Large mesenteric hematoma after extracorporeal shock wave lithotripsy for pancreatic stones: A case report

Safety evaluation of extracorporeal shockwave lithotripsy for pancreatic stones: Experience based on a large chronic pancreatitis cohort

BACKGROUND

The safety of extracorporeal shock wave lithotripsy for pancreatic stones (P-ESWL) and adverse events were not evaluated and classified within large sample population. This study aimed to evaluate the safety and classify the adverse events of P-ESWL based on a large sample cohort.

METHODS

This is an observational study based on the large prospective chronic pancreatitis (CP) cohort. Patients with painful pancreatic stones over 5 mm who underwent P-ESWL between March 2011 and June 2018 at Shanghai Changhai Hospital were included. Adverse events after P-ESWL including complications and transient adverse events (TAEs) were recorded. Risk factors of adverse events were analyzed through univariable and multivariable logistics regression analysis. Sensitivity analysis was conducted to test the stability of the study.

RESULTS

Totally 2,071 patients underwent 5,002 sessions of P-ESWL were included. The overall complication rate and TAEs rate after all P-ESWL procedures were 5.2% and 20.9%. The complications and TAEs rate decreased obviously within the first 6 sessions. Several independent risk factors for adverse events after P-ESWL were identified. Sensitivity analysis suggested the stability of the results.

CONCLUSIONS

P-ESWL is a safe treatment for pancreatic stones. Multiple P-ESWL sessions did not increase the complications and TAEs rate. ClincialTrials.gov number, NCT05916547.

Adverse events of pancreatic extracorporeal shock wave lithotripsy: a literature review

Pancreatic stones are the result of pathophysiologic changes in chronic pancreatitis with an incidence of more than 90%. At present, pancreatic extracorporeal shock wave lithotripsy (P-ESWL) can be used as the first-line treatment for large or complex stones. Although a large number of studies have proven the safety and effectiveness of P-ESWL, we should also pay attention to postoperative adverse events, mainly due to the scattering of shock waves in the conduction pathway. Adverse events can be classified as either complications or transient adverse events according to the severity. Because the anatomic location of organs along the shock wave conducting pathway differs greatly, adverse events after P-ESWL are varied and difficult to predict. This paper outlines the mechanism, definition, classification, management and risk factors for adverse events related to P-ESWL. It also discusses the technique of P-ESWL, indications and contraindications of P-ESWL, and adverse events in special populations.

Lung contusion after extracorporeal shock wave lithotripsy for pancreatic stones: A case report

BACKGROUND

Pancreatic extracorporeal shock wave lithotripsy (P-ESWL) is recommended as the first-line treatment for large pancreatic stones. While complications such as post-P-ESWL pancreatitis, bleeding, infection, steinstrasse, and perforation have been reported in the past 30 years, lung contusion has never been reported. The present case demonstrates lung contusion as a complication after P-ESWL.

METHODS

A 48-year-old man was admitted to our department due to painful chronic pancreatitis with pancreatic duct stones. Computed tomography revealed normal lungs. P-ESWL was performed. The shock wave head contacted with right upper quadrant and the path of shock wave was at a 45° angle to the ventral midline. After P-ESWL, multiple patchy high-density shadows in the lower lobe of right lung were found, which was normal before P-ESWL. The patient had no symptoms of lung injury.

RESULTS AND CONCLUSION

Laboratory studies revealed elevated D-dimer from 0.33 to 0.74 ug/mL, which was consistent with abnormal clotting of lung contusion. Chest computed tomography showed slight pleural effusion. Considering the interval between 2 X-rays was only 3 hours, we inferred that lung contusion was related to P-ESWL. The patient displayed stable vital signs, therefore, no specific interventions were conducted. Three days after P-ESWL, endoscopic retrograde cholangiopancreatography was performed and the lung shadows were partially absorbed. Considering the location of shock wave head, it was possible to cause lung contusion in lower lobe of right lung. More than 10,000 P-ESWL therapeutic sessions had been performed in our center since 2010, and it is the first case about lung contusion as a complication. It is also the first report to describe lung contusion after P-ESWL. Although the patient was asymptomatic, it should raise awareness of clinicians.

Optimal Timing of Endoscopic Intervention After Extracorporeal Shock-Wave Lithotripsy in the Treatment of Chronic Calcified Pancreatitis

OBJECTIVES

The interval between extracorporeal shock-wave lithotripsy (ESWL) and endoscopic retrograde cholangiopancreatography (ERCP) may cause differences in cannulation and stone removal. This study was to investigate the optimal timing of ERCP after ESWL.

METHODS

Patients with chronic calcified pancreatitis, who underwent ESWL and subsequent ERCP in Changhai Hospital from February 2012 to February 2015, were retrospectively analyzed. The interval between ESWL and ERCP was used to divide patients into groups A (<12 hours), B (12-36 hours), and C (>36 hours). Cannulation success, stone clearance, and post-ESWL/ERCP complications were compared.

RESULTS

A total of 507 patients were enrolled. There were no significant differences regarding the successful cannulation and stone removal rates between the 3 groups. In patients without prior ERCP, the successful cannulation rates were 71.4%, 81.9%, and 90.9% (P = 0.004), and the successful clearance rates were 76.2%, 85.1%, and 90.9% (P = 0.031) for these 3 groups, respectively, showing significant differences. There were no differences in the successful cannulation and stone extraction rates for patients with prior ERCP.

CONCLUSIONS

The interval between ESWL and ERCP in chronic calcified pancreatitis patients with prior ERCP is not relevant, while delaying endoscopic intervention is recommended in those with native papilla.

Risk factor for diabetes mellitus in pediatric chronic pancreatitis patients

Pediatric patients suffer from chronic pancreatitis (CP), especially those with diabetes mellitus (DM). This study aimed to identify the incidence of and risk factors for DM in pediatric CP.CP patients admitted to our center from January 2000 to December 2013 were assigned to the pediatric (<18 years old) and adult group according to their age at onset of CP. Cumulative rates of DM and risk factors for both groups were calculated and identified.The median follow-up duration for the whole cohort was 7.6 years. In these 2153 patients, 13.5% of them were pediatrics. The mean age at the onset and the diagnosis of CP in pediatrics were 11.622 and 19.727, respectively. DM was detected in 13.1% patients and 31.0% patients in the pediatric group and adult group, respectively. Age at the onset of CP, smoking history, body mass index (BMI), and etiology of CP were identified risk factors for DM in pediatrics.DM was detected in 13.1% pediatric patients. Age at the onset of CP, smoking history, BMI, and etiology of CP were identified risk factors for the development of DM in pediatric CP patients. The high-risk populations were suggested to be monitored frequently. They could also benefit from a lifestyle modification.

A case of spontaneous mesenteric hematoma successfully diagnosed and treated with aggressive imaging

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Spontaneous mesenteric hematoma is an uncommon syndrome, and often misdiagnosed as other non-hemorrhagic acute abdomen.

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Close monitoring for any signs of further deterioration, as well as aggressive imaging diagnosis, enabled us to make early diagnosis and treatment.

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Sharing our experience may help physicians initiate treatment of mesenteric hematomas early to prevent life-threatening adverse events.

Introduction

Spontaneous mesenteric hematoma is an uncommon syndrome triggered by bleeding localized in the mesenteric vascular tree of a bowel segment for no apparent underlying reason. We herein report a surgical patient with an extremely rapidly growing spontaneous mesenteric hematoma that we successfully diagnosed using careful radiologic examination.

Presentation of case

A 56-year-old old male presenting sudden onset lower abdominal pain was referred to our emergency department. At the time of admission, his physical examination revealed stable vital signs without radiological abnormality. On the following day, the patient suddenly presented hypotension, tachycardia, and increased abdominal pain. Contrast-enhanced computed tomography examination showed a mass with both high- and low-density areas with a 130 mm maximum diameter bordering the transverse colon. Since interventional radiologists were not available, we decided to perform emergency exploratory laparotomy. On laparotomy, a 13 × 8 cm hematoma was found in the mesentery of the transverse colon. As bleeding was noted from the branches of the middle colic artery and gastrocolic artery, these responsible vessels were ligated. The patient was finally given the diagnosis of spontaneous mesenteric hematoma.

Discussion and conclusion

The present case, initially diagnosed as enterocolitis, suddenly manifested hypovolemic shock. Close monitoring for any signs of further deterioration, as well as aggressive imaging diagnosis, enabled us to avoid delays in treatment. Early diagnosis and treatment of mesenteric hematomas are essential to prevent them from rupturing and triggering life-threatening adverse events.