Large Pancreatic Duct Stones Research Articles

Efficacy of extracorporeal shock wave lithotripsy of pancreatic stone in chronic pancreatitis

Background: To study overall outcome of ESWL therapy in large pancreatic duct stone as first line therapy in chronic pancreatitis.Methods: A prospective, observational study which took place in MGM medical college and the patient were admitted in general surgery department. Patients were selected based on the inclusion criteria composed of upper abdominal pain, weight loss, oily stools and presence of pancreatic stones or ductal irregularity/ parenchymal atrophy determined by various radiological investigations.Results: In this study 11 patients with pancreatic stones were recruited in duration of 2 years. Among 11 patients included in this study 63.33% were males and 36.375% were females. The mean age of males and females were 35.57 and 40.50 years respectively. It was observed that all study subjects had abdominal pain and history of pancreatitis. 36% patient had single calculi and 64% patient had multiple calculi. 18% calculi were present in the body of pancreas and 46% calculi in head of pancreas. All these patient had undergone ESWL procedures with minimum number of 400 shocks and maximum number of 4600. Among the patients it was noted that 73% had successful complete clearance of calculi, 18% had partial clearance and 9% had no clearanceConclusions: ESWL is efficient tool for the treatment of pancreatic calculi but can be used alone it is adjunct tool to ERCP. Endoscopy, etc.

A comparative study between single-operator pancreatoscopy with intraductal lithotripsy and extracorporeal shock wave lithotripsy for the management of large main pancreatic duct stones.

Endoscopic management of large main pancreatic ductal (MPD) stones often require treatment with lithotripsy. Extracorporeal shock wave lithotripsy (ESWL) has been the mainstay therapy, and single-operator pancreatoscopy with intraductal (intracorporeal) lithotripsy (SOPIL) is an emerging technique. However, no comparative studies between these techniques exist. We therefore aimed to compare ESWL to SOPIL for the treatment of large MPD stones. This is a retrospective cohort study comparing patients who were treated with ESWL or SOPIL from September 2013 to September 2019 at a single tertiary center. Logistic regression was performed to identify factors associated with technical success and efficient stone clearance (≤ 2 procedures to clear stones). There were 240 patients who were treated with ESWL and 18 treated with SOPIL. The overall technical success rate of stone clearance was 224/258 (86.8%), which was similar between the ESWL and SOPIL groups (86.7% vs 88.9%, p = 1.000). A SOPIL approach required fewer total procedures (1.6 ± 0.6 vs 3.1 ± 1.5, p < 0.001) and less aggregate procedure time (101.6 ± 68.2 vs 191.8 ± 111.6min, p = 0.001). Adverse event rates were similar between the groups (6.3% vs 5.6%, p = 1.000). The use of SOPIL was independently associated with greater efficiency compared to ESWL (OR 5.241 [1.348-20.369], p = 0.017). Stone size > 10mm was associated with less efficient stone clearance (OR 0.484 [0.256-0.912], p = 0.025). Both ESWL and SOPIL are safe and effective endoscopic adjunct modalities for treating large pancreatic duct stones. SOPIL is an emerging alternative to ESWL that is potentially more efficient for lithotripsy and MPD stone clearance.

Use of a novel single-use disposable duodenoscope for ERCP: selected clips from a real-world case series

Background and AimsSingle-use/disposable duodenoscopes represent one strategy to decrease the risk of patient infection related to ERCP. A preliminary case series was performed to demonstrate the feasibility and performance of a new single-use duodenoscope in a real-world clinical setting.MethodsA single expert endoscopist performed ERCP for standard indications using a single-use duodenoscope.ResultsVideos of several key steps of ERCP obtained from 4 patients are shown to demonstrate that these steps can successfully be performed using the new single-use device. Clip 1 shows a patient with a large pancreatic duct stone in whom the image quality and maneuverability are demonstrated. Clip 2 shows a patient with choledocholithiasis and demonstrates bile duct cannulation, cholangiography, and sphincterotomy. Clip 3 shows a patient with acute cholecystitis and choledocholithiasis who underwent bile duct cannulation, sphincterotomy, and balloon sweeps. Clip 4 shows a patient with a history of liver transplant and refractory biliary anastomotic stricture who presented with abnormal liver tests and fever and underwent removal of a metal stent and placement of plastic stents.ConclusionsA single-use duodenoscope can successfully accomplish fundamental steps of ERCP. This device can potentially eliminate the risk of patient-to-patient infections linked to contaminated instruments. Larger studies are required to assess device performance.

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

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.

S0027 Predictors of Technical Success and Lower Procedure Burden for Single Operator Pancreatoscopy With Intraductal Lithotripsy vs Extracorporeal Shock Wave Lithotripsy Approaches for Large Main Pancreatic Duct Stones

S0027 Predictors of Technical Success and Lower Procedure Burden for Single Operator Pancreatoscopy With Intraductal Lithotripsy vs Extracorporeal Shock Wave Lithotripsy Approaches for Large Main Pancreatic Duct Stones

Novel Technique Using EUS Guided Submucosal Injection to Aid Minor Papilla Identification in a Patient With Pancreas Divisum and Pancreaticolithiasis

Introduction: Pancreas divisum can make pancreaticobiliary endoscopy a challenge. Minor papilla identification and cannulation can be difficult and lead to procedural failures. We present a novel technique of endoscopic ultrasound (EUS) guided submucosal injection to aid localization of the minor papilla in a patient with pancreas divisum, chronic pancreatitis, and a large pancreatic duct stone. Case: A 69 year old Caucasian male with recurrent acute pancreatitis was referred for EUS to evaluate pancreatic duct dilation and pancreas divisum noted on magnetic resonance cholangiopancreatography. EUS was consistent with chronic pancreatitis based on the Rosemont criteria, with pertinent findings to include a dilated pancreatic duct (5 mm) and a large calcified stone in the pancreatic head. Given his history of recurrent pancreatitis, endoscopic retrograde cholangiopancreatography (ERCP) was performed with the goal of papillotomy and stone extraction. ERCP confirmed pancreas divisum, however minor papilla identification was unsuccessful despite gentle exploration of duodenal folds and application of methylene blue. After discussion with the patient, he returned for a combined EUS/ERCP procedure. A linear echoendoscope was used to identify the main pancreatic duct stone, which was in the distal duct of Santorini. A submucosal injection with methylene blue was then performed via a 25 gauge FNA needle at the level of the stone. Upon re-inspection with the duodenoscope, the minor papilla was identified immediately adjacent to the injection site. The minor papilla was cannulated and pancreatogram confirmed pancreas divisum and a proximal filling defect. A 5 Fr x 5 cm dual flanged plastic pancreatic stent was placed for extracorporeal shock wave lithotripsy (ESWL) targeting. He returned after ESWL for ERCP with stent removal. Pancreatogram confirmed no large filling defect within the pancreatic duct. Balloon sweeps with a 9 mm extraction balloon yielded stone fragments. He has had no further episodes of acute pancreatitis. Discussion: Minor papilla identification and cannulation can be challenging. When the minor papilla cannot be readily identified, there are limited described techniques to help identify the minor papilla (spraying methylene blue, secretin administration). Here we describe a case using EUS guided submucosal injection to identify the minor papilla in a patient with pancreas divisum demonstrating that EUS can be used to locate the minor papilla.1277_A.tif Figure 1: Calcified pancreatic duct stone in the dorsal pancreatic duct.1277_B.tif Figure 2: Minor papilla identified just distal to the site of submucosal methylene blue injection.1277_C.tif Figure 3: Following cannulation, a dual flanged 5 Fr x 5 cm plastic pancreatic duct stent was placed through the minor papilla adjacent to the submucosal methylene blue injection.

Combined Puestow and choledocoduodenostomy for concomitant large pancreatic duct and primary choledochal stones: A case series

IntroductionMultiple and large pancreatic duct stones concomitant with primary choledochal stones is a rare case. Patients usually present with recurrent jaundice and signs of pancreatitis. Endoscopic retrograde cholangiopancreatography (ERCP) is the leading method to manage the patients. But ERCP has difficulties when facing the multiple and large stones Presentation of caseOur first case was a 51-years-old man who was admitted to our surgery unit with a diagnosis of chronic pancreatitis. Plain abdominal radiogram, Abdominal MSCT and Magnetic Resonance Cholangiopancreatography (MRCP) showed opacity suspected as stone at the pancreatic duct and distal part of the common bile duct. The second case was a 48-years-old female with the clinical presentation of left upper quadrant pain and history of chronic pancreatitis and intermittent jaundice. Plain abdominal radiogram and MRCP revealed multiple stones in the main pancreatic duct and common bile duct stones. Our third case was female, 60-years-old, who was hospitalized with jaundice and recurrent upper abdominal pain with a history of open cholecystectomy one month previously. Radiologic examination showed multiple stones in the main pancreatic duct and common bile duct. Combined longitudinal pancreatojejunostomy Roux-en-Y and Choledoco-duodenostomy were performed successfully in all cases. Postoperative follow-up showed good recovery of all patients. DiscussionSince ERCP is not proper to be used for multiple and large pancreatic duct stones, we performed a combination of longitudinal pancreatojejunostomy Roux-en-Y and choledoco-duodenostomy to treat the patients and prevent the recurrence. ConclusionThe incidence of multiple pancreatic duct stones and large choledochal stones is infrequent. Surgical treatment with combined longitudinal pancreatojejunostomy Roux-en-Y and Choledoco-duodenostomy is safe and effective to resolve jaundice and recurrent pain caused by chronic pancreatitis.

Rectally administered indomethacin to prevent post-ESWL-pancreatitis (RIPEP): study protocol for a randomized controlled trial

BackgroundPancreatic extracorporeal shock wave lithotripsy (P-ESWL) is the first-line therapy for large pancreatic duct stones. Although it is a highly effective and safe procedure for the fragmentation of pancreatic stones, it is still not complication-free. Just like endoscopic retrograde cholangiopancreatography (ERCP), pancreatitis is the most common complication. To date, nonsteroidal anti-inflammatory drugs (NSAIDs) have proven to be the only effective prophylactic medication for post-ERCP pancreatitis and the European, American and Japanese Society for Gastrointestinal Endoscopy guidelines have recommended prophylactic rectally administered indomethacin for all patients undergoing ERCP. Given the little research about effective prevention for post P-ESWL pancreatitis, we aim to determine whether rectally administered indomethacin can reduce post-ESWL-pancreatitis.Methods/designThe RIPEP study is a prospective, randomized, double-blinded, placebo-controlled trial. One thousand three hundred and seventy patients with chronic pancreatitis and pancreatic stones (>5 mm in diameter) treated with P-ESWL at Changhai Hospital will be randomly allocated to rectally administered indomethacin or placebo therapy before the procedure. The primary endpoint is the incidence of post-ESWL pancreatitis. Secondary endpoints include the severity of pancreatitis, occurrence rate of asymptomatic hyperamylasemia and other complications.DiscussionThe RIPEP trial is designed to show that rectally administered indomethacin reduces the development and severity of post-ESWL pancreatitis and benefits patients treated with P-ESWL.Trial registrationClinicalTrials.gov, ID: NCT02797067. Registered on 17 November 2016.

Electrohydraulic lithotripsy of large pancreatic duct stones by using digital pancreatoscopy

Electrohydraulic lithotripsy of large pancreatic duct stones by using digital pancreatoscopy

Mo1387 Evaluation of Patients With Large Pancreatic Duct Stones Treated by Extracorporeal Shock Wave Lithotripsy and Endoscopic Retrograde Cholangiopancreatography

Mo1387 Evaluation of Patients With Large Pancreatic Duct Stones Treated by Extracorporeal Shock Wave Lithotripsy and Endoscopic Retrograde Cholangiopancreatography

Sa1451 Systematic Process Improvement Applied to Scheduling and Performing ESWL Followed by ERCP for Large Pancreatic Duct Calculi: Waste Reduction and Quality Improvement

Aside from surgical drainage of the pancreatic duct, extracorporeal shockwave lithotripsy (ESWL) followed by ERCP is an accepted treatment modality for large pancreatic duct stones. In our institution, ESWL is performed exclusively by the Urology service. Due to the number of services and resources involved, scheduling patients for ESWL/ERCP has been difficult and has resulted in a high defect rate, long patient wait times and increased waste, all of which negatively impact quality of care. We sought to determine whether application of an institution-wide systematic method for process improvement to the entire process of scheduling and performing ERCP/ESWL could result in decreased waste and therefore higher quality of care.

Laparoscopic Frey Procedure for Chronic Pancreatitis

Chronic pancreatitis can be relentless, resulting in debilitating pain and endocrine and exocrine insufficiency. Medical interventions are used initially but when these fail, surgical therapy is often indicated. Surgical options include resection, drainage, and hybrid procedures. Hybrid procedures, such as the Frey procedure are associated with improved outcomes in select patients. These advantages are even greater when the Frey is performed laparoscopically. A patient with chronic pancreatitis was referred to our clinic. Preoperative imaging revealed a dilated main pancreatic duct with multiple large pancreatic duct stones. She subsequently underwent a laparoscopic Frey procedure. The patient did very well with no pancreatic leak, wound infection, or delayed gastric emptying. She was discharged home on postoperative day 6, symptom free with no narcotic requirement. For patients in whom the laparoscopic Frey procedure is possible, it can be used to treat chronic pancreatitis with the benefits of a minimally invasive approach.

Temporary Placement of a Fully Covered Self-expandable Metal Stent in the Pancreatic Duct for Aiding Extraction of Large Pancreatic Duct Stones with PD Strictures: Preliminary Data

Purpose: Placement of fully covered self-expandable metal stents (FCSEMS) has not been reported to aid extraction of large pancreatic duct stones. Methods: Four symptomatic patients with large (>10 mm) pancreatic duct stones, who could not be cleared of stones using a balloon catheter and basket using ERCP alone, were selected for FCSEMS placement. After placement of FCSEMS (10-mm diameter) in the pancreatic duct for 1 week to 5 months (mean duration: 77 days), standard endoscopic maneuvers cleared large pancreatic duct stones.Technical success and safety of temporary placement of a FCSEMS in the PD for aiding extraction of large PD stones. Technical success was defined as successful placement of stents and the ability to achieve PD clearance in two endoscopic encounters. Complications were assessed according to consensus criteria. Results: The procedure was technically successful in all four patients. At 6-month follow-up, no residual stones were seen on pancreatography, and all patients were doing well without any symptom recurrence. Conclusion: Temporary placement of a FSCEMS in the PD for aiding extraction of large PD stones is a safe technique that facilitates the removal of large stones.

Pancreatoscopic Removal of a Large Impacted Pancreatic Duct Stone

Pancreatic duct stones are a common complication of chronic pancreatitis. Although most pancreatic duct stones can be targeted by extracorporeal shock wave lithotripsy and extracted by endoscopic retrograde cholangiopancreatography, large and radiolucent stones remain a therapeutic challenge. The author describes a case of a 54-year-old man with chronic pancreatitis and a large pancreatic duct stone with a downstream stricture within the pancreatic head. After balloon dilation of the obstruction, direct pancreatoscopy with an ultraslim endoscope was performed and the stone under direct vision was extracted successfully. This article is part of an expert video encyclopedia.

Long-term clinical outcomes of extracorporeal shockwave lithotripsy in painful chronic calcific pancreatitis

Long-term results of extracorporeal shockwave lithotripsy (ESWL) for large pancreatic duct (PD) stones in patients with idiopathic calcific pancreatitis (CP) are scanty. To evaluate intermediate and long-term results of ESWL in a large cohort of patients with idiopathic CP. Cross-sectional study; retrospective chart review. A high-volume, tertiary-care center for endoscopy and GI diseases. A total of 636 patients with idiopathic CP who underwent ESWL and ERCP were followed-up. Patients were divided into intermediate (24-60 months) and long-term (>60 months) follow-up groups. ESWL and ERCP. Improvement in pain, analgesic use, hospitalization for pain, recurrence of calculi, need for additional intervention, and quality of life. A total of 636 of 1006 patients who underwent ESWL between 2004 and 2009 were followed for a maximum of 96 months. There were 364 patients in the intermediate follow-up group and 272 in the long-term follow-up group. After ESWL and ERCP, absence of pain was seen in 250 patients (68.7%), mild-to-moderate pain in 94 patients (25.4%), and severe pain in 20 patients (5.5%) of the intermediate group. In the long-term group, 164 patients (60.3%) had no pain, 97 patients (35.7%) had mild or moderate episodes of pain, whereas 11 patients (4.04%) had episodic severe pain. Recurrence of calculi was seen in 51 patients (14.01%) in the intermediate follow-up group and in 62 patients (22.8%) in the long-term group. Quality of life improved in a significant number of patients in both groups. Retrospective study, single center, recall bias, and subjective pain and quality-of-life measurement scale. ESWL for large PD calculi offers good results in patients of idiopathic CP on intermediate and long-term follow-up.

Is endoscopic therapy the treatment of choice in all patients with chronic pancreatitis?

Chronic pancreatitis (CP) is a progressive inflammatory disease of the pancreas characterized by destruction of the pancreatic parenchyma with subsequent fibrosis that leads to pancreatic exocrine and endocrine insufficiency. Abdominal pain and local complications (bile duct or duodenal stenosis and pancreatic tumor) secondary to CP are indications for therapy. At the beginning, medical therapy is used. More invasive treatment is recommended for patients with pancreatic duct stones (PDS) and pancreatic obstruction in whom standard medical therapy is not sufficient. Recently, Clarke et al assessed the long-term effectiveness of endoscopic therapy (ET) in CP patients. The authors compared ET with medical treatment. They reported that ET was clinically successful in 50% of patients with symptomatic CP. In this commentary, current CP treatment, including indications for ET and surgery in CP patients, is discussed. Recommendations for endoscopic treatment of CP according to the European Society of Gastrointestinal Endoscopy Clinical Guidelines are reviewed. Different surgical methods used in the treatment of CP patients are also discussed. ET is the most useful in patients with large PDS, pancreatic duct obstruction and dilation. It should be the first-line option because it is less invasive than surgery. Surgery should be the first-line option in patients in whom ET has failed or in those with a pancreatic mass with suspicion of malignancy. ET is a very effective and less invasive procedure, but it cannot be recommended as the treatment of choice in all CP patients.

ENDOSCOPIC PANCREATIC SPHINCTEROTOMY PLUS LARGE-BALLOON DILATION FOR REMOVAL OF A LARGE IMPACTED PANCREATIC DUCT STONE (WITH VIDEO)

Pancreatic duct stones are a common complication of chronic pancreatitis. We describe successful endoscopic removal of a large pancreatic duct stone using large-balloon dilation in combination with pancreatic sphincterotomy. A 63-year-old woman was admitted for endoscopic treatment of acute on chronic pancreatitis with diabetes and epigastric pain with liver dysfunction due to a large impacted stone within the distal main pancreatic duct. Endoscopic pancreatic sphincterotomy was carried out using a wire-guided pull-type sphincterotome. Although we could carry out a relatively large incision, the stone could not be extracted. We therefore carried out papillary dilation using a large balloon (diameter 12 to 15 mm) to make room alongside the stone. A 10 × 20-mm white pancreatic duct stone was extracted during the process of pulling a dilating balloon into the working channel of the endoscope. Eventually, the second stone was removed without any procedure-related complication.

A Minimally Invasive Alternative for Managing Large Pancreatic Duct Stones Using a Modified Expandable Metal Mesh Stent

Background and Aim: Endoscopic clearance of large or impacted stones in the main pancreatic duct (MPD) remains a clinical challenge. In this study, we attempted to technically modify the metallic stent to facilitate the clearance of large pancreatic stones in 4 patients, hoping to lower the operative risks and shorten hospital stay. Patients and Methods: Four patients with chronic pancreatitis and large stones in the MPD received endoscopic treatment. Inclusion criteria were:(1) pancreatic intraductal stones (number>3; diameter >10 mm) and strictures identified in the distal MPD; (2) calculi mainly located in the head, neckand/or body of the pancreas, and (3) failed clearance of stones using a balloon catheter or Dormia basket. Before clearing the pancreatic calculi completely, a technically modified uncovered self-expandable metallic pancreatic stent was implanted in the MPD for 4–7 days to dilate the ductal stenosis, and then drawn out through the working channel. Results: As theMPD had been sufficiently expanded by the stent, the calculi were removed completely and uneventfully by the balloon or Dormia basket in all 4 patients, without inducing major postoperative complications. A 9- to 15-month follow-up did not find major complications or recurrence of large calculi in the MPD. Conclusions: Technically modified metallic stenting is a minimally invasive and clinically feasible alternative to extra-corporeal shock wave lithotripsy in the management of large pancreatic duct Stones.

Endoscopic Management of a Large Pancreatic Duct Stone

Endoscopic Management of a Large Pancreatic Duct Stone