neoplasia type 1 syndrome was seen in one case. The final histopathological diagnosis was parathyroid carcinoma in two, hyperplasia in three, and parathyroid adenoma in 39 cases. Normocalcemia was seen in 27.2%, hypercalcemic crisis in 15.9%, and 25% of patients required semi-emergency parathyroidectomy. The outcome was favorable in all, as none had any further attacks of pancreatitis. In our study, the prevalence of pancreatitis in PHPT cases was 8.03%. The majority of patients were young. Normocalcemia was seen in 12 patients, so even if calcium levels are normal, PHPT should be suspected in young patients with pancreatitis. Parathyroidectomy resulted in the complete resolution of symptoms of pancreatitis in all 44 patients.

Melioidosis with amoebic coinfection presenting as multifocal liver and splenic abscess

We present a case of chronic calcific pancreatitis with diabetes mellitus who presented with multifocal liver and splenic abscesses which were found to be a coinfection of Entamoeba histolytica and Burkholderia pseudomallei. The existence of concurrent infection by two such unrelated organisms provides an example of the enigma of infections in areas of decreased host resistance.

Total robotic lateral pancreaticojejunostomy and modified Frey's procedure for chronic calcific pancreatitis.

Surgical intervention has been shown to have good post-operative outcomes in patients with chronic pancreatitis with pain refractory to oral analgesics. We present our initial experience with robotic lateral pancreaticojejunostomy (LPJ) and modified Frey's procedure (MFP). Patients with chronic calcific pancreatitis were evaluated with routine biochemical and radiological investigations. The indication of surgery was intractable pain which was recorded by an Intensity Frequency, Consequence (IFC) pain score. The patient was placed in a reverse Trendelenburg position with four 8-mm robotic ports and one 12-mm assistant port. Robotic ultrasound was utilized to identify the pancreatic duct. After retrieving all the calculi, which was confirmed by pancreatoscopy with the help of a video choledochoscope and performing the head coring in particular cases, the Roux-en-Y LPJ was performed. Among five patients (4 males, one female), robotic LPJ was performed in 2 and MFP in 3 patients. The cohort's median age was 32 (interquartile range (IQR), 28, 40) years, and the median (IQR) pancreatic duct size was 9 (9, 13) mm. The median (IQR) duration of the procedure was 385 (380, 405) minutes, with a median (IQR) blood loss of 100 (50-100) ml, and the patients were discharged on median post-operative day 5. The patients continue to do well at a median follow-up of 3-30months without the requirement of oral analgesics. Robotic LPJ and MFP are feasible in experienced hands with good post-operative outcomes and enhanced quality of life. Intra-operative pancreatoscopy with the help of a choledochoscope can be utilized to ascertain the complete clearance of pancreatic duct stones and the consequent pain relief.

Per-oral pancreatoscopy-guided lithotripsy vs. extracorporeal shock wave lithotripsy for treating refractory main pancreatic duct stones in chronic pancreatitis: Protocol for an open-label multi-center randomized clinical trial

Backgrounds/ObjectivesPatients with chronic pancreatitis may develop pancreatic duct stones that can obstruct outflow leading to ductal hypertension and pain. Both endoscopic retrograde pancreatography (ERP) with per-oral pancreatoscopy (POP) and intraductal lithotripsy and extracorporeal shock wave lithotripsy (ESWL) are feasible options to attempt ductal stone clearance. This study aims to compare POP-guided lithotripsy with ESWL in the management of refractory symptomatic main pancreatic duct stones. MethodsThis is an open-label, multi-center, parallel, randomized clinical trial. Patients with chronic pancreatitis and main pancreatic duct stones ≥5 mm who fail standard ERP methods for stone removal will be eligible for this study. In total, 150 subjects will be randomized 1:1 to either ESWL or POP. A maximum of 4 sessions of either ESWL or POP will be allowed in each arm, with crossover permitted thereafter. The primary outcome is complete stone clearance and secondary outcomes include quality of life, pain scores, number of interventions, and daily opiate requirements. ConclusionsThis study aims to answer the question of which lithotripsy method is superior in removing refractory pancreatic duct stones while addressing the effects of lithotripsy on quality of life and pain in patients with chronic calcific pancreatitis (ClinicalTrials.gov NCT04115826).