Single-operator Pancreatoscopy Research Articles

Endoscopic interventions in pancreatic strictures and stones-A structured approach.

Chronic pancreatitis (CP) is an irreversible disease of varied etiology characterized by destruction of pancreatic tissue and loss of both exocrine and endocrine function. Pain is the dominant and most common presenting symptom. The common cause for pain in CP is ductal hypertension due to obstruction of the flow of pancreatic juice in the main pancreatic duct either due to stones or stricture or a combination of both. With advances in technology and techniques, endoscopic retrograde cholangiography (ERCP) and stenting should be the first line of therapy for strictures of the main pancreatic duct (MPD). Small calculi in the MPD can be extracted by ERCP and balloon trawl. Extracorporeal shockwave lithotripsy (ESWL) remains the standard of care for large pancreatic calculi and aims to fragment the stones 3mm or less that can easily be extracted by a subsequent ERCP. Single operator pancreatoscopy with intraductal lithotripsy is a technique in evolution and can be tried when ESWL is not available or is unsuccessful in producing stone fragmentation.

Efficacy of Single-operator Pancreatoscopy for the Treatment of Pancreatic Duct Stones

Efficacy of Single-operator Pancreatoscopy for the Treatment of Pancreatic Duct Stones

Correction: Digital single-operator pancreatoscopy for the treatment of symptomatic pancreatic duct stones: a prospective multicenter cohort trial.

Correction: Digital single-operator pancreatoscopy for the treatment of symptomatic pancreatic duct stones: a prospective multicenter cohort trial.

A novel technique for the treatment of impacted pancreatic stones after pancreatoduodenectomy using transanastomotic fluoroscopic-guided electrohydraulic lithotripsy.

Nowadays the role of endoscopic intervention is becoming more important in patients with obstructive pancreatitis. Although a recent study reported that 90 % of patients with obstructing pancreatic stones achieved pancreatic ductal clearance using digital single-operator pancreatoscopy (D-SOP) with electrohydraulic lithotripsy (EHL) or laser lithotripsy [1], endoscopic treatment of obstructive pancreatic stones is still challenging in patients with surgically altered anatomy. Here, we report a novel technique for the treatment of impacted pancreatic stones after pancreatoduodenectomy without using D-SOP.

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.

A244 SUCCESS RATE AND SAFETY OF SINGLE-OPERATOR PANCREATOSCOPY (SOP) IN THE EVALUATION OF SUSPECTED PANCREATIC DUCT NEOPLASIA: A RETROSPECTIVE COHORT STUDY

Abstract Background Pancreatic intraductal papillary mucinous neoplasms (IPMNs) carry malignant risk and they account for up to 7% of pancreatic neoplasms, hence it is crucial to identify high-risk lesions to determine timely therapy Distinction between main duct-IPMN (MD-IPMN) and other pancreatic disorders often relies on endoscopic ultrasound, MRI, and CT findings. These findings are very accurate in advanced cases, yet they are less sensitive for the diagnosis of early lesions Direct endoscopic visualization of the biliary and pancreatic ducts has gained an increased interest due to the development of single-operator scopes with a better image resolution. Several case series and a retrospective single-center cohort study report the beneficial role of single operator pancreatoscopy (SOP) in the evaluation and sampling of indeterminate PD lesions Aims Evaluate our experience with SOP and determine its 1.Efficacy and safety in diagnosing MD-IPMN and PD neoplasia 2.Sensitivity (Sn) and specificity (Sp) in diagnosing high risk PD lesions Methods All patients (age ≥18 year old) who had attempted SOP using the SpyGlass (Boston Scientific Corp, Natick, MA) between June 2013 and November 2019 for the evaluation of indeterminate main PD strictures, dilatation, or with suspected or known MD-IPMN were included The primary outcome was the efficacy and safety of SOP in diagnosing high-risk PD lesions A minimum of 12 months follow-up (F/U) from index SOP was required to define a true negative for patients (pts) with benign SOP findings Results A total of 43 pts underwent SOP; 18 (42%) males and 25 (58%) females, with a mean age of 66.1 years. Technical success was (n=35/43; 81.4%) In the diagnosed MD-IPMN group (n=14/35; 40%), all underwent surgery except three; one is awaiting surgery, the second had an aborted Whipple’s and the last was lost to F/U. The remaining eleven pts (78.6%) had confirmed diagnosis of MD-IPMN with moderate or high-grade dysplasia, or pancreatic cancer Of those who had benign SOP findings (n=21), nineteen (90.5%) did not develop pancreatic neoplasm during a mean F/U period of 59.3 months (range 13 to 84 months). One Pt developed mild pancreatitis Conclusions This study suggests that SOP is a safe, effective and feasible procedure that should be considered in the diagnostic algorithm of indeterminate main PD strictures, dilatation, or those with suspected or known MD-IPMN with or without side branch involvement. We demonstrate a high technical success rate, Sn, and Sp of 81.4%, 100%, and 100%, respectively If all pts with incomplete outcomes data are considered to have be diagnostically inaccurate, the Sn and Sp remain high at 81.4% and 86.4% respectively. The adverse events seem similar to ERCP with only one Pt. (2.7%) developed mild pancreatitis, although this sample has insufficient numbers to evaluate rare events Funding Agencies None

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

Extracorporeal Shock Wave Lithotripsy Versus Single Operator Pancreatoscopy and Intraductal Lithotripsy for the Treatment of Pancreatic Duct Stones

Extracorporeal Shock Wave Lithotripsy Versus Single Operator Pancreatoscopy and Intraductal Lithotripsy for the Treatment of Pancreatic Duct Stones

Safety and efficacy of digital single-operator pancreatoscopy for obstructing pancreatic ductal stones.

Abstract Background and study aims The role of the digital single-operator pancreatoscopy (D-SOP) with electrohydraulic (EHL) or laser lithotripsy (LL) in treating pancreatic ductal stones is unclear. We investigated the safety and efficacy of D-SOP with EHL or LL in patients with obstructing pancreatic duct stones. Patients and methods Retrospective analysis of 109 patients who underwent D-SOP for pancreatic stones at 17 tertiary centers in the United States and Europe from February 2015 to September 2017. Logistic regression was performed to identify factors associated with the need for more than one D-SOP with EHL/LL. Results Most patients were males (70.6 %),mean age 54.7 years. Fifty-nine (54.1 %) underwent EHL and 50 (45.9 %) underwent LL. Mean procedure time was longer in the EHL group (74.4 min vs 53.8 min; P &lt; 0.001). Ducts were completely cleared (technical success) in 89.9 % of patients (94.1 % in EHL vs 100 % in LL; P = 0.243), achieved in a single session in 73.5 % of patients (77.1 % by EHL and 70 % by LL; P= 0.5).D-SOP failed in 11 patients (10.1 %); 6 patients were treated with extracorporeal shockwave lithotripsy (ESWL), 1 with surgery,1 with combined treatment (ESWL + D-SOP EHL) and 3 with other. Fourteen adverse events occurred in 11 patients (10.1 %). Patients with more than three ductal stones were more likely to have technical failure compared to those with less than three stones (17 % vs. 4.8 %; P = 0.04). Having more than three stones was independently associated with the need for more than one D-SOC EHL/LL session (OR 2.94, 95 % CI 1.13 – 7.65). Conclusion D-SOP with EHL or LL is effective and safe in patients with pancreatic ductal stones.

Electrohydraulic Lithotripsy for Pancreatic Duct Stones Under Digital Single-Operator Pancreatoscopy (with Video).

Recently, a digital single-operator cholangiopancreatoscope (DSOC) has become available. This system allows the performance of electrohydraulic lithotripsy (EHL) even within the main pancreatic duct (MPD). However, there are only few reports of EHL for MPD stones using SPY-DS. The aim of this study was to evaluate the technical feasibility and efficacy of EHL for MPD stones under DSOC guidance. Between October 2016 and August 2017, patients with MPD stones were retrospectively enrolled in this study. The presence of MPD stones was diagnosed by endoscopic ultrasound and MRCP. The patients' baseline characteristics and those of the stones, including their size, number, and site in the MPD, number of EHL procedures, and adverse events, were reviewed. A total of 21 patients were retrospectively enrolled. The etiologies of chronic pancreatitis were idiopathic (n = 4) and alcohol induced (n = 17). The pancreatic stone was variously located in the head (n = 6), body (n = 11), tail (n = 1), head and body (n = 2), and body and tail (n = 1) of the pancreas. Median pancreatic stone size was 12mm, and the mean number of ERCP sessions was 1.29 (range 1-3). EHL was successfully performed in 15 patients (85.7%, 18/21), and the rate of complete stone clearance was 88.2% (18/21). Severe adverse events were not seen in any of the patients, although one patient developed mild acute pancreatitis. In conclusion, although additional case reports and prospective studies are needed, EHL under DSOC may be an option to treat MPD stones.

Current role of endoscopic pancreatoscopy.

To provide an overview of the field of pancreatoscopy and to summarize the data informing its clinical utility. Regarding the technological advance of pancreatoscopy, recent studies are the first to report the use of digital, single-operator pancreatoscopy (SpyGlass DS; Boston Scientific, Natick, MA). New data on the use of preoperative pancreatoscopy offer promising results for the potential to optimize treatment of intraductal papillary mucinous neoplasms and to differentiate between benign and malignant pancreatic strictures. Finally, there has been accumulating evidence for the use of pancreatoscopy-guided lithotripsy for the management of painful chronic calcific pancreatitis. Endoscopic pancreatoscopy offers the advantage of direct visualization of the pancreatic duct, allowing for optimal macroscopic assessment, targeted tissue acquisition and guided therapies such as lithotripsy of pancreatic duct stones. The data informing some aspects remain limited, but the accumulating literature forms our understanding of the current and future role of pancreatoscopy in the management of pancreatic disease.

Sa1499 Digital Single Operator Pancreatoscopy in the Management of Pancreatic Stones

Sa1499 Digital Single Operator Pancreatoscopy in the Management of Pancreatic Stones

Large impacted pancreatic stone removed with single-operator pancreatoscopy and electrohydraulic lithotripsy

Large impacted pancreatic stone removed with single-operator pancreatoscopy and electrohydraulic lithotripsy

Single-operator pancreatoscopy is helpful in the evaluation of suspected intraductal papillary mucinous neoplasms (IPMN)

Background and objectiveEven when advanced cross-sectional imaging modalities have been employed, endoscopic evaluation of intraductal papillary mucinous neoplasms (IPMN) is often required in order to assess the final character and extent of lesions. The current study addresses the use of SpyGlass single-operator peroral pancreatoscopy in suspected IPMN. DesignA prospective, non-randomized exploratory cohort study. SettingSingle-center. Patients and interventionA prospective study-cohort of 44 consecutive patients in a single tertiary referral center who underwent ERCP and peroral pancreatoscopy, was prospectively collected between July 2007 and March 2013 because of a radiological signs of IPMN. These IPMN-findings were discovered incidentally in 44% of the cases. Main outcome measurementsDiagnostic accuracy (specificity & sensitivity) and complications. ResultsThe targeted region of the pancreatic duct was reached with the SpyGlass system in 41 patients (median age 65 years, 41% female). Three patients were excluded from analysis because of failed deep cannulation of the pancreatic duct. Brush cytology was taken in 88% and direct biopsies in 41%. IPMN with intermediate or high-grade dysplasia was the main final diagnosis (76%) in 22 patients who had surgery. Out of the 17 patients with a final diagnosis of MD-IPMN, 76% were correctly identified by pancreatoscopy. Of the 9 patients with a final diagnosis of BD-IPMN, the pancreatoscopy identified 78% of the cases correctly.The incidence of post-ERCP pancreatitis was 17%. Pancreatoscopy was found to have provided additional diagnostic information in the vast majority of the cases and to affect clinical decision-making in 76%. LimitationsSingle-center study. ConclusionsSingle-operator peroral pancreatoscopy contributed to the clinical evaluation of IPMN lesions and influenced decision-making concerning their clinical management. The problem of post-procedural pancreatitis needs further attention.

Single-operator Pancreatoscopy (SpyGlass™) for Diagnosis and Treatment of Pancreatic Duct Stones

Single-operator Pancreatoscopy (SpyGlass™) for Diagnosis and Treatment of Pancreatic Duct Stones

Use of Single-Operator Pancreatoscopy (SpyGlass™) in the Evaluation of Main Pancreatic Duct Intraductal Papillary Mucinous Neoplasms

Use of Single-Operator Pancreatoscopy (SpyGlass™) in the Evaluation of Main Pancreatic Duct Intraductal Papillary Mucinous Neoplasms

Single Operator Pancreatoscopy in the Evaluation & Treatment of Pancreatic Disease

Single Operator Pancreatoscopy in the Evaluation & Treatment of Pancreatic Disease