Pancreatic Duct Calculi Research Articles

Citric Acid Loaded Hydrogel-Coated Stent for Dissolving Pancreatic Duct Calculi.

In recent years, the incidence of chronic pancreatitis has increased significantly. Pancreatic calculi obstruct the pancreatic duct and induce abdominal pain in the patients. Pancreatic duct stenting is the major treatment option for chronic pancreatitis with calculi. In this study, a new kind of drug-eluting stent, a pancreatic stent coated by methacrylated gelatin (GelMA) hydrogel loaded with citric acid (CA), was designed for the interventional treatment of pancreatic duct calculi. The CA loading capacity reached up to 0.7 g CA/g hydrogel-coated stent. The GelMA hydrogel coating has higher mechanical strength and lower swelling performance after loading with CA. The in vitro experiments of stents exhibited good performance in CA sustained release and the calculi can be dissolved in almost 3 days. The stents also showed good blood compatibility and cell compatibility. This research has important clinical value in the treatment of chronic pancreatitis with pancreatic calculi.

Predictive Factors Correlated with Successful Early Endoscopic Removal of Pancreaticolithiasis in Chronic Pancreatitis after Extracorporeal Shock Wave Lithotripsy.

The treatment of chronic pancreatitis (CP) and symptomatic pancreatic duct (PD) calculi often involves techniques like endoscopic retrograde cholangiopancreatography (ERCP), extracorporeal shock wave lithotripsy (ESWL), or a combination of both. However, identifying predictive factors for the successful removal of these calculi remains variable. This study aimed to determine the factors predicting successful ESWL and endoscopic removal in CP and PD calculi patients. We examined data from CP patients who underwent complete PD calculi removal via ESWL combined with ERCP between July 2012 and 2022, and assessed baseline characteristics, imaging findings, and treatment details. Patients were categorized into early- and late-endoscopic complete removal groups (EER and LER groups, respectively). Of the 27 patients analyzed, 74.1% were male with an average age of 44 ± 9.6 years. EER was achieved in 74% of the patients. Patients in the EER group exhibited smaller PD calculi diameter (8.5 vs. 19 mm, p = 0.012) and lower calculus density (964.6 vs. 1313.3 HU, p = 0.041) compared to the LER group. Notably, PD stricture and the rate of PD stent insertion were not different between the groups. A calculus density threshold of 1300 HU on non-contrast CT demonstrated 71% sensitivity and 80% specificity in predicting EER. Smaller and low-density PD calculi may serve as predictors for successful EER, potentially aiding in the management of CP patients with PD calculi.

Extra-Corporeal Shock Wave Lithotripsy for Pancreatic Duct Calculi: A Perspective From a Practice in the United States.

Extra-Corporeal Shock Wave Lithotripsy for Pancreatic Duct Calculi: A Perspective From a Practice in the United States.

Effect of pancreatic extracorporeal shock wave lithotripsy on chronic pancreatitis stones

Objective: To analyze the therapeutic effect and safety of pancreatic extracorporeal shock wave lithotripsy(P-ESWL) for patients with chronic pancreatitis complicated by stones of the pancreatic duct and to investigate the influencing factors. Methods: A retrospective analysis was performed on clinical data from 81 patients with chronic pancreatitis complicated by pancreatic duct calculus treated with P-ESWL in the Department of Hepatobiliary Surgery, the First Affiliated Hospital of Xi 'an Jiaotong University from July 2019 to May 2022. There were 55 males(67.9%) and 26 females(32.1%). The age was (47±15)years (range: 17 to 77 years). The maximum diameter(M(IQR)) of the stone was 11.64(7.60) mm, and the CT value of the stone was 869 (571) HU. There were 32 patients (39.5%) with a single pancreatic duct stone and 49 patients(60.5%) with multiple pancreatic duct stones. The effectiveness, remission rate of abdominal pain, and complications of P-ESWL were evaluated. Student's t test, Mann Whitney U test, χ2 test, or Fisher's exact test was used to compare the characteristics between the effective and ineffective groups of lithotripsy. The factors influencing the effect of lithotripsy were analyzed by univariate and multivariate logistic regression analysis. Results: Eighty-one patients with chronic pancreatitis were treated with P-ESWL 144 times, with an average of 1.78 (95%CI:1.60 to 1.96) times per person. Among them, 38 patients(46.9%) were treated with endoscopy. There were 64 cases(79.0%) with effective removal of pancreatic duct calculi and 17 cases(21.0%) with ineffective removal. Of the 61 patients with chronic pancreatitis accompanied by abdominal pain, 52 cases(85.2%) had pain relief after lithotripsy. After lithotripsy treatment, 45 patients(55.6%) developed skin ecchymosis, 23 patients(28.4%) had sinus bradycardia, 3 patients(3.7%) had acute pancreatitis, 1 patient(1.2%) had a stone lesion, and 1 patient(1.2%) had a hepatic hematoma. Univariate and multivariate logistic regression analysis showed that the factors affecting the efficacy of lithotripsy included the age of patient(OR=0.92, 95%CI: 0.86 to 0.97), the maximum diameter of the stone(OR=1.12,95%CI:1.02 to 1.24) and the CT value of the stone(OR=1.44, 95%CI: 1.17 to 1.86). Conclusions: P-ESWL is effective in the treatment of patients with chronic pancreatitis complicated by calculi of the main pancreatic duct.Factors affecting the efficacy of lithotripsy include patient's age, maximum stone diameter, and CT value of calculi.

An international experience with single-operator cholangiopancreatoscopy in patients with altered anatomy

Background and study aims The utility of digital single- operator cholangiopancreatoscopy (D-SOCP) in surgically altered anatomy (SAA) is limited. We aimed to evaluate the technical success and safety of D-SOCP in patients SAA. Patients and methods Patients with SAA who underwent D-SOCP between February 2015 and June 2020 were retrospectively evaluated. Technical success was defined as completing the intended procedure with the use of D-SOCP. Results Thirty-five patients underwent D-SOCP (34 D-SOC, 1 D-SOP). Bilroth II was the most common type of SAA (45.7 %), followed by Whipple reconstruction (31.4 %). Twenty-three patients (65.7 %) patients had prior failed ERCP due to the presence of complex biliary stone (52.2 %). A therapeutic duodenoscope was utilized in the majority of the cases (68.6 %), while a therapeutic gastroscope (22.7 %) or adult colonoscope (8.5 %) were used in the remaining procedures. Choledocholithiasis (61.2 %) and pancreatic duct calculi (3.2 %) were the most common indications for D-SOCP. Technical success was achieved in all 35 patients (100 %) and majority (91.4 %) requiring a single session. Complex interventions included electrohydraulic or laser lithotripsy, biliary or pancreatic stent placement, stricture dilation, and target tissue biopsies. Two mild adverse events occurred (pancreatitis and transient bacteremia). Conclusions In SAA, D-SOCP is a safe and effective modality to diagnose and treat complex pancreatobiliary disorders, especially in cases where standard ERCP attempts may fail.

Chronic pancreatitis for the clinician: complications and special forms of the disease. Interdisciplinary position paper of the Catalan Society of Digestology (SCD) and the Catalan Pancreatic Society (SCPanc).

Chronic pancreatitis tends to develop a number of complications that may constitute the form of presentation of the disease. Some societies have issued guidelines for diagnosis and treatment of chronic pancreatitis complications, but the level of evidence for any topic is usually low and recommendations tend to be weak. We aimed to provide defined position statements for the clinician based on updated review of published literature and on multidisciplinary expert agreement. The goal was to propose defined terminology and rational diagnostic/therapeutic circuits based on current knowledge. To this end 14 sections related to complications and special forms of chronic pancreatitis (early chronic, groove and autoimmune pancreatitis) were reviewed by 21 specialists from 6 different fields to generate 32 statements. Featured statements assert common bile duct stenosis does not require invasive treatment (endoscopic or surgical) unless cholestasis, cholangitis, lithiasis or other symptoms develop. Pancreatic duct strictures and calculi should be approached (after ruling out malignancy) if causing pain, pancreatitis, pseudocysts or other complications. Treatment of symptomatic pseudocysts must be individualized, considering associated main duct stenosis, vascular and pericystic complications. Higher risk conditions for pancreatic cancer are advance age, smoking, genetic background, recent diagnosis of chronic pancreatitis or diabetes, and appearance of new symptoms. Groove pancreatitis can initially be treated with conservative measures. Both prednisolone or rituximab can induce remission and maintenance of autoimmune pancreatitis. Internal fistula, vascular complications, bacterial overgrowth, osteoporosis and renal lithiasis require specific therapeutic approaches.

A clinical study on lateral pancreaticojejunostomy in a case of chronic pancreatitis

Lateral pancreaticojejunostomy is a seldom performed procedure in a peripheral tertiary health care centre. Very few numbers of cases are reported that undergoes surgical procedures for chronic pancreatitis. We report a such rare case in our institute that undergone pancreatic drainage procedure. A 70 year old poor patient was admitted in our institute with a complaint of chronic abdominal pain, subsequently diagnosed to be having chronic pancreatitis with complications with pancreatic duct calculus. Pancreatic drainage procedure, lateral pancreaticojejunostomy was performed and we analysed for the outcome of the procedure with regards to pain relief, anastomotic leak, quality of life and return to work. Patient recovered well post-operatively, reported pain relief, suffered no anastomotic leak and experienced improved quality of life. Lateral pancreaticojejunostomy provides excellent surgical choice for patients of chronic pancreatitis with pancreatic duct calculus with acceptable rates of pain relief, morbidity and mortality, without worsening pancreatic insufficiency.

Mass Forming Chronic Pancreatitis Mimicking a Pancreatic Neoplasm: A Case Report

Chronic pancreatitis can present as a focal inflammatory mass mimicking pancreatic neoplasm and also it has increased risk of developing pancreatic cancer. Even with the help of multiple new imaging modalities, convincing differentiating points between these two entities is not available. Hereby, the author present a case of 50-year-old female with epigastric pain since one month. No significant past history or any history of addictions was present. On clinical examination, there was tenderness in epigastric region, however no lump could be felt. Her laboratory parameters revealed, raised bilirubin levels. Amylase and lipase levels were slightly raised. Computed Tomography (CT) revealed heterogeneously enhancing mass involving head and uncinate process of pancreas with loss of fat planes between lesion and superior mesenteric vessels, atrophic pancreas with dilated pancreatic duct and multiple ductal calculi. CT guided biopsy of pancreatic mass was performed. Histopathology revealed pancreatic tissue with fibrocollagenous and fibroadipose tissue with dense and diffuse infiltration by mononuclear cells, histiocytes and a few foamy macrophages suggestive of acute on chronic inflammation with no evidence of any malignant cells.

S0016 Efficacy of Pancreatoscopy for Pancreatic Duct Calculi: A Systematic Review and Meta-Analysis

S0016 Efficacy of Pancreatoscopy for Pancreatic Duct Calculi: A Systematic Review and Meta-Analysis

Efficacy of pancreatoscopy for pancreatic duct stones: A systematic review and meta-analysis.

BACKGROUNDPancreatic duct stones can lead to significant abdominal pain for patients. Per oral pancreatoscopy (POP)-guided intracorporal lithotripsy is being increasingly used for the management of main pancreatic duct calculi (PDC) in chronic pancreatitis. POP uses two techniques: Electrohydraulic lithotripsy (EHL) and laser lithotripsy (LL). Data on the safety and efficacy are limited for this procedure. We performed a systematic review and meta-analysis with a primary aim to calculate the pooled technical and clinical success rates of POP. The secondary aim was to assess pooled rates of technical success, clinical success for the two individual techniques, and adverse event rates.AIMTo perform a systematic review and meta-analysis of POP, EHL and LL for management of PDC in chronic pancreatitis.METHODSWe conducted a comprehensive search of multiple electronic databases and conference proceedings including PubMed, EMBASE, Cochrane, Google Scholar and Web of Science databases (from 1999 to October 2019) to identify studies with patient age greater than 17 and any gender that reported on outcomes of POP, EHL and LL. The primary outcome assessed involved the pooled technical success and clinical success rate of POP. The secondary outcome included the pooled technical success and clinical success rate for EHL and LL. We also assessed the pooled rate of adverse events for POP, EHL and LL including a subgroup analysis for the rate of adverse event subtypes for POP: Hemorrhage, post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP), perforation, abdominal pain, fever and infections. Technical success was defined as the rate of clearing pancreatic duct stones and clinical success as the improvement in pain. Random-effects model was used for analysis. Heterogeneity between study-specific estimates was calculated using the Cochran Q statistical test and I2 statistics. Publication bias was ascertained, qualitatively by visual inspection of funnel plot and quantitatively by the Egger test.RESULTSA total of 16 studies including 383 patients met the inclusion criteria. The technical success rate of POP was 76.4% (95%CI: 65.9-84.5; I2 = 64%) and clinical success rate was 76.8% (95%CI: 65.2-85.4; I2 = 66%). The technical success rate of EHL was 70.3% (95%CI: 57.8-80.3; I2 = 36%) and clinical success rate of EHL was 66.5% (95%CI: 55.2-76.2; I2 = 19%). The technical success rate of LL was 89.3% (95%CI: 70.5-96.7; I2 = 70%) and clinical success rate of LL was 88.2% (95%CI: 66.4-96.6; I2 = 77%). The incidence of pooled adverse events for POP was 14.9% (95%CI: 9.2-23.2; I2 = 49%), for EHL was 11.2% (95%CI: 5.9-20.3; I2 = 15%) and for LL was 13.1% (95%CI: 6.3-25.4; I2 = 31%). Subgroup analysis of adverse events showed rates of PEP at 7% (95%CI: 3.5-13.6; I2 = 38%), fever at 3.7% (95%CI: 2-6.9; I2 = 0), abdominal pain at 4.7% (95%CI: 2.7-7.8; I2 = 0), perforation at 4.3% (95%CI: 2.1-8.4; I2 = 0), hemorrhage at 3.4% (95%CI: 1.7-6.6; I2 = 0) and no mortality. There was evidence of publication bias based on funnel plot analysis and Egger’s test.CONCLUSIONOur study highlights the high technical and clinical success rates for POP, EHL and LL. POP-guided lithotripsy could be a viable option for management of chronic pancreatitis with PDC.

Extracorporeal Shock Wave Lithotripsy for Large Common Bile Duct and Pancreatic Duct Stones: Efficacy, Safety and Analysis of Factors That Favor Stone Fragmentation

Abstract Background: Extracorporeal shockwave lithotripsy (ESWL) with subsequent endoscopic extraction of residual fragments is an established treatment option in technically challenging situations for extraction of pancreatic and common bile duct calculi. Common bile duct (CBD) stone fragmentation rates of 71 to 95% have been reported with ESWL, leading to final duct clearance rates of 70 to 90%. While complete clearance of 76% and partial clearance of 17% of pancreatic duct calculi have been documented with ESWL, our study was undertaken to investigate the efficacy and safety of ESWL in clearance of difficult bile duct and large pancreatic duct calculi. Methods: The study population consisted of 61 patients who had either large or difficult bile duct calculi or large pancreatic duct calculi documented on ultrasonography abdomen or magnetic resonance cholangiopancreatography (MRCP). All patients were subjected to ESWL sessions with endoscopic nasobiliary drainage (ENBD) placement till stones got fragmented. Results: A total of 1,284 patients underwent ERCP for either choledocholithiasis or pancreatic duct calculi during the study period (June 2015 to December 2016). Out of them 61 patients had either large or difficult CBD calculi or large pancreatic duct calculi. Forty (65.57%) had choledocholithiasis (Group-A) and 21 (34.42%) had chronic calcific pancreatitis (Group-B). CBD was cleared in 37 patients (92.5%) and 3 patients (7.5%) underwent surgical intervention. Main pancreatic duct (MPD) was cleared in all patients with clearance rate of 100%. Conclusions: ESWL is an effective and safe method for clearance of difficult CBD and pancreatic duct calculi. Combined efficacy of duct clearance is >90%. Complications are minimal and managed conservatively.

Rare case of a large pancreatic duct calculus causing pancreatitis

Rare case of a large pancreatic duct calculus causing pancreatitis

Role of ERCP SpyGlass Electrohydraulic Lithotripsy in Patients with Chronic Pancreatitis and Pancreatic Duct Calculi Causing Duct Obstruction: A Case Series

Role of ERCP SpyGlass Electrohydraulic Lithotripsy in Patients with Chronic Pancreatitis and Pancreatic Duct Calculi Causing Duct Obstruction: A Case Series

Role of ERCP SpyGlass Electrohydraulic Lithotripsy in Patients With Chronic Pancreatitis and Pancreatic Duct Calculi Causing Duct Obstruction: An Updated Case Series

Role of ERCP SpyGlass Electrohydraulic Lithotripsy in Patients With Chronic Pancreatitis and Pancreatic Duct Calculi Causing Duct Obstruction: An Updated Case Series

Role of ERCP SpyGlass® Electrohydraulic Lithotripsy in Patients With Chronic Pancreatitis and Pancreatic Duct Calculi Causing Duct Obstruction: A Case Series

Introduction: ERCP with SpyGlass® cholangioscopy and electrohydraulic lithotripsy (EHL) is an established treatment for large common bile duct stones. However, the role of SpyGlass® EHL in treating patients with pancreatic duct calculi has yet to be well studied. The current management of pancreatic duct stones consists of extracorporeal shock wave lithotripsy (ESWL) or surgical intervention. The purpose of this case series is to study the safety and efficacy of SpyGlass® EHL in patients with pancreatic duct calculi. Methods: In patients with chronic pancreatitis and pancreatic duct stones, we performed ERCP with SpyGlass® pancreatoscopy and EHL in an attempt to break the calculi into smaller fragments in order to relieve the pancreatic duct obstruction. Consecutive patients with pancreatic duct stones were included in the study. Pancreatic duct stents were placed following lithotripsy in all patients. The stents were later removed at a 4-6 week interval after the procedure. Results: ERCP with SpyGlass® EHL was performed in 7 patients with chronic pancreatitis and stones. Two patients were relieved of their obstruction after only 1 procedure. Four patients required 2 procedures, and 1 patient required 3 procedures. ERCP with SpyGlass® EHL was successful in relieving the main pancreatic duct obstruction in 5 patients. The remaining 2 patients were referred to a multidisciplinary pancreas team for ESWL therapy. However, both these patients ended up requiring surgery. One patient received Puestow’s procedure while the other received Berger’s operation. Two patients had pain following the ERCP and EHL treatment and required overnight hospitalization. One patient had mild pancreatitis. No other complications were reported. Conclusion: ERCP with EHL appears to be a safe and effective therapeutic procedure in the majority of patients with chronic pancreatitis and pancreatic duct calculi. Larger studies are needed to validate the results of our pilot study.

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.

A Rare Cause of Chronic Diarrhea and Weight Loss

A78-year-old woman was evaluated for fatigue, unintentional weight loss of 38 pounds, and diarrhea over the past year. She appeared in no acute distress. Her blood pressure was 120/80 mm Hg and her heart rate was 76 beats/min. She was 61 inches tall and weighed 96 pounds, with a body mass index of 18 kg/m. An abdominal examination was significant for mild epigastric tenderness to palpation. The patient would have approximately 7 nonbloody watery bowel movements during the day with occasional nocturnal diarrhea. Her bowel movements were not affected by fasting. She had associated lower abdominal pain and intermittent epigastric pain. Prior work-up included negative stool studies for Clostridium difficile, ova and parasites, culture, and Gram stain. Laboratory studies showed a normal hemoglobin level, mean corpuscular volume, thyroid-stimulating hormone level, alanine aminotransferase level, total bilirubin level, albumin level, and C-reactive protein level. She had an abnormal alkaline phosphatase level of 130 IU/L (38–126 IU/L), an aspartate aminotransferase level of 52 IU/L (15–41 IU/L), a g-glutamyl transpeptidase level of 49 IU/L (<41 IU/L), and a lipase level of less than 3 U (15–70 U/L). A colonoscopy and upper endoscopy showed no gross or histologic evidence of malignancy, celiac disease, or microscopic colitis. A contrast-enhanced computed tomographic scan of the abdomen and pelvis showed cirrhosis, an obstructing distal pancreatic duct calculus, and complete fatty replacement of the pancreas, which was highly suggestive of lipomatous pseudohypertrophy (Figure A). An endoscopic ultrasound was performed and confirmed the diagnosis and excluded an underlying pancreatic adenocarcinoma (Figure B). The patient denied alcohol use. Viral hepatitis serologies, iron saturation level, ceruloplasmin level, autoimmune serologies, and a-1 antitrypsin level all were normal. The most likely etiology of the patient’s cirrhosis was nonalcoholic steatohepatitis. The patient denied previous episodes of pancreatitis, but the presumptive etiology of the distal pancreatic duct calculus was chronic pancreatitis. Pancreatic enzyme replacement therapywas initiated and the patient reported resolution of her symptoms 2 days later. At our patient’s follow-up visit 1 month after initiation of pancreatic enzyme replacement therapy, her weight increased to 101 pounds and her symptoms resolved. Lipomatous pseudohypertrophy is a rare idiopathic clinical entity that has been described only in case reports and case series. Based on a small case series and literature review, Altinel et al determined that this condition occurs with equal frequency in males and females, with approximately 70% of cases diffusely involving the pancreas. Histologically, adipose pseudotumor replacement of pancreatic exocrine tissue is seen. Because of its low prevalence, the etiology of lipomatous pseudohypertrophy has yet to be determined. Varying presentations have been described including large pancreatic tumors subsequently diagnosed as lipomatous

Inferior Vena Cava Thrombosis in Acute Pancreatitis: A Rare Vascular Complication

Introduction: The systemic complications of acute pancreatitis are myriad and are mostly a consequence of systemic inflammatory response. Isolated portal and superior mesenteric vein thrombosis are well recognized complications of acute pancreatitis, while thrombosis involving the inferior vena cava (IVC) is extremely rare. Case Report: A 79-year-old male with history of chronic alcoholism presented with upper abdominal pain of 3 weeks' duration. Initial evaluation revealed epigastric tenderness and a serum lipase level of 1,041 U/L. Abdominal computerized tomography showed inflammatory stranding in the pancreatic head, 7-mm pancreatic duct calculus, and punctate calcifications in the pancreatic body suggestive of acute on chronic pancreatitis. He also had a pancreatic pseudocyst and 3.4-cm thrombosis in the IVC above the level of right renal vein with 60% luminal obstruction. He was started on intravenous heparin. He developed abdominal distension and a fall in the hematocrit in the next 2 days. Repeat imaging revealed hemorrhage into the pseudocyst with probable rupture into the peritoneal cavity. Anticoagulation was stopped and he was conservatively managed with blood transfusion. An IVC filter was placed. The workup for hypercoagulabe state including factor V Leiden mutation, prothrombin gene mutation, and activity of protein C, protein S, and antithrombin III was unremarkable. An ERCP done later showed pancreatic duct stricture with calculus that was not amenable to endoscopic treatment. He is on followup and is doing symptomatically well. Discussion: Venous thrombosis occurring outside the splanchnic circulation is very rarely described in pancreatitis. Release of pancreatic proteolytic enzymes due to acute inflammation is the most likely mechanism responsible for thrombosis of the splenic, portal, and superior mesenteric veins. IVC thrombosis can result from systemic inflammatory response with hypercoagulable state or a pancreatic cyst that compresses or penetrates the IVC. Pulmonary thromboembolism is a potential cause of mortality and morbidity in patients with IVC thrombosis, hence early recognition of this complication is vital. There are isolated reports of patients with acute pancreatitis and extra-splanchnic venous thrombosis who have been successfully treated with anticoagulation. In the setting of a pancreatic pseudocyst, anticoagulation is fraught with danger as it can result in hemorrhage into the cyst as described in our case. IVC filter placement is a good alternative in patients who cannot undergo anticoagulation or develop bleeding after anticoagulation. Literature regarding the optimal strategy and the duration of anticoagulation in these patients is minimal.

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

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.

577 Per Oral Pancreatoscopy With Intraductal Holmium Laser Lithotripsy for Treatment of Main Pancreatic Duct Calculi: A Multi-Center U.S. Experience

Per Oral Pancreatoscopy With Intraductal Holmium Laser Lithotripsy for Treatment of Main Pancreatic Duct Calculi: A Multi-Center U.S. Experience Raj J. Shah*, Augustin R. Attwell, Isaac Raijman, Michel Kahaleh, Sandeep Patel University of Colorado Hospital, Aurora, CO; Weill Cornell University, New York, NY; University of Texas, San Antonio, San Antonio, TX; Digestive Associates of Houston, Houston, TX Background: Theoretical advantages of per oral pancreatoscopy (POP)-guided laser (LL) vs. electrohydraulic (EHL) lithotripsy of pancreatic duct (PD) stones is treating firmer calculi and reusing fibers; however, more precision is required. An advantage over ESWL is fragmenting and removing stones during the same procedure. We evaluated the technical success of LL for PD stones. Methods: Patients undergoing POP-LL at four U.S. centers were retrospectively identified. Opiate use, hospitalizations, pain scores, duct clearance, ESWL, and complications were recorded. Study definitions: Technical Success: complete or partial stone clearance. Clinical Success: greater than 50% reduction in opiate use, pain scores, or hospitalizations. Stone fragments were retrieved using baskets and balloons and strictures were dilated and stented. Follow-up was obtained by chart review and patient contact. Categorical variables are reported as medians. Results: Between October 2008 and November 2011, 28 patients [26M, 12F, age 51(17-74) years] underwent POP for PD stones with attempted LL using Spyglass. CP etiology: alcohol (N 14, 50%), idiopathic (N 7, 28%), other (N 7, 28%). Baseline parameters: pain requiring hospitalization (N 19, 68%), chronic opiate use (N 14, 50%), weight loss (N 11, 39%). Interventions preceding index POP-LL: ERCP [(22/28 (79%) had 1 (1-5)]; ESWL [9/28 (32%) had 2 (1-3)]; POP /EHL with failed or incomplete stone fragmentation [7/28 (25%) had 1 (1-3)]. At index POP, a median of 1 (1-5) stone 15mm (4-32mm)in size was located in the head (N 9, 25%) neck (N 3, 11%), body (N 9, 36%), tail (N 1, 4%%) or multiple sites (N 6, 21%). LL settings: 1-10J/5-10W using 200365nm probes and range of 2850-7763 pulses. Stricture dilation was performed in 21/28 (75%)patients and all were stented. Mild complications in 7/28 (25%) index POP-LL procedures. 100% follow-up for 11 (1-25) months. Additional interventions: 38 ERCPs [median 1 (1-6) per patient] and 11 POP (1-3 per pt) were performed to achieve 97% Technical Success with complete (24/28; 86%) and partial (3/28; 11%) clearance. Six patients are ongoing endotherapy for strictures (N 4), stones (N 1), or both (N 1). Clinical Success in 27/28 (96%) by improvement in pain (N 26), reduction in narcotics (N 25) or hospitalizations (N 19). No stone recurrence or surgery was observed. Conclusions: 1) When POP reaches the target stone, LL performed at expert centers results in a high rate of complete stone clearance and clinical improvement at nearly one year of follow-up. 2) POP-LL appears to have utility in cases where fragmentation with EHL is ineffective or incomplete. 3) Although ESWL was adjunctive in 1 of 3 patients with obstructing stones, ERCP-POP may be a preferred primary modality due to the ability to stent strictures and extract stone fragments at the same procedural session.