Removal Of Pancreatic Stones Research Articles

Current status and future perspectives for endoscopic treatment of local complications in chronic pancreatitis.

Chronic pancreatitis is a progressive disease characterized by irregular fibrosis, cellular infiltration, and parenchymal loss within the pancreas. Chronic pancreatitis treatment includes lifestyle modifications based on disease etiology, dietary adjustments appropriate for each stage and condition, drug therapy, endoscopic treatments, and surgical treatments. Although surgical treatments of symptomatic chronic pancreatitis provide good pain relief, endoscopic therapies are recommended as the first-line treatment because they are minimally invasive. In recent years, endoscopic therapy has emerged as an alternative treatment method to surgery for managing local complications in patients with chronic pancreatitis. For pancreatic stone removal, a combination of extracorporeal shock wave lithotripsy and endoscopic extraction is used. For refractory pancreatic duct stones, intracorporeal fragmentation techniques, such as pancreatoscopy-guided electrohydraulic lithotripsy and laser lithotripsy, offer additional options. Interventional endoscopic ultrasound has become the primary treatment modality for pancreatic pseudocysts, except in the absence of disconnected pancreatic duct syndrome. This review focuses on the current status of endoscopic therapies for common local complications of chronic pancreatitis, including updated information in the past few years.

Role of advanced endoscopy in the management of inflammatory digestive diseases (pancreas and biliary tract).

The progress of endoscopic diagnosis and treatment for inflammatory diseases of the biliary tract and pancreas have been remarkable. Endoscopic ultrasonography (EUS) and EUS-elastography are used for the diagnosis of early chronic pancreatitis and evaluation of endocrine and exocrine function in chronic pancreatitis. Notably, extracorporeal shock wave lithotripsy and electrohydraulic shock wave lithotripsy have improved the endoscopic stone removal rate in patients for whom pancreatic stone removal is difficult. Studies have reported the use of self-expanding metal stents for stent placement for pancreatic duct stenosis and EUS-guided pancreatic drainage for refractory pancreatic duct strictures. Furthermore, EUS-guided drainage using a double-pigtailed plastic stent has been performed for the management of symptomatic pancreatic fluid collection after acute pancreatitis. Recently, lumen-apposing metal stents have led to advances in the treatment of walled-off necrosis after acute pancreatitis. EUS-guided biliary drainage is an alternative to refractory endoscopic biliary drainage and percutaneous transhepatic biliary drainage for the treatment of acute cholangitis. The placement of an inside stent followed by switching to uncovered self-expanding metal stents in difficult-to-treat cases has been proposed for acute cholangitis by malignant biliary obstruction. Endoscopic transpapillary gallbladder drainage is an alternative to percutaneous transhepatic gallbladder drainage for severe and some cases of moderate acute cholecystitis. EUS-guided gallbladder drainage has been reported as an alternative to percutaneous transhepatic gallbladder drainage and endoscopic transpapillary gallbladder drainage. However, it is important to understand the advantages and disadvantages of each drainage method and select the optimal drainage method for each case.

Intractable Pancreatic Stone Removal Using SpyGlass™ DS II with Electrohydraulic Lithotripsy: A Case Report and Literature Review

Pancreatic stones are a common finding of chronic pancreatitis and may causerecurrent abdominal pain and pancreatitis. Pancreatic stones are often accompaniedby stenosis of the pancreatic duct and are often impacted within the pancreaticduct, so it is not easy to remove the pancreatic stones using a basket. Until now,extracorporeal shock wave lithotripsy has been used, but it requires repeatedprocedures and the success rate is not very high. The recently developed SpyGlass™DS II (Boston Scientific, Marlborough, MA, USA) has a 3.5 mm diameter that allowsinsertion into the dilated pancreatic duct, it is possible to remove the pancreaticstones using electrohydraulic lithotripsy (EHL) or laser lithotripsy while directlyviewing the pancreatic stones. In this paper, we would like to introduce a method toremove multiple pancreatic stones larger than 10 mm using SpyGlass™ DS II with EHL.

超音波内視鏡下経胃的膵管ステント留置とESWLが有用であった膵石症の1例

超音波内視鏡下経胃的膵管ステント留置とESWLが有用であった膵石症の1例

Radial incision and cutting combined with balloon dilation for refractory pancreaticojejunostomy anastomotic strictures.

Abstract Background and study aims Endoscopic balloon dilation (BD) and temporary stent placement for pancreaticojejunostomy anastomotic stricture (PJAS) achieves good short-term outcomes; however, stricture recurrences remain frequent. We examined the feasibility of performing radial incision and cutting (RIC) combined with BD for refractory PJAS. Patients and methods Five consecutive patients with refractory PJAS who underwent RIC with BD between 2015 and 2018 were retrospectively investigated. We evaluated the technical and clinical success, adverse event (AE), and recurrence rates associated with RIC with BD. Results In all five patients, technical and clinical success were achieved. Pancreatic stone removal was simultaneously performed in one patient. The mean procedure time was 18 minutes (range 12–23 minutes). There were no procedure-related AEs. All patients were followed for over 2 years, with a mean follow-up period of 33 months (range 24–40 months). During the follow-up period, none of the patients developed stricture recurrence and all anastomoses remained patent. Conclusions This is the first report of RIC with BD for the treatment of refractory PJAS, showing favorable results. This combined procedure might be a useful option for treating refractory PJAS.

Long-term outcome of endotherapy for pancreatic stones by using a dedicated pancreatic basket catheter.

Although endotherapy for pancreatic stones is less invasive compared with surgical interventions, its recurrence rate is high and residual pancreatic stones can be a cause of recurrence. We previously reported usefulness of a novel basket catheter with nitinol fine reticular structure for pancreatic stone retraction. In this retrospective study, we aimed to evaluate the long-term outcomes of endotherapy for pancreatic stones with and without the use of this dedicated basket catheter. We retrospectively compared patients with symptomatic pancreatic stones who underwent the initial endotherapy between 2008 and 2019. The primary outcome was the symptomatic recurrence after complete stone clearance. Secondary outcomes were the rate of complete stone clearance, complications, risk factors for recurrences, and the treatment cost. A total of 101 patients who underwent endotherapy for pancreatic stones were analyzed: 41 patients by using the dedicated basket catheter and 60 patients by only the conventional devices. The complete stone clearance was achieved in 87.8% in the dedicated basket group and 88.3% in the conventional device group. Symptomatic recurrence was observed in 16.7% of the dedicated basket group and 47.2% of the conventional device group (P<0.01). In the multivariate analysis, the use of the dedicated basket catheter was significantly associated with the reduced risk of symptomatic recurrence (hazard ratio, 0.40; 95% confidence interval, 0.15-0.92, P=0.031). The complication rate and the cost were comparable between the two groups. The use of this dedicated pancreatic basket catheter significantly reduced symptomatic recurrence after complete pancreatic stone removal.

Removal of pancreatic stones stuck in basket catheter with peroral pancreatoscopy and electronic hydraulic lithotripsy.

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Performance of digital single-operator cholangiopancreatoscope for biliopancreatic diseases in real life: results from a prospective multicenter study

Objectives Peroralcholangio-pancreatoscopy (POCP) is used for diagnosis and treatment of biliopancreatic disease when standard endoscopy (ERCP) or pre-operative imaging workup failed. We aimed to evaluate the diagnostic and therapeutic performance of POCP in complex biliary and pancreatic diseases. Materials and methods Patients with indeterminate biliary or pancreatic duct (PD) strictures, and patients with failure of complex biliary or pancreatic stones removal, were enrolled (six centers). The primary endpoint evaluated malignancy diagnostic performances (accuracy, sensitivity, specificity) and therapeutic performances (biliary or pancreatic stones extraction). Secondary endpoints evaluated: technical success in lesion visualization, ease of maneuvering, image quality and 30-days complications. Results From November 2016 to March 2018, 66 patients were included: 29/37 women/men, median age (IQR): 73 (64–82). Fifty-three patients had diagnostic POCP and 13 patients therapeutic POCP. One endoscopist with one or two endoscopy nurses performed 94% of the POCP. The ‘POCP visual impression’ of malignancy showed 92.0% sensitivity, 92.9 % specificity and 92.5 % overall accuracy compared with the final diagnosis. ‘POCP-guided samples histological analysis’ showed 75.0 % sensitivity and 91.6% specificity. The technical success for lesion visualization was 98.5%. The median VAS scores for insertions in bile and PD were respectively 9.0 (8.1–9.6) and 9.0 (8.8–10.0). Median VAS score for access to the lesion and image quality were respectively 9.0 (7.7–9.6) and 9.0 (7.9–9.7). Only three 30-day minor complications occurred without any major complications. Conclusions POCP was an effective, safe and easy-to-use tool in routine clinical practice for the management of complex diagnostic and therapeutic biliary and pancreatic diseases (NCT03190343).

1420 No Stone Left Unturned: Use of a Novel Device for Pancreatic Calculi Extraction

INTRODUCTION: Pancreatic calculi are found in up to 60% of patients with chronic pancreatitis and can cause pancreatic ductal obstruction and chronic pain. Previous endoscopic methods for pancreatic stone removal include blind mechanical lithotripsy with a balloon or basket, or directly visualized laser or electrohydraulic lithotripsy (EHL). However, these techniques have variable success rates with significant complications. Here we present the first use of the SpyGlass™ Retrieval Basket for extraction of pancreatic duct stones. CASE DESCRIPTION/METHODS: A 65-year-old male with compensated alcoholic cirrhosis and chronic recurrent pancreatitis was referred for evaluation of a diffusely dilated pancreatic duct (PD) seen on MRI. The patient underwent an endoscopic ultrasound (EUS) which showed a tortuous main PD dilated to 8.6 mm. Two hyperechoic foci up to 10 mm were found in the main PD suggestive of calculi. The patient underwent endoscopic retrograde cholangiopancreatography (ERCP). Pancreatogram revealed a dilated and beaded main PD with stones in the head and neck portion of the main PD. A pancreatic sphincterotomy was performed; and the main PD was dilated and swept with a Hurricane balloon removing one stone and debris. Complete ductal clearance could not be achieved using mechanical lithotripsy with a balloon, so the patient returned for a subsequent ERCP. We then used SpyGlass™ for direct pancreatoscopy, which revealed multiple large calculi in the genu of the main PD. The SpyGlass™ Retrieval Basket was advanced through the SpyScope™ and used to manipulate, dislodge and remove the PD stones. Six stones were extracted from the duct. The patient had mild post-ERCP pain, which was treated with oral medications. DISCUSSION: The Spyglass™ Retrieval Basket is a device developed for directly visualized stone extraction through the SpyGlass™ system. In contrast to EHL or laser lithotripsy it does not require fragmentation of stones, which may reduce the risk of post-procedural pancreatitis and perforation. This is the first use of the SpyGlass™ Retrieval Basket to extract stones from the pancreatic duct.

A case of chronic pancreatitis with complete removal of pancreatic stones by grasping forceps

A case of chronic pancreatitis with complete removal of pancreatic stones by grasping forceps

膵・胆管合流異常症に伴う膵石に内視鏡的膵石除去術が奏功した1例

膵・胆管合流異常症に伴う膵石に内視鏡的膵石除去術が奏功した1例

A novel basket catheter to facilitate endoscopic removal of pancreatic stones (with video)

Endoscopic removal of pancreatic stones in patients with chronic pancreatitis is still challenging. With a conventional basket catheter, introduction to the target area or catching pancreatic stones is sometimes difficult. To evaluate a novel double-lumen basket catheter composed of nitinol wires with fine reticular structures in the distal end and loose mesh in the proximal part. A prospective feasibility study. Tertiary-care center. This study involved 10 patients with main pancreatic duct stones of 5 mm or less in the shorter diameter of the largest stone. In the first 5 cases, a nitinol basket catheter was used as salvage after stone extraction with a conventional basket catheter and retrieval balloon (salvage group). In the following 5 cases, stones were initially removed by using a nitinol basket catheter, and the presence of residual stones was evaluated by pancreatogram along with balloon sweep (initial group). Success rate of removal of the target stones and procedure-related adverse events. A nitinol basket catheter was easily introduced to the target stone in all patients. In the salvage group, additional stones were retrieved with a nitinol basket catheter in 3 of 5 patients. In the initial group, stone extraction by a nitinol basket catheter was successful, and no residual stones were extracted by additional balloon cleaning in any patients. Basket impaction or after-ERCP pancreatitis was not observed. A small sample size without a control group. This novel nitinol basket catheter is useful for the extraction of small pancreatic stones. A randomized, controlled trial is warranted to confirm its efficacy.

A difficult case of pancreatic stone removal by endoscopic lithotomy

A 43-year-old male was admitted to our hospital with a pancreatic stone and chronic pancreatitis. Extracorporeal shock wave lithotripsy (ESWL) and endoscopic lithotomy were attempted to remove the stone but proved ineffective because the stone was impacted. Electrohydraulic lithotripsy (EHL) was then performed using the SpyGlass system, but failed to break the stone. Consequently, we recommended a surgical procedure to the patient, but he declined. Therefore, ESWL therapy was continued, eventually disintegrating the pancreatic stone, and endoscopic lithotomy was performed to remove the stone fragments. We consider that EHL cracked the stone and increased the effect of ESWL. After removal of the stone, an endoscopic pancreatic stent was inserted into the main pancreatic duct. This report describes a difficult case of pancreatic stone removal requiring long-term repeated ESWL and endoscopic lithotomy.

Su1384 A Novel Basket Catheter “Reforma” to Facilitate Endoscopic Removal of Pancreatic Stones

Endoscopic removal of pancreatic stones in the main pancreatic duct (MPD) in patients with chronic pancreatitis is still challenging because there is no dedicated device for the narrow, irregular and tortuous duct. When using a conventional basket catheter for biliary stones, it is sometimes difficult to advance the basket to the stones or to catch the stones or the fragments after extracorporeal shockwave lithotripsy (ESWL). A novel basket catheter has been developed to facilitate the removal of pancreatic stones.

Extracorporeal shock wave lithotripsy (ESWL) for large pancreatic stones: are these shocks worth while?

Chronic pancreatitis is characterized by irreversible damage to the pancreas that leads to pain and/or exocrine and endocrine insufficiency [1–3]. Abdominal pain is the most common and distressing symptom and is the most common indication for endoscopic or surgical intervention [1, 4, 5]. One of the mechanisms responsible for pain in chronic pancreatitis is obstruction to the pancreatic duct by strictures or calculi and relief of this obstruction by surgical or endoscopic drainage relieves pain in a majority of patients [6–8]. Endoscopic drainage procedures for relief of pain include pancreatic sphincterotomy, dilation of pancreatic strictures, removal of pancreatic stones and the placement of pancreatic stents to overcome the obstruction [8]. On plain X-ray of the abdomen, pancreatic calcification can be seen in up to 30% of patients with chronic pancreatitis [4]. The advent of newer imaging modalities like computed tomography (CT) has improved the ability to detect pancreatic calcification [9]. Up to 70% of patients with alcohol-related chronic pancreatitis can have pancreatic calcification after 10 years of disease [10]. The calcification can be either due to parenchymal or ductal calculi. Pancreatic duct calculi have been reported in 50% to 90% of patients with chronic pancreatitis and there is higher incidence of ductal calculi in patients with tropical pancreatitis [2, 11]. The ductal calculi cause obstruction leading to an increase in intraductal as well as parenchymal pressure and ischemia, thus causing pain [12]. The factors correlating with pain are the stone size and the diameter of the pancreatic duct. The goal of endoscopic treatment for chronic painful pancreatitis with ductal calculi is complete clearance of calculi from the duct, thus relieving the obstruction and pain [13–16]. Endoscopic extraction of pancreatic duct calculi is usually more difficult than extraction of bile duct stones because pancreatic stones are generally spiculated, hard and multiple, and on many occasions are impacted behind strictures. Endoscopic sphincterotomy followed by balloon or Dormia-assisted stone extraction is usually successful when the stones are of small size and are located in the head or body of the pancreas, and there is no ductal stricture [17]. The presence of ductal stricture or large calculi creates difficulty in endoscopic clearance and requires either decrease in the size of calculi by breaking them into small pieces or enlarging the ampullary orifice so as to successfully deliver intact large stones. Endoscopic balloon sphincteroplasty of the papilla has been used to enlarge the papillary orifice and to successfully extract intact ductal calculi >1 cm, especially radiolucent stones [18]. However, this technique is technically demanding, and has potentially serious complications including bleeding, retroduodenal perforation and pancreatitis [18]. An alternative method is to break the large stones into small pieces so that they can be easily extracted through the papilla. This can be done by using mechanical lithotripsy, intraductal electrohydraulic lithotripsy (EHL) and extracorporeal shock wave lithotripsy (ESWL). Mechanical lithotripsy using a throughthe-scope mechanical lithotripter is technically difficult and is not successful in all cases with large pancreatic calculi, especially when there is difficulty in grasping large stones [19]. Intraductal EHL is cumbersome and requires specialized D. K. Bhasin : S. S. Rana Department of Gastroenterology, Post Graduate Institute of Medical Education and Research (PGIMER), Sector 12, Chandigarh 160 012, India

Endoscopic Approach via the Minor Duodenal Papilla

Background/Aims: We describe procedures for endoscopic approach via the minor papilla in symptomatic patients with pancreas divisum, pancreatic stones, and stricture of the Santorini’s duct, and neoplasms of the minor papilla: endoscopic minor papilla sphincterotomy, endoscopic pancreatic stone removal, endoscopic stent placement in Santorini’s duct, and resection of minor papilla neoplasms. Methods: The most important procedural detail was insertion of a guide wire into Santorini’s duct via the minor papilla, requiring gentle manipulation of both the cannula and guide wire to avoid subsequent complications such as pancreatitis. Results: Minor papilla sphincterotomy was most effective in the treatment of patients with pancreas divisum and associated with acute recurrent pancreatitis; these patients are the best candidates for endoscopic dorsal duct decompression including minor papilla sphincterotomy and stenting. Endoscopic treatment via the minor duodenal papilla was the only useful method for patients whose lesions could not be approached via the major papilla. It is a safe procedure to relieve pain. Long-term results of dorsal ductal stenting were satisfactory in 76 and 90% of patients (19/25 and 9/10, respectively). Conclusion: The high level of endoscopic skills necessary and the small number of patients who need these procedures should limit this approach to select institutions with appropriate endoscopic expertise.

Biliary and pancreatic stone extraction devices

Biliary and pancreatic stone extraction devices

Current treatment options for chronic pancreatitis

Chronic pancreatitis (CP) is characterized by progressive and ultimately irreversible pancreatic injury. Alcohol abuse is the most common cause of CP in the Western world. As the pathophysiology of this disorder is better understood, it is probable that the treatment will be more successful. Therapeutic efforts for CP are focused on the treatment of maldigestion, pain, and diabetes. Dosage and timing of enteric-coated pancreatic enzymes are important issues in the treatment of malabsorption due to CP. Non-enteric-coated enzyme preparations along with acid suppression (histamine-2 blockers or proton-pump inhibitors) are of limited to modest effectiveness in treating pain caused by CP but are worth a trial in patients with less advanced disease. Extracorporeal shock wave lithotripsy (ESWL) of calcified stones is sometimes needed to achieve stone fragmentation before endoscopic removal. The role of ESWL alone in relieving calcified CP pain needs further study. Endoscopic therapy is aimed at decompressing the obstructed pancreatic duct and removal of pancreatic stone and is associated with pain relief in many patients. The role of endoscopic ultrasonography-guided celiac plexus block should be limited to treating those patients with CP whose pain has not responded to other modalities. Radiation therapy to the whole pancreas for CP pain relief is a revived treatment option that needs further study to confirm the safety and efficacy. Total pancreatectomy followed by autologous islet cell autotransplantation appears to be a potential therapeutic approach but should be considered as the last option in patients with refractory pain who have failed conventional medical, endoscopic, and surgical options.

Endoscopic vs. Surgical Drainage for Chronic Pancreatitis

Pancreatic-duct (PD) obstruction is an important etiologic factor for pain in chronic pancreatitis (CP) patients; thus, PD decompression is an appropriate treatment for symptomatic patients with markedly dilated PDs. To compare outcomes of endoscopic and surgical drainage, researchers from Amsterdam enrolled 39 patients with CP, obstruction of the PD (due to strictures, stones, or both), dilation of the PD (≥5 mm proximal to stenosis), and severe recurrent pancreatic pain (not relieved by non-narcotic analgesics). Patients were randomized to endoscopic therapy, consisting of sphincterotomy, pancreatic stone removal (extracorporeal shockwave lithotripsy for stones …

EFFECT OF EXTRACORPOREAL SHOCKWAVE LITHOTRIPSY AND ENDOSCOPIC TREATMENT ON SYMPTOMS AND PANCREATIC FUNCTION IN PANCREATOLITHIASIS

Aims: To investigate the efficacy of extracorporeal shockwave lithotripsy (ESWL) combined with endoscopic treatment for pancreatolithiasis and assess the pancreatic functions after treatment.Patients: Forty‐eight cases with pancreatolithiasis in the main pancreatic duct (MPD) treated by ESWL combined with endoscopic treatments were investigated.Methods: The disappearance rate of abdominal symptoms, the frequency of admission for acute exacerbation of pancreatitis before and after treatment, the relationship of removal of pancreatic stones with recurrence and stricture of the MPD, and pancreatic functions before and after treatment were examined.Results: Treatment for pancreatolithiasis improved symptoms in 95.1% and significantly reduced the frequency of admission for 1 year from 1.4 to 0.2 on average. Pancreatic stones were excellently eliminated in 93.8%. Even in cases complicated with the stricture of MPD, combination with endoscopic techniques provided treatment efficacy comparable to that in cases without such complications. The Bentiromide test significantly improved within 3 months after treatment. It improved 1–2 and 2–3 years after treatment but there was no significant difference. Endocrine functions were maintained in 93.6%, 74.3%, 66.7%, and 64.3% within 3 months, 1–2 years, 2–3 years, and 3 or more years, respectively, after treatment.Conclusions: ESWL combined with endoscopic treatment provides comparable treatment efficacy in cases with and without stricture of the MPD. Treatment for pancreatolithiasis is useful for not only alleviating abdominal symptoms but also maintaining pancreatic exocrine function and management of the diabetes.