Treatment Of Pancreatic Duct Stones Research Articles

Development of a novel CT-based index for predicting the number of extracorporeal shockwave lithotripsy (ESWL) sessions required for successful fragmentation of obstructing pancreatic duct stones

Background & aimExtracorporeal shock wave lithotripsy (ESWL) is used for the treatment of pancreatic duct stones (PDS) in patients with chronic pancreatitis (CP). We aimed to develop a CT based index to predict the required number of ESWL sessions for technical success. MethodsWe retrospectively evaluated patients with PDS secondary to CP who underwent ESWL. Technical success was defined as the complete fragmentation of stones to <3 mm. CT features including PDS size, number, location, and density in Hounsfield units (HU) were noted. We analyzed the relationship between PDS characteristics and the number of ESWL sessions required for technical success. A multiple linear regression model was used to combine size and density into the pancreatic duct stone (PDS) index that was translated into a web-based calculator. ResultsThere were 206 subjects (mean age 38.6 ± 13.7 years, 59.2% male) who underwent ESWL. PDS size showed a moderate correlation with the number of ESWL sessions (r = 0.42, p < 0.01). PDS in the head required a fewer number of sessions in comparison to those in the body (1.4 ± 0.6 vs. 1.6 ± 0.7, p = 0.01). There was a strong correlation between PDS density and the number of ESWL sessions (r = 0.617, p-value <0.01). The PDS index {0.3793 + [0.0009755 x PDS density (HU)] + [0.02549 x PDS size (mm)]} could accurately predict the required number of ESWL sessions with an AUC of 0.872 (p < 0.01). ConclusionThe PDS index is a useful predictor of the number of ESWL sessions needed for technical success that can help in planning and patient counseling.

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

Efficacy of Single-operator Pancreatoscopy 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

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

Management of Pancreatic Duct Stones.

Pancreatic duct stones are sequela of chronic pancreatitis. They can cause pancreatic duct obstruction which is the most important cause of pain in chronic pancreatitis. Stone resolution has shown to improve pain. The goal of this review is to highlight recent endoscopic and surgical advancements in treatment of pancreatic duct stones. Stone fragmentation by extracorporeal shock wave lithotripsy has become first line and the mainstay of treatment for majority of patients with pancreatic duct stones. Introduction of digital video pancreatoscopy in the last few years with the capability of guided lithotripsy has provided a robust therapeutic option where extracorporeal shock wave lithotripsy is unsuccessful or unavailable. Historically, surgery has been considered a more reliable and durable option when feasible. However, it had not been compared with more effective endoscopic therapy. Lithotripsy (extracorporeal and pancreatoscopy guided) is evolving as a strong treatment modality for pancreatic stones.

Pancreatoscopy in endoscopic treatment of pancreatic duct stones: a systematic review.

Treatment of chronic calcifying pancreatitis is challenging and requires an interdisciplinary approach including endoscopist, surgeon and radiologist. With advances in endoscopic technology therapeutic interventions in the pancreatic duct became available. Extracorporeal shock wave lithotripsy (ESWL) is still recommended to be first line treatment, hence peroral pancreatoscopy- (POP) -guided intracorporal lithotripsy is a promising supplement in endoscopic therapy especially if ESWL is unsuccessful or not available. Evidence from published trials, abstracts and case reports on direct pancreatoscopic treatment of main pancreatic duct (MPD) stones was reviewed with focus on efficiency and safety of available technologies, endoscopes and lithotripsy devices. A systematic Medline and Cochrane Database search for relevant studies was performed. Seventeen relevant publications meeting the inclusion criteria have been identified (two prospective series, seven retrospective trials, six case reports, two abstracts, for a total of 225 patients). Successful ductal clearance for POP-guided treatment was reported between 37.5% and 100%. Clinical success was reported between 74% and 100%. Adverse event (AE) rate for POP-guided therapy is reported with 0-30%. There is no reported mortality following POP treatment. Three ongoing trials found to be registered. POP-guided lithotripsy seems to be a promising alternative in a very selected patient cohort. Good powered randomized controlled trials are needed to prove efficiency and safety of the new technique also for large numbers of patients before it can be recommended as general practice. The focus of future studies should not only be on technical success, but also clinical success and patient-reported outcomes (quality of life).

Pancreatoscopy-guided laser dissection and ablation for treatment of benign and neoplastic pancreatic disorders: an initial report (with videos)

Per-oral pancreatoscopy (POP) permits direct evaluation of the pancreatic duct for the visualization and sampling of neoplastic lesions and treatment of pancreatic duct stones by using intraductal lithotripsy techniques. Pancreatic laser endotherapy of mucosa has been described in animal models for tumor ablation, but human experience is lacking. We describe 3 unique and challenging clinical situations that benefited from pancreatic laser dissection and ablation. Case 1 was a 75-year-old woman with presumed divisum-associated chronic pancreatitis who had recurrent acute pancreatitis despite minor papilla sphincterotomy and therapeutic stent placement. POP showed a side-branch intraductal papillary mucinous neoplasm within the neck of the pancreas. POP-guided holmium laser ablation of neoplastic tissue was performed, followed by pancreatic stent placement every 6 months, with no further hospitalizations at 20 months of follow-up. Case 2 was a 69-year-old woman with divisum-associated chronic calcific pancreatitis and recalcitrant mid-body stenosis. Previous attempts at balloon dilation and stent placement failed to resolve the stenosis. POP-guided holmium laser dissection of the stenosis was pursued, with immediate radiographic resolution. Case 3 was a 65-year-old woman with chronic calcific pancreatitis and a large stone burden who underwent POP-guided electrohydraulic lithotripsy and partial stone extraction followed by stent placement. Unfortunately, the stent fractured during the subsequent removal attempt because the fragment was impacted in the pancreatic body. POP-guided laser dissection and lithotripsy were used to debulk dense fibrous tissue and stones surrounding the stent fragment, respectively, followed by removal. Pancreatoscopy-guided laser endotherapy is a novel and potentially useful technique to manage difficult benign and neoplastic pancreatic disorders.

Treatment of pancreatic duct stones with extracorporeal shock wave lithotripsy combined with endoscopic retrograde cholangiopancreatography: a report of cases

Treatment of pancreatic duct stones with extracorporeal shock wave lithotripsy combined with endoscopic retrograde cholangiopancreatography: a report of cases

Surgical and micro-invasive treatment of pancreatic duct stones: an analysis of 42 patients

Pancreatic duct stone is a sequel of chronic pancreatitis and may be found in the main ducts, side branches or parenchyma. These stones obstruct the pancreatic ducts and produce ductal hypertension, which leads to pain, the cardinal feature of CP. Surgical operation has been the preferred treatment of pancreatic duct stones in many domestic and external pancreatic medical centers. Lithotomy by longitudinal pancreatic duct incision and Roux-en-Y anastomosis of pancreatic duct to jejunum is the main and effective surgical procedure, while micro-surgery was also rational for the treatment of pancreatic duct stones. However, further studies with a larger sample size and longer follow-up duration are needed to improve the surgical technique and verify our initial results. Key words: Pancreatic duct stone; Surgical procedures; Micro-invasive surgery

Efficacy, Safety, and Outcomes of Endoscopic Retrograde Cholangiopancreatography With Per-Oral Pancreatoscopy: A Multicenter Experience.

Per-oral pancreatoscopy can be used for both evaluation and treatment of pancreatic duct stones during endoscopic retrograde cholangiopancreatography, evaluating and treating pancreatic duct strictures of indeterminate etiology, and visual inspection and direct biopsy of pancreatic duct mucosa for diagnosis of intraductal papillary mucinous neoplasm (IPMN). We aim to describe the efficacy, safety, and outcomes of pancreatoscopy in a large, multicenter series of patients. A multicenter retrospective review was conducted of all patients who underwent per-oral pancreatoscopy at 2 large tertiary-care medical centers. Review of relevant medical records, laboratory data, imaging studies, endoscopic procedure notes, telephone follow-up notes, and progress notes was performed. Thirty-three patients underwent 41 pancreatoscopy procedures. Indications included: 20 (48.8%) for diagnosis and treatment of pancreatic duct stones, 16 (39%) for investigation of IPMN, and 5 (12.2%) for evaluation of pancreatic duct strictures.In 20 procedures performed for stone disease, complete pancreatic duct clearance was achieved in 17 of 20 (85%) cases. Strictures were successfully dilated in 5 of 5 (100%) procedures. Direct visualization and biopsy demonstrated IPMN in 11 of 11 (100%) cases. Adverse events occurred in 3 of 41 (7.3%) of procedures, all of which were mild. In this large series, we demonstrate that in patients with difficult to manage stone disease, strictures and possible malignant ductal pathology, pancreatoscopy is an effective and safe tool that can facilitate both diagnosis and effective therapy. Adverse events in our study were mild and within acceptable limits, further demonstrating that this is a safe procedure that should be offered to appropriate patients.

Endoscopic treatment of pancreatic duct stones under direct vision: Revolution or resignation? Systematic review.

The main treatment aim in chronic pancreatitis (CP) is symptom control and especially pain relief. Management of stone-predominant CP is challenging and requires a multidisciplinary approach. Extracorporeal shock wave lithotripsy (ESWL) has emerged as the cornerstone of non-surgical treatment as a result of disappointing results of available endoscopic treatment options during the last decades. With new developments in the field of direct peroral pancreatoscopy (POP) and intracorporeal lithotripsy, direct intraluminal treatment of main pancreatic duct (MPD) stones returns to the spotlight. Herein, we reviewed the current data on direct pancreatoscopic treatment of MPD stones with a focus on efficiency and safety of available technologies, endoscopes and lithotripsy devices. A systematic Medline search for relevant studies was done. Ten relevant publications meeting the inclusion criteria were identified (two prospective series, six retrospective trials, two case reports, n=87 patients). Successful ductal clearance for POP-guided treatment was reported as between 43% and 100% compared to ESWL with 59% to 80%. Adverse event rate for POP-guided therapy was reported as 0-13.5%. One study showed a noticeable higher adverse event rate of 43%. In this trial, POP was carried out after ESWL. There is no reported mortality following POP treatment. Available results are promising in terms of ductal clearance and pain relief compared to standard endoscopic techniques and ESWL as the current gold standard for lithotripsy. Interpretation of this data is limited by the small number of cases for POP and the lack of prospective randomized controlled trials.

Efficacy of combined endoscopic lithotomy and extracorporeal shock wave lithotripsy, and additional electrohydraulic lithotripsy using the SpyGlass direct visualization system or X-ray guided EHL as needed, for pancreatic lithiasis.

Introduction. To evaluate the efficacy of combined endoscopic lithotomy and extracorporeal shock wave lithotripsy (ESWL), and additional electrohydraulic lithotripsy (EHL) as needed, for the treatment of pancreatic duct stones, we retrospectively evaluated 98 patients with chronic pancreatitis and pancreatic lithiasis. Methods. For the management of main pancreatic duct (MPD) stones in 98 patients, we performed combined endoscopic treatment (ET)/ESWL therapy as the first treatment option. When combined ET/ESWL was unsuccessful, EHL with the SpyGlass Direct Visualization system or X-ray guided EHL was performed. Outpatient ESWL was reserved as one of the final treatment options. Results. Fragmentation was successful in 80 (81.6%) patients as follows: combined ET/ESWL: 67 cases; SpyGlass EHL: 4 cases; X-ray guided EHL: 3 cases; and outpatient ESWL: 6 cases. Successful outcome was obtained by combined ET/ESWL in 67 of the 98 patients (74.5%), by EHL in 7 of 14 patients (7.1%), and by outpatient ESWL in 6 of 6 patients (6.1%). Negotiating the guidewire through a severe MPD stricture was significantly associated with a higher rate of stone fragmentation (P = 0.0003). Conclusions. In cases where combined ET/ESWL was not successful for stone clearance, EHL using the SpyGlass system or X-ray guided EHL was effective in cases where the guidewire could be negotiated through the MPD stricture and it increased the fragmentation rate.

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

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

Endoscopic Versus Surgical Treatment of Downstream Pancreatic Duct Stones in Chronic Pancreatitis

Pancreatic duct stone is thought not only to be the cause of abdominal pain but also to be a risk factor for pancreatic cancer. Several treatment options have been implemented in the treatment of pancreatic duct stones. Stone location is a critical factor in selecting treatment. We present the results of 27 endoscopic treatments and 35 surgical treatments performed in three hospitals at a single university between January 2000 and January 2005. The results were compared retrospectively in terms of success rate of stone removal, length of hospital stay, complications, pain relief, and changes of pancreatic functions. In our study, endoscopy resulted in a similar success rate of stone removal and short-term pain relief rate as the surgical approach and with a shorter length of hospital stay. However, the surgical group had a more favorable long-term clinical result, as well as a lower number of hospital readmissions at the 5-year follow-up point. Based on long-term results, surgical treatment is more effective than endoscopy.

Typing of and surgical treatment choice for pancreatic duct stone

Objective To determine the types of and surgical treatment choice for pancreatic duct stone (PDS).Methods The clinical data of 59 patients with PDS treated in our hospital were retrospectively analyzed to types of and surgical treatment choice for the disease.Results According to the imaging examination and operative findings,PDS could be classified into 4 different types and 5 groups with respective manners of surgical treatment.Conclusion The rational surgical treatment based on correct classification plays an important role in the treatment of PDS. Key words: Pancreatic duct stone; Classification; Surgical treatment

Diagnosis and treatment of pancreatic duct stones companying acute occurrence of chronic pancreatitis

Objective To explore the therapeutic scheme of pancreatic duct stones companying acute occurrence of chronic pancreatitis.Methods A total of 11 cases of pancreatic duct stones companying acute occurrence of chronic pancreatitis were surgically treated in our hospitaI from January 1998 tO September 2006.Of the 11 patients,2 were subjected tO pancreatico-lithotomy,duodenal papillotomy and hepatocholangiostomy,5 to pancreatico-lithotomy and pancreaticoiejunostomy,2 to resection of pancreatic tail with pancreaticojejunostomy and the other 2 to single resection of pancreatic tail.Results In general,the initial symptom of pancreatic duct stones companying acute occurrence of chronic pancreatitis was characterized by acute upper abdominal pain.B-mode ultrasonography and CT were important for its early diagnosis and ERCP was also of help to diagnosis.After operation,chronic abdominal pain disappeared in 54.54%(6/11)and ameliorated in 45.45%(5/11).Pancreatic fistula or bleeding occurred in 27.27%(3/11)of the patients.The follow-up of a mean of(39.2±36.2)months in 9 patients showed that there was no complication.Conclusion Pancreatic duct stones companying acute occurrence of chronic pancreatitis should be managed by conservative treatment in the early phase of disease.and correlative operation 3 months later. Key words: Pancreatitis; Pancreatic duct stone; Treatment

The Diagnosis and Treatment of Pancreatic duct Stone

目的 探讨胰管结石的诊治方法.方法 回顾性分析本院近10年来收治的28例患者的临床资料.结果 B超检查(28例):胰腺内回声不均,胰管扩张,胰管内见强光团,后伴声影(28例);大部分结石位于胰头部(24例),胰体尾结石(4).CT检查(15例):可见胰头区增大,胰管扩张,胰头区钙化斑点(15例),胰体尾散在钙化点(4例).ERCP检查(10例):6例胰管显影,可见胰管扩张粗细不均,胰管内有透明阴影,固定;4例胰管未显影.手术治疗(22例):胰管切开取石、胰管-空肠Roux-Y-eh吻合术14例;胰管切开取石、胰管-空肠、胆总管-空肠吻合术5例;3例胰管结石合并胰腺癌的病人(术中冰冻病理检查证实为胰腺癌)分别行胰体尾脾脏切除,胰管空肠吻合术(1例)、胰十二指肠切除术(1例)和胰腺癌扩大根治术(1例).患者手术后均恢复顺利.结论 B超是最经济、简便、实用、有效的诊断手段,应列为首选方法.CT、ERCP检查也具有确诊价值.治疗原则是去除结石,解除胰管梗阻,建立通畅的胰液引流.手术方式以胰管切开取石、胰管(及胆总管)空肠吻合术为首选,也可根据具体情况,选择胰体尾切除、胰管空肠吻合术,或胰十二指肠切除术等.若取石困难,为了避免胰头组织损伤过大,不必勉强取石。

Extracorporeal shock wave lithotripsy for the treatment of pancreatic duct stones

The purpose of endoscopic therapy in chronic pancreatitis is to decompress the main pancreatic duct and to remove the obstacles that impede the ductal flow of pancreatic juice. The availability of extracorporeal shock wave lithotripsy (ESWL) has improved the results of endoscopic drainage of the main pancreatic duct and has also expanded the indications of endoscopic therapy for chronic pancreatitis. This article briefly reviews ESWL for pancreatic duct stones in patients with chronic pancreatitis, including our experience with ESWL. ESWL is an effective and safe procedure for endoscopically unremovable main pancreatic duct stones, and, in selected patients, ESWL alone may be effective.

The classification and management of pancreatic duct stone

To set up a stand for surgical classification of pancreatic duct stone and evaluate the benefits of different management according to the classification. Retrospectively analysis the diagnosis and prognosis of different management of 33 cases pancreatic duct stones to establish a new standard of classification and strategy of management of pancreatic duct stone. According to the results of imaging examination (B-US, CT, ERCP) and finding during surgery, pancreatic duct stone can be classified into four different types: Type I: The stones mainly located in the head of pancreas. Endoscopic pancreas drainage and remove of stones is the first line choice of treatment. If it fail the Whipple procedure should be applied. Type II, The stones mainly located in the body of pancreas. It can be treated by Pusetow procedure. Type III, The stones mainly located in the tail of pancreas. The resection of the tail of pancreas or combined with spleenectomy was recommended for the management of this type stones. Type IV, The stones can be found from the head to tail of the main duct of pancreas. The Pusetow-Gillesby procedure or dividing of the neck of pancreas removing stones from both ends of pancreatic duct and reconstructed by two ends pancreatic duct-ileostomy in Roux-en-Y fashion are the choice of management. The invadulaized strategy of the management based upon correct diagnosis and classification play the most important role in the treatment of pancreatic duct stone.

Pilot study of pancreatoscopic lithotripsy using a 5-fr instrument: selected patients may benefit.

Despite advances in endoscopic procedures and extracorporeal shock wave lithotripsy (ESWL), the removal of impacted pancreatic duct stones demands a certain amount of time. The aim of this study was to determine which patient group might suitable for our single-session treatment. The study included 17 patients who were symptomatic due to relapsing pancreatitis with pancreatic duct stones. A 5-Fr miniscope was inserted via the papilla to the impacted pancreatic duct stone and pancreatoscopic laser lithotripsy (PSLL) was performed, under direct vision, in only one session. If complete extraction of the pancreatic duct stones was not achieved with PSLL, ESWL was adopted in subsequent sessions. Complete extraction of the pancreatic duct stones using PSLL in a single session was achieved in eight of 17 patients. Single-session PSLL was only suitable for patients with pancreatic duct stones smaller than 17 mm in diameter and with no severe stricture or sharp bend in the pancreatic duct proximal to the stones. Our single-session endoscopic treatment of pancreatic duct stones was useful in a selected patient group.

Pancreatic duct stones in chronic pancreatitis: Criteria for treatment intensity and success

Background: The aim of the study was to evaluate interventional endoscopic management of pancreatic duct stones in patients with chronic pancreatitis by describing therapeutic methods and defining factors that predict technical success. Methods: Records were retrospectively analyzed for 125 patients with symptoms caused by chronic pancreatitis with pancreatic duct stones (single 43, multiple 82) treated by interventional endoscopy, including extracorporeal shockwave lithotripsy. Results: Technical success was achieved in 85% of patients (11 patients by mechanical lithotripsy, 114 by piezoelectric extracorporeal shockwave lithotripsy). There were no serious complications from lithotripsy. Univariate analysis disclosed a statistically significant association between treatment success and patient age as well as prepapillary location of stones. A greater therapeutic effort was necessary in patients with stones located in the tail of the pancreas, 2 or more stones, a stone 12 mm or more in diameter, or who have had a longer duration (>8 years) of the disease. However, with exception of the last parameter, correction for multiple testing of data removed statistical significance. Conclusions: Extracorporeal shockwave lithotripsy enhances endoscopic measures for treatment of pancreatic duct stones when mechanical lithotripsy fails. Middle-aged patients in the early stages of chronic pancreatitis with stones in a prepapillary location proved to be the best candidates for successful treatment. Unfavorable patient-related or morphologic factors can be compensated for through more intense efforts at therapy. (Gastrointest Endosc 2002;56:501-6.)