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Bush N, Chandragiri P, Gaurav NA, Sonaiya S, Lahooti I, Singh A, Gupta A, Afghani E, Papachristou G, Khashab MA, Lee PJ, Talukdar R, Lakhtakia S, Singh VK, Han S, Tandan M, Akshintala VS. 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. Pancreatology 2024; 24:643-648. [PMID: 38584052 DOI: 10.1016/j.pan.2024.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Revised: 03/19/2024] [Accepted: 03/26/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND & AIM Extracorporeal 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. METHODS We 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. RESULTS There 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). CONCLUSION The PDS index is a useful predictor of the number of ESWL sessions needed for technical success that can help in planning and patient counseling.
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Affiliation(s)
- Nikhil Bush
- Pancreatitis Center, Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Praneeth Chandragiri
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Nitish Ashok Gaurav
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Sneh Sonaiya
- Pancreatitis Center, Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Ila Lahooti
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Anmol Singh
- Pancreatitis Center, Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Abhinav Gupta
- Pancreatitis Center, Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Elham Afghani
- Pancreatitis Center, Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Georgios Papachristou
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Mouen A Khashab
- Pancreatitis Center, Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Peter J Lee
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Rupjyoti Talukdar
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Sundeep Lakhtakia
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Vikesh K Singh
- Pancreatitis Center, Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Samuel Han
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Manu Tandan
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Venkata S Akshintala
- Pancreatitis Center, Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA.
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2
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Iwata K, Iwashita T, Mukai T, Iwasa Y, Okuno M, Yoshida K, Maruta A, Uemura S, Yasuda I, Shimizu M. Peroral Pancreatoscopy-Guided Lithotripsy Compared with Extracorporeal Shock Wave Lithotripsy in the Management of Pancreatic Duct Stones in Chronic Pancreatitis: A Multicenter Retrospective Cohort Study. Diagnostics (Basel) 2024; 14:891. [PMID: 38732306 PMCID: PMC11082964 DOI: 10.3390/diagnostics14090891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 04/12/2024] [Accepted: 04/22/2024] [Indexed: 05/13/2024] Open
Abstract
BACKGROUND Extracorporeal shock wave lithotripsy (ESWL) is a common treatment for pancreatic stones in chronic pancreatitis. In contrast, peroral pancreatoscopy-guided lithotripsy (POPS-L) remains underexplored, with limited comparative studies to ESWL. This study compared the treatment outcomes of disposable POPS-L tools and ESWL for pancreatic stones. METHODS A retrospective analysis was conducted on 66 patients who had undergone pancreatic stone treatment at three institutions between 2006 and 2022. The treatment outcomes of POPS-L and ESWL were compared. RESULTS This study included 19 and 47 patients who had undergone POPS-L and ESWL, respectively. In a comparison between POPS-L and ESWL, the stone clearance rates were 78.9% vs. 70.2% (p = 0.55), while the procedure-related complication rates were 21% vs. 6.3% (p = 0.09). The median total session counts were 1 vs. 5 (p < 0.01). The cumulative stone recurrence rates were comparable in both groups. Multivariate analysis revealed no significant factors influencing the stone clearance rates, and the choice between POPS-L and ESWL did not affect the stone clearance rates. CONCLUSIONS POPS-L and ESWL exhibited comparable treatment outcomes in terms of stone clearance, complications, and recurrence rates. Furthermore, POPS-L is advantageous due to the need for fewer sessions to achieve pancreatic stone clearance.
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Affiliation(s)
- Keisuke Iwata
- Department of Gastroenterology, Gifu Municipal Hospital, Gifu 500-8513, Japan
| | - Takuji Iwashita
- First Department of Internal Medicine, Gifu University, Gifu 501-1194, Japan
| | - Tsuyoshi Mukai
- Department of Gastroenterological Endoscopy, Kanazawa Medical University, Ishikawa 920-0293, Japan
| | - Yuhei Iwasa
- Department of Gastroenterology, Gifu Municipal Hospital, Gifu 500-8513, Japan
| | - Mitsuru Okuno
- Department of Gastroenterology, Gifu Municipal Hospital, Gifu 500-8513, Japan
| | - Kensaku Yoshida
- Department of Gastroenterology, Gifu Prefectural General Medical Center, Gifu 500-8717, Japan
| | - Akinori Maruta
- Department of Gastroenterology, Gifu Prefectural General Medical Center, Gifu 500-8717, Japan
| | - Shinya Uemura
- First Department of Internal Medicine, Gifu University, Gifu 501-1194, Japan
| | - Ichiro Yasuda
- Third Department of Internal Medicine, Graduate School of Medicine University of Toyama, Toyama 930-0194, Japan
| | - Masahito Shimizu
- First Department of Internal Medicine, Gifu University, Gifu 501-1194, Japan
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Tandan M, Pal P, Reddy DN. Management of Pancreatic Duct Stones: Extracorporeal Approach. Gastrointest Endosc Clin N Am 2023; 33:807-820. [PMID: 37709412 DOI: 10.1016/j.giec.2023.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Abstract
Stone clearance with extracorporeal shock wave lithotripsy is a safe and effective procedure for large pancreatic calculi not extractable by the standard endoscopic retrograde cholangiopancreatography techniques. In properly selected patients, this minimally invasive approach should be offered as the first line of therapy instead of surgery. Complete stone clearance can be achieved in three-fourths with long-term pain relief in two-thirds of patients. Re-intervention is required in less than half of the patients. Future studies should compare the extracorporeal approach with intraductal lithotripsy using the pancreatoscope.
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Affiliation(s)
- Manu Tandan
- Asian Institute of Gastroenterology, 6-3-661, Somajiguda, Hyderabad, TG 500082, India.
| | - Partha Pal
- Asian Institute of Gastroenterology, 6-3-661, Somajiguda, Hyderabad, TG 500082, India
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4
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Endo S, Kawaguchi S, Satoh T, Shirane N. Extracorporeal shock wave lithotripsy and endoscopic pancreatic stenting without pancreatic sphincterotomy for the treatment of pancreatolithiasis: a case series. Clin J Gastroenterol 2023:10.1007/s12328-023-01803-z. [PMID: 37087534 DOI: 10.1007/s12328-023-01803-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 04/12/2023] [Indexed: 04/24/2023]
Abstract
Endoscopic therapy and extracorporeal shock wave lithotripsy (ESWL) are recommended as the first choice in treating pancreatolithiasis. Endoscopic therapy is generally performed using endoscopic pancreatic sphincterotomy (EPST). Herein, we report our experience implementing a treatment protocol, combining endoscopic therapy and ESWL without EPST, for pancreatolithiasis. The inpatient treatment plan was performed every 3 months with a set number of sessions of ESWL with endoscopic pancreatic stenting (EPS) implanted or replaced. Finally, treatment was terminated when the stone was removed after implantation of a 10-Fr stent and crushed to approximately 3 mm or after spontaneous stone discharge. Eight patients were included in this study; the median time to stone disappearance was 208.5 days. The median number of inpatient treatment cycles, endoscopic retrograde cholangiopancreatography, and ESWL sessions was 2.5, 3, and 3, respectively. No serious adverse events were observed in all patients. Therefore, combining ESWL and EPS without EPST can safely treat pancreatolithiasis.
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Affiliation(s)
- Shinya Endo
- Department of Gastroenterology, Shizuoka General Hospital, 4-27-1, Kita-Ando, Aoi-Ku, Shizuoka-City, Shizuoka, 420-8527, Japan.
| | - Shinya Kawaguchi
- Department of Gastroenterology, Shizuoka General Hospital, 4-27-1, Kita-Ando, Aoi-Ku, Shizuoka-City, Shizuoka, 420-8527, Japan
| | - Tatsunori Satoh
- Department of Gastroenterology, Shizuoka General Hospital, 4-27-1, Kita-Ando, Aoi-Ku, Shizuoka-City, Shizuoka, 420-8527, Japan
| | - Naofumi Shirane
- Department of Gastroenterology, Shizuoka General Hospital, 4-27-1, Kita-Ando, Aoi-Ku, Shizuoka-City, Shizuoka, 420-8527, Japan
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5
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Pu W, Ma C, Wang B, Wang Y, Wang H, Xu B, He P, Cui H, Chen H. Electrohydraulic lithotripsy through endoscopic retrograde cholangiopancreatography combined with SpyGlass in the treatment of complex pancreatic duct stones: A case report and literature review. Front Surg 2023; 10:1059595. [PMID: 36741501 PMCID: PMC9889859 DOI: 10.3389/fsurg.2023.1059595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 01/02/2023] [Indexed: 01/19/2023] Open
Abstract
The incidence of pancreatic duct stones (PDS) is less than 1%. After the formation of stones, the lumen of the pancreatic duct is blocked, and the pancreatic juice cannot be discharged smoothly, resulting in the impairment of the internal and external secretions of the pancreas. Several national guidelines now recommend endoscopic retrograde cholangiopancreatography (ERCP) as the treatment for PDS. The emergence of SpyGlass makes it possible to visualize the ERCP blind area of the pancreatic system directly. Electrohydraulic lithotripsy (EHL) under SpyGlass can crush large and pressure-resistant stones into smaller fragments, significantly improving the success of the endoscopic treatment of large stones. Here, we report a patient presented with acute alcohol-associated pancreatitis, found to have PDS on imaging, who underwent ERCP combined with SpyGlass (EHL), avoiding surgery, reducing trauma, and being discharged from the hospital with a rapid recovery. Therefore, endoscopic therapy is effective and safe for PDS patients. The combination therapy of this patient is the first use of SpyGlass for PDS in our centre, which marks a new stage in the application of endoscopic therapy for pancreatic diseases.
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Affiliation(s)
- Weigao Pu
- The Second Clinical Medical College, Lanzhou University, Lanzhou, China,Department of Tumor Surgery, Lanzhou University Second Hospital, Lanzhou, China
| | - Chenhui Ma
- The Second Clinical Medical College, Lanzhou University, Lanzhou, China,Department of Tumor Surgery, Lanzhou University Second Hospital, Lanzhou, China
| | - Bofang Wang
- The Second Clinical Medical College, Lanzhou University, Lanzhou, China,Department of Tumor Surgery, Lanzhou University Second Hospital, Lanzhou, China
| | - Yunpeng Wang
- The Second Clinical Medical College, Lanzhou University, Lanzhou, China,Department of Tumor Surgery, Lanzhou University Second Hospital, Lanzhou, China
| | - Haiyun Wang
- The Second Clinical Medical College, Lanzhou University, Lanzhou, China,Department of Tumor Surgery, Lanzhou University Second Hospital, Lanzhou, China
| | - Bo Xu
- The Second Clinical Medical College, Lanzhou University, Lanzhou, China,Department of Tumor Surgery, Lanzhou University Second Hospital, Lanzhou, China
| | - Puyi He
- The Second Clinical Medical College, Lanzhou University, Lanzhou, China,Department of Tumor Surgery, Lanzhou University Second Hospital, Lanzhou, China
| | - Hongbin Cui
- Department of Tumor Surgery, Lanzhou University Second Hospital, Lanzhou, China,Correspondence: Hao Chen Hongbin Cui
| | - Hao Chen
- The Second Clinical Medical College, Lanzhou University, Lanzhou, China,Department of Tumor Surgery, Lanzhou University Second Hospital, Lanzhou, China,Department of Science and Technology, Key Laboratory of Digestive System Tumors of Gansu Province, Lanzhou, China,Correspondence: Hao Chen Hongbin Cui
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6
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Per-oral pancreatoscopy-guided lithotripsy vs. extracorporeal shock wave lithotripsy for treating refractory main pancreatic duct stones in chronic pancreatitis: Protocol for an open-label multi-center randomized clinical trial. Pancreatology 2022; 22:1120-1125. [PMID: 36273991 DOI: 10.1016/j.pan.2022.09.245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Revised: 08/26/2022] [Accepted: 09/29/2022] [Indexed: 12/04/2022]
Abstract
BACKGROUNDS/OBJECTIVES Patients with chronic pancreatitis may develop pancreatic duct stones that can obstruct outflow leading to ductal hypertension and pain. Both endoscopic retrograde pancreatography (ERP) with per-oral pancreatoscopy (POP) and intraductal lithotripsy and extracorporeal shock wave lithotripsy (ESWL) are feasible options to attempt ductal stone clearance. This study aims to compare POP-guided lithotripsy with ESWL in the management of refractory symptomatic main pancreatic duct stones. METHODS This is an open-label, multi-center, parallel, randomized clinical trial. Patients with chronic pancreatitis and main pancreatic duct stones ≥5 mm who fail standard ERP methods for stone removal will be eligible for this study. In total, 150 subjects will be randomized 1:1 to either ESWL or POP. A maximum of 4 sessions of either ESWL or POP will be allowed in each arm, with crossover permitted thereafter. The primary outcome is complete stone clearance and secondary outcomes include quality of life, pain scores, number of interventions, and daily opiate requirements. CONCLUSIONS This study aims to answer the question of which lithotripsy method is superior in removing refractory pancreatic duct stones while addressing the effects of lithotripsy on quality of life and pain in patients with chronic calcific pancreatitis (ClinicalTrials.gov NCT04115826).
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7
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Strand DS, Law RJ, Yang D, Elmunzer BJ. AGA Clinical Practice Update on the Endoscopic Approach to Recurrent Acute and Chronic Pancreatitis: Expert Review. Gastroenterology 2022; 163:1107-1114. [PMID: 36008176 DOI: 10.1053/j.gastro.2022.07.079] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 06/08/2022] [Accepted: 07/01/2022] [Indexed: 02/07/2023]
Abstract
DESCRIPTION The purpose of this American Gastroenterological Association (AGA) Clinical Practice Update Expert Review is to provide practical, evidence-based guidance to clinicians regarding the role of endoscopy for recurrent acute and chronic pancreatitis. METHODS This expert review was commissioned and approved by the AGA Institute Clinical Practice Updates Committee and the AGA Governing Board to provide guidance on a topic of clinical importance to the AGA membership, underwent internal peer review by the Clinical Practice Updates Committee (CPUC), and external peer review through standard procedures of Gastroenterology. This review is framed around the 8 best practice advice points agreed upon by the authors, based on the results of randomized controlled trials, observational studies, systematic reviews and meta-analyses, as well expert consensus in this field. Best Practice Advice Statements BEST PRACTICE ADVICE 1: After an unrevealing initial evaluation, endoscopic ultrasound is the preferred diagnostic test for unexplained acute and recurrent pancreatitis. Magnetic resonance imaging with contrast and cholangiopancreatography is a reasonable complementary or alternative test to endoscopic ultrasound, based on local expertise and availability. BEST PRACTICE ADVICE 2: The role of endoscopic retrograde cholangiopancreatography (ERCP) for reducing the frequency of acute pancreatitis episodes in patients with pancreas divisum is controversial, but minor papilla endotherapy may be considered, particularly for those with objective signs of outflow obstruction, such as a dilated dorsal pancreatic duct and/or santorinicele. There is no role for ERCP to treat pain alone in patients with pancreas divisum. BEST PRACTICE ADVICE 3: The role of ERCP for reducing the frequency of pancreatitis episodes in patients with unexplained recurrent acute pancreatitis and standard pancreatic ductal anatomy is controversial and should only be considered after a comprehensive discussion of the uncertain benefits and potentially severe procedure-related adverse events. When pursued, ERCP with biliary sphincterotomy alone may be preferable to dual sphincterotomy. BEST PRACTICE ADVICE 4: Surgical intervention should be considered over endoscopic therapy for long-term treatment of patients with painful obstructive chronic pancreatitis. Endoscopic intervention is a reasonable alternative to surgery for suboptimal operative candidates or those who favor a less invasive approach, assuming they are clearly informed that the best practice advice primarily favors surgery. BEST PRACTICE ADVICE 5: When ERCP is pursued, small (≤5mm) main pancreatic duct stones can be treated with pancreatography and conventional stone extraction maneuvers. For larger stones, extracorporeal shockwave lithotripsy and/or pancreatoscopy with intraductal lithotripsy may be required. BEST PRACTICE ADVICE 6: When ERCP is pursued, prolonged stent therapy (6-12 months) is effective for treating symptoms and remodeling main pancreatic duct strictures. The preferred approach is to place and sequentially add multiple plastic stents in parallel (upsizing); emerging evidence suggests that fully covered self-expanding metal stents may have a role for this indication, but additional research is necessary. BEST PRACTICE ADVICE 7: ERCP with stent insertion is the preferred treatment for benign biliary stricture due to chronic pancreatitis. FCSEMS placement is favored over multiple plastic stents whenever feasible, given similar efficacy but significantly reduced need for stent exchange procedures during the treatment course. BEST PRACTICE ADVICE 8: Celiac plexus block should not be routinely performed for the management of pain due to chronic pancreatitis. The decision to proceed with celiac plexus block in selected patients with debilitating pain in whom other therapeutic measures have failed can be considered on a case-by-case basis, but only after discussion of the unclear outcomes of this intervention and its procedural risks.
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Affiliation(s)
- Daniel S Strand
- Division of Gastroenterology and Hepatology, University of Virginia Health System, Charlottesville, Virginia
| | - Ryan J Law
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Dennis Yang
- Center for Interventional Endoscopy, AdventHealth, Orlando, Florida.
| | - B Joseph Elmunzer
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina
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Bao W, Wu D, Han W, Kong R, Wang N, Lu J. Efficacy of Different Pancreatic Interventional Treatments for Chronic Calcific Pancreatitis: A Two-Year Multicenter Retrospective Study. Int J Gen Med 2022; 15:7511-7521. [PMID: 36187161 PMCID: PMC9522486 DOI: 10.2147/ijgm.s383780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 09/07/2022] [Indexed: 11/23/2022] Open
Abstract
Background Extracorporeal shock wave lithotripsy (ESWL) and endoscopic retrograde cholangiopancreatography (ERCP) are the main treatments for chronic calcific pancreatitis (CCP). However, clinical outcomes remain unclear for patients underwent different interventional therapies based on these two techniques. Methods A total of 125 patients with CCP who underwent ESWL, ERCP or a combined treatment at two medical centers from January 2019 to January 2020 were considered. Patients were divided into four groups according to intervention types (ESWL-alone, ERCP-alone, ESWL-ERCP and ERCP-ESWL). A retrospective survey with a follow-up for 2 years was conducted. The main outcome measures were postoperative complications, abdominal pain and re-intervention during the follow-up. Possible prognostic factors were evaluated by multivariate analysis. Results Patients in ESWL-ERCP group had the highest complete pain relief rate (49.28%), the lowest pain frequency (1 time/year) and intensity (VAS-score, 1.84±1.93) during the follow-up, which were statistically significant compared with the other three groups. ESWL-ERCP group also had the lowest postoperative complication rate (6%), while the highest complication rate (16%) was observed in ESWL-alone group. Both ESWL-alone and ESWL-ERCP group had significant lower frequencies of re-interventions (0.44 ± 0.73, 0.57±0.98, respectively) after the initial treatments. An analysis of treatment-based prognostic factors found significant interactions between age, course of CCP, max pancreatic duct stone diameter, calcium, glycosylated hemoglobin (HbA1c) and triglyceride. Conclusion ESWL-ERCP was considered as the most effective interventional therapy for CCP with a better safety in a two-year follow-up. Prognostic factors may help to determine the patients who benefit by this technique.
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Affiliation(s)
- Wen Bao
- Department of Gastroenterology, Shanghai Tenth People’s Hospital, Tongji University, Shanghai, 200072, People’s Republic of China
| | - Deqing Wu
- Department of Gastroenterology, Shanghai Tenth People’s Hospital, Tongji University, Shanghai, 200072, People’s Republic of China
| | - Wei Han
- Department of Gastroenterology, Shanghai Tenth People’s Hospital, Tongji University, Shanghai, 200072, People’s Republic of China
| | - Rui Kong
- Department of Gastroenterology, Shanghai Tenth People’s Hospital, Tongji University, Shanghai, 200072, People’s Republic of China
| | - Nan Wang
- Department of Gastroenterology, Shanghai Tenth People’s Hospital, Tongji University, Shanghai, 200072, People’s Republic of China
| | - Jie Lu
- Department of Gastroenterology, Gongli Hospital, School of Medicine, Shanghai University, Shanghai, 200135, People’s Republic of China
- Correspondence: Jie Lu, Email
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9
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Pancreatic Stones and Extracorporeal Shockwave Lithotripsy: A Review of the Literature. Pancreas 2022; 51:916-922. [PMID: 36607935 DOI: 10.1097/mpa.0000000000002129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
ABSTRACT Pancreatic stones are sequelae of chronic pancreatitis, resulting in poor quality of life, frequent hospitalizations, and a significant economic burden. Extracorporeal shock wave lithotripsy (ESWL) can be used to treat pancreatic stones and is less invasive when compared to other modalities. In this review article, we have discussed the role of ESWL in the treatment of pancreatic stones and how it differs from other modalities. Databases were searched electronically for articles discussing the treatment of pancreatic ductal stones by ESWL or other modalities. Articles discussing or comparing treatment success rates were preferentially included. An inductive approach was used to identify articles related to the treatment of pancreatic stones with ESWL throughout the review process. Although laser lithotripsy and electrohydraulic lithotripsy appear to have higher success rates, the potential for ESWL to affect clinical outcomes is substantial, especially in individuals with a higher risk for invasive procedures. The decision to perform ESWL should be considered if the outcome will substantially alter the clinical management when performed by an experienced endoscopist. Further randomized controlled trials are needed to compare ESWL and peroral pancreatic lithotripsy methods.
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10
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Kuo CY, Wu JW, Yeh JH, Wang WL, Tu CH, Chiu HM, Liao WC. Implementing precision medicine in endoscopy practice. J Gastroenterol Hepatol 2022; 37:1455-1468. [PMID: 35778863 DOI: 10.1111/jgh.15933] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 06/17/2022] [Accepted: 06/28/2022] [Indexed: 12/12/2022]
Abstract
In contrast to the "one-size-fits-all" approach, precision medicine focuses on providing health care tailored to individual variabilities. Implementing precision medicine in endoscopy practice involves selecting the appropriate procedures among the endoscopic armamentarium in the diagnosis and management of patients in a logical sequence, jointly considering the pretest probabilities of possible diagnoses, patients' comorbidities and preference, and risk-benefit ratio of the individual procedures given the clinical scenario. The aim of this review is to summarize evidence-supported strategies and measures that may enhance precision medicine in general endoscopy practice.
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Affiliation(s)
- Chen-Ya Kuo
- Department of Internal Medicine, Fu Jen Catholic University Hospital, New Taipei City, Taiwan
| | - Jer-Wei Wu
- Department of Internal Medicine, National Taiwan University Hospital Jin-Shan Branch, New Taipei City, Taiwan
| | - Jen-Hao Yeh
- Department of Internal Medicine, E-DA Dachang Hospital, Kaohsiung, Taiwan
| | - Wen-Lun Wang
- Department of Internal Medicine, E-DA Hospital, Kaohsiung, Taiwan.,School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Chia-Hung Tu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Han-Mo Chiu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.,Internal Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Wei-Chih Liao
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.,Internal Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
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11
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van der Wiel SE, Stassen PMC, Poley JW, De Jong DM, de Jonge PJF, Bruno MJ. Pancreatoscopy-guided electrohydraulic lithotripsy for the treatment of obstructive pancreatic duct stones: a prospective consecutive case series. Gastrointest Endosc 2022; 95:905-914.e2. [PMID: 34906545 DOI: 10.1016/j.gie.2021.11.047] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 11/30/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Pancreatoscopy-guided electrohydraulic lithotripsy (EHL) has shown potential in the treatment of patients with obstructive chronic calcifying pancreatitis (CCP). We aimed to prospectively investigate the efficacy and safety of EHL as first-line therapy in patients with CCP of the pancreatic duct (PD). METHODS A prospective single-center consecutive case series was performed including symptomatic CCP patients with obstructing stones >5 mm in the head or neck of the pancreas. Stone fragmentation was performed using EHL. Primary study outcome was technical success. Secondary outcomes were clinical success, adverse events, and number of interventions. RESULTS Thirty-four consecutive patients were included. Complete or partial stone clearance after EHL was achieved in 24 patients (70.6%). Pancreatoscopy was not performed because of failure to cannulate the PD (n = 5) or resolution of stones after stent placement at the index endoscopic retrograde pancreaticography (ERP) procedure (n = 3). After successful PD cannulation, pancreatoscopy was technically successful in 24 of 26 patients (92.3%). In 1 patient, the stone could not be visualized because of a resilient stricture. Complete stone clearance was achieved in 20 patients (80%) and partial clearance in 5 patients (20%), after a median of 2 ERP procedures (interquartile range, 2) and 1 EHL procedure (interquartile range, 1). In patients who underwent pancreatoscopy with EHL, mean Izbicki pain score at baseline was 62.3 ± 23.1 (25/25) and dropped significantly to 27.5 ± 35.0 (22/25) at the 6-month follow-up (P < .001). The most common adverse event was acute pancreatitis, all mild and treated conservatively (n = 7). CONCLUSIONS Pancreatoscopy-guided EHL is a promising treatment for symptomatic CCP patients with obstructive PD stones. (Clinical trial registration number: NTR6853.).
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Affiliation(s)
- Sophia E van der Wiel
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Pauline M C Stassen
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Jan-Werner Poley
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - David M De Jong
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Pieter Jan F de Jonge
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
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12
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Dirweesh A, Trikudanathan G, Freeman ML. Endoscopic Management of Complications in Chronic Pancreatitis. Dig Dis Sci 2022; 67:1624-1634. [PMID: 35226223 DOI: 10.1007/s10620-022-07391-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/04/2022] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW Management of complications in patients with chronic pancreatitis is often suboptimal. This review discusses detailed endoscopic approaches for managing complications in CP. LITERATURE FINDINGS CP is characterized by progressive and irreversible destruction of pancreatic parenchyma and ductal system resulting in fibrosis, scarring, and loss of glandular function. Abdominal pain remains is the most common symptom of the disease and the main aim of medical, endoscopic, and surgical therapy is to help relieve symptoms, prevent disease progression, and manage complications related to CP. In fact, advances in our understanding of CP have improved medical care and quality of life in these patients. With significant sequela, morbidity and a progressive nature, a thorough understanding of the pathophysiology, natural course, diagnostic approaches, and optimal management strategies for this disease is warranted. The existing modalities and new innovations in this field are safe, effective, and likely to have a positive impact on management of complication in CP whenever used in the right context.
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Affiliation(s)
- Ahmed Dirweesh
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, MMC 36, 420 Delaware St SE, Minneapolis, MN, 55455, USA
| | - Guru Trikudanathan
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, MMC 36, 420 Delaware St SE, Minneapolis, MN, 55455, USA
| | - Martin L Freeman
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, MMC 36, 420 Delaware St SE, Minneapolis, MN, 55455, USA.
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13
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Affiliation(s)
- Santhi Swaroop Vege
- From the Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN (S.S.V.); and the Department of Gastroenterology, Hepatology, and Nutrition, Division of Internal Medicine, University of Texas M.D. Anderson Cancer Center, Houston (S.T.C.)
| | - Suresh T Chari
- From the Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN (S.S.V.); and the Department of Gastroenterology, Hepatology, and Nutrition, Division of Internal Medicine, University of Texas M.D. Anderson Cancer Center, Houston (S.T.C.)
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14
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Yamamoto S, Inui K, Katano Y, Miyoshi H, Kobayashi T, Tachi Y, Torii Y. Pancreatic Stones: Clinical Outcomes With Nonsurgical Treatment in a Japanese Single-Center Study. Pancreas 2022; 51:205-211. [PMID: 35404899 DOI: 10.1097/mpa.0000000000001996] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES While chronic pancreatitis associated with pancreatolithiasis presents with pain, exocrine and endocrine pancreatic functions worsen with time. We examined outcomes of nonsurgical treatment. METHODS Between 1992 and 2020, we treated pancreatolithiasis nonsurgically in 165 patients with chronic pancreatitis using extracorporeal shock wave lithotripsy alone or followed by endoscopic procedures. The mean follow-up duration was 49 months (standard deviation, 56 months) and the age was 56 years (standard deviation, 13 years). The male:female ratio was 5.1:1 (138 men, 27 women). We followed treatment results including relief of abdominal pain, stone clearance and recurrence, and pancreatic exocrine function (bentiromide-p-aminobenzoic acid testing). RESULTS Treatment relieved pain in 117 of 124 patients (94%). The overall stone clearance was achieved in 130 of 165 patients (79%). Stones recurred during follow-up in 50 of 130 patients (38%). One fifth of recurrences were early, often involving stricture of the main pancreatic duct. After 1 year, 65% of the patients had improved or stable exocrine function. CONCLUSIONS Nonsurgical stone removal usually improved symptoms and preserved pancreatic exocrine function. Nonsurgical treatment with extracorporeal shock wave lithotripsy followed by endoscopic treatment if needed is useful as initial management for pancreatolithiasis.
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Affiliation(s)
| | - Kazuo Inui
- Department of Gastroenterology, Yamashita Hospital, Ichinomiya
| | - Yoshiaki Katano
- From the Department of Gastroenterology, Fujita Health University Bantane Hospital, Nagoya, Japan
| | - Hironao Miyoshi
- From the Department of Gastroenterology, Fujita Health University Bantane Hospital, Nagoya, Japan
| | - Takashi Kobayashi
- From the Department of Gastroenterology, Fujita Health University Bantane Hospital, Nagoya, Japan
| | - Yoshihiko Tachi
- Department of Gastroenterology, Fujita Health University Okazaki Medical Center, Okazaki, Japan
| | - Yoshinori Torii
- From the Department of Gastroenterology, Fujita Health University Bantane Hospital, Nagoya, Japan
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15
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The role of extracorporeal shock wave lithotripsy in the treatment of chronic pancreatitis. Acta Gastroenterol Belg 2021; 84:620-626. [PMID: 34965044 DOI: 10.51821/84.4.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Pain is the most frequent symptom in chronic pancreatitis (CP) and has an important impact on quality of life. One of its major pathophysiological mechanisms is ductal hypertension, caused by main pancreatic duct stones and/or strictures. In this article, we focus on extracorporeal shock wave lithotripsy (ESWL) as a treatment for main pancreatic duct stones, which have been reported in >50% of CP patients. ESWL uses acoustic pulses to generate compressive stress on the stones, resulting in their gradual fragmentation. In patients with radiopaque obstructive main pancreatic duct (MPD) stones larger than 5 mm, located in the pancreas head or body, ESWL improves ductal clearance, thereby relieving pain and improving quality of life. In case of insufficient ductal clearance or the presence of an MPD stricture, ESWL can be followed by endoscopic retrograde cholangiopancreatography (ERCP) to increase success rate. Alternatively, direct pancreaticoscopy with intracorporeal lithotripsy or surgery can be performed.
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16
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Guzmán-Calderón E, Martinez-Moreno B, Casellas JA, Aparicio JR. Per-oral pancreatoscopy-guided lithotripsy for the endoscopic management of pancreatolithiasis: A systematic review and meta-analysis. J Dig Dis 2021; 22:572-581. [PMID: 34436824 DOI: 10.1111/1751-2980.13041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 07/30/2021] [Accepted: 08/15/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Pancreatic stones result from chronic pancreatitis and can occur in the main pancreatic duct, pancreatic branches or parenchyma. Although extracorporeal shock wave lithotripsy (ESWL) is considered the first-line treatment, per-oral pancreatoscopy (POP) has emerged as a useful method for treating pancreatic stones. The aim of this systematic review and meta-analysis was to determine the efficacy and safety of POP-guided lithotripsy, electrohydraulic lithotripsy (EHL) and laser lithotripsy (LL), in patients with pancreatolithiasis. METHODS Literature review was conducted in PubMed, OVID, MEDLINE and Cochrane Library databases for studies published up to August 2020. RESULTS Altogether 15 studies were analyzed, of which 11 were retrospective and four were prospective. The studies comprised 370 patients, of whom 66.4% were male. The patients underwent 218 EHL and 155 LL. The pooled technical and clinical success rate of the overall POP was 88.1% and 87.1%. For EHL-POP, the pooled technical success rate was 90.9% (95% CI 87.2%-95.2%) and the pooled clinical success rate was 89.8% (95% CI 87.2%-95.2%). While for LL-POP, the pooled technical and clinical success rate was 88.4% (95% CI 85.9%-95.1%) and 85.8% (95% CI 80.6%-91.6%). In total 43 adverse events occurred (12.1%; 95% CI 8.7%-15.5%). CONCLUSION POP-guided lithotripsy has a high rate of technical and clinical success for managing pancreatolithiasis with a low complication rate. Both EHL-POP and LL-POP achieve similar efficacy in the endoscopic therapy of pancreatolithiasis. Further large randomized controlled trials are needed to compare EHL-POP and LL-POP with ESWL and evaluate whether POP may replace ESWL as the first-line management of pancreatolithiasis.
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Affiliation(s)
- Edson Guzmán-Calderón
- Gastroenterology Unit, Hospital Nacional Edgardo Rebagliati Martins, Lima, Peru.,Universidad Peruana de Ciencias Aplicadas, Lima, Peru.,Gastroenterology Unit, Angloamericana Clinic, Lima, Peru
| | | | - Juan A Casellas
- Gastroenterology Unit, Hospital General Universitario de Alicante, Alicante, Spain
| | - José Ramón Aparicio
- Gastroenterology Unit, Hospital General Universitario de Alicante, Alicante, Spain
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17
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Comparison of Urologist- vs Gastroenterologist-Directed Extracorporeal Shock Wave Lithotripsy for Pancreaticolithiasis. Clin Gastroenterol Hepatol 2021; 19:1234-1239. [PMID: 32712398 PMCID: PMC8786309 DOI: 10.1016/j.cgh.2020.07.042] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 07/16/2020] [Accepted: 07/20/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Extracorporeal shock wave lithotripsy (ESWL) for pancreaticolithiasis is most commonly performed by urologists. We investigated the effects of transitioning from urologist- to gastroenterologist-directed ESWL on case complexity, process measures, and duct clearance. METHODS We performed a retrospective study of patients who underwent ESWL for pancreaticolithiasis from 2014 through 2019 at a single center. We collected demographic, clinical, radiographic, and procedural data in duplicate and compared case complexity and process measures between the periods the procedure was performed by urologists (January 2014 through February 2017; 18 patients, 0.47 patients/month) vs gastroenterologists (March 2017 through December 2019; 61 patients; 1.79 patients/month). We also compared data on pancreatic duct stone characteristics and technical success (duct clearance, determined by imaging analysis). RESULTS There were no differences in patient demographics, comorbidities, pancreatic stone morphology, or time from referral to ESWL during the period the procedure was performed by urologists vs gastroenterologists. Patients received a higher mean number of ESWL shocks per session during the gastroenterology period (4341) than during the urology period (3117) (P < .001). A higher proportion of patients underwent same-session endoscopic retrograde cholangiopancreatography during the gastroenterology time period (66%) than the urology time period (6%) (P < .001). A higher proportion of patients had partial or complete duct clearance during the gastroenterology period (71%) than during the urology period (44%) (P = .04). During the urology period, a higher proportion of patients were hospitalized following ESWL, although there was no difference in captured adverse events between the periods. CONCLUSIONS Transition from urologist- to gastroenterologist-directed ESWL did not affect case complexity or wait times for ESWL. However, the transition did result in increased procedure volume, more shocks per ESWL session, and improved duct clearance.
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18
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Guo JY, Qian YY, Sun H, Chen H, Zou WB, Hu LH, Li ZS, Xin L, Liao Z. Optimal Timing of Endoscopic Intervention After Extracorporeal Shock-Wave Lithotripsy in the Treatment of Chronic Calcified Pancreatitis. Pancreas 2021; 50:633-638. [PMID: 33939679 DOI: 10.1097/mpa.0000000000001810] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
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.
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Affiliation(s)
| | | | - Hui Sun
- Department of Gastroenterology, the Second People's Hospital of Karamay, Karamay, Xinjiang Uygur Autonomous Region, China
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19
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Schneider A, Hirth M. Pain Management in Chronic Pancreatitis: Summary of Clinical Practice, Current Challenges and Potential Contribution of the M-ANNHEIM Classification. Drugs 2021; 81:533-546. [PMID: 33587287 DOI: 10.1007/s40265-021-01472-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/23/2021] [Indexed: 01/06/2023]
Abstract
Abdominal pain, diarrhea with weight loss, and endocrine insufficiency represent the dominant symptoms of chronic pancreatitis (CP). High intensity of pain and constant pain have been shown to reduce quality of life in CP and may result in disability and increased health resource utilization. Various basic challenges and unanswered questions still exist regarding the treatment of pain in CP. Recently, limited evidence has been gained that early surgery for painful disease might be associated with better treatment results. Thus, timing of pancreatic surgery in painful disease represents a major issue that needs to be clarified in future studies. In this context, surveillance of patients is necessary in clinical practice. It appears that a generally accepted classification of the disease represents a major requirement for inter-institutional comparison of data with future progress in clinical research. Among recently proposed classification systems, the M-ANNHEIM classification system of CP with its recently presented M-ANNHEIM Surgery Score might be a useful tool to picture the course of the disease and to monitor treatment results. Future research is required to clarify the possible role of this system in the management of pain in CP. In the present article, we provide an overview of current status, challenges, and unanswered questions in the treatment of pain in CP, and we demonstrate the potential benefits of the M-ANNHEIM classification system in the management of painful CP.
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Affiliation(s)
- Alexander Schneider
- Department of Gastroenterology and Hepatology, Medical Center Bad Hersfeld-Rotenburg, Bad Hersfeld, Germany. .,Department of Medicine II, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany.
| | - Michael Hirth
- Department of Medicine II, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
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20
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Valente R, Waldthaler A, Scandavini CM, Vujasinovic M, Del Chiaro M, Arnelo U, Löhr JM. Conservative Treatment of Chronic Pancreatitis: A Practical Approach. Scand J Surg 2021; 109:59-68. [PMID: 32192418 DOI: 10.1177/1457496920905559] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Chronic pancreatitis is a long-standing, inflammatory condition of the pancreas that leads to the progressive damage and loss of function of pancreatic parenchyma and to the development of possible locoregional and systemic medical complications. MATERIALS AND METHODS In this review, we tried to summarize the current evidence on non-surgical treatment trying to suggest a practical approach to the management of chronic pancreatitis. RESULTS Besides the unclear pathophysiological mechanism and a poorly unknown epidemiology, chronic pancreatitis is a complex syndrome that displays different possible challenges for physicians. Despite being traditionally considered as a benign disease, chronic pancreatitis encompasses 10-year mortality rates which are superior to the ones reported for some of the most common cancers. CONCLUSIONS Chronic pancreatitis encompasses the management of multiple and complex medical co-morbidities that needs to be understood and addressed in a multidisciplinary specialist context.
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Affiliation(s)
- R Valente
- Division of Surgery, HPB Disease Unit, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden.,CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - A Waldthaler
- Endoscopy Unit, Karolinska University Hospital, Stockholm, Sweden
| | - C M Scandavini
- Division of Surgery, HPB Disease Unit, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
| | - M Vujasinovic
- CLINTEC, Karolinska Institutet, Stockholm, Sweden.,Endoscopy Unit, Karolinska University Hospital, Stockholm, Sweden
| | - M Del Chiaro
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - U Arnelo
- CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - J-M Löhr
- Division of Surgery, HPB Disease Unit, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden.,CLINTEC, Karolinska Institutet, Stockholm, Sweden
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21
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Saghir SM, Mashiana HS, Mohan BP, Dhindsa BS, Dhaliwal A, Chandan S, Bhogal N, Bhat I, Singh S, Adler DG. Efficacy of pancreatoscopy for pancreatic duct stones: A systematic review and meta-analysis. World J Gastroenterol 2020; 26:5207-5219. [PMID: 32982119 PMCID: PMC7495039 DOI: 10.3748/wjg.v26.i34.5207] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 06/29/2020] [Accepted: 08/21/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Pancreatic 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.
AIM To perform a systematic review and meta-analysis of POP, EHL and LL for management of PDC in chronic pancreatitis.
METHODS We 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.
RESULTS A 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.
CONCLUSION Our 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.
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Affiliation(s)
- Syed M Saghir
- Department of Internal Medicine, University of Nevada Las Vegas School of Medicine, Las Vegas, NV 89102, United States
| | - Harmeet S Mashiana
- Division of Gastroenterology and Hepatology, University of Nebraska School of Medicine, Omaha, NE 68198-2000, United States
| | - Babu P Mohan
- Division of Gastroenterology and Hepatology, University of Utah Health, Salt Lake City, UT 84132, United States
| | - Banreet S Dhindsa
- Department of Internal Medicine, University of Nevada Las Vegas School of Medicine, Las Vegas, NV 89102, United States
| | - Amaninder Dhaliwal
- Division of Gastroenterology and Hepatology, University of Nebraska School of Medicine, Omaha, NE 68198-2000, United States
| | - Saurabh Chandan
- Division of Gastroenterology and Hepatology, University of Nebraska School of Medicine, Omaha, NE 68198-2000, United States
| | - Neil Bhogal
- Division of Gastroenterology and Hepatology, University of Nebraska School of Medicine, Omaha, NE 68198-2000, United States
| | - Ishfaq Bhat
- Division of Gastroenterology and Hepatology, University of Nebraska School of Medicine, Omaha, NE 68198-2000, United States
| | - Shailender Singh
- Division of Gastroenterology and Hepatology, University of Nebraska School of Medicine, Omaha, NE 68198-2000, United States
| | - Douglas G Adler
- Division of Gastroenterology and Hepatology, University of Utah Health, Salt Lake City, UT 84132, United States
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22
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Kitano M, Gress TM, Garg PK, Itoi T, Irisawa A, Isayama H, Kanno A, Takase K, Levy M, Yasuda I, Lévy P, Isaji S, Fernandez-Del Castillo C, Drewes AM, Sheel ARG, Neoptolemos JP, Shimosegawa T, Boermeester M, Wilcox CM, Whitcomb DC. International consensus guidelines on interventional endoscopy in chronic pancreatitis. Recommendations from the working group for the international consensus guidelines for chronic pancreatitis in collaboration with the International Association of Pancreatology, the American Pancreatic Association, the Japan Pancreas Society, and European Pancreatic Club. Pancreatology 2020; 20:1045-1055. [PMID: 32792253 DOI: 10.1016/j.pan.2020.05.022] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 05/29/2020] [Accepted: 05/30/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVES This paper is part of the international consensus guidelines on chronic pancreatitis, presenting for interventional endoscopy. METHODS An international working group with experts on interventional endoscopy evaluated 26 statements generated from evidence on 9 clinically relevant questions. The Grading of Recommendations Assessment, Development, and Evaluation approach was used to evaluate the level of evidence. To determine the level of agreement, a nine-point Likert scale was used for voting on the statements. RESULTS Strong consensus was obtained for 15 statements relating to nine questions including the recommendation that endoscopic intervention should be offered to patients with persistent severe pain but not to those without pain. Endoscopic decompression of the pancreatic duct could be used for immediate pain relief, and then offered surgery if this fails or needs repeated endoscopy. Endoscopic drainage is preferred for portal-splenic vein thrombosis and pancreatic fistula. A plastic stent should be placed and replaced 2-3 months later after insertion. Endoscopic extraction is indicated for stone fragments remaining after ESWL. Interventional treatment should be performed for symptomatic/complicated pancreatic pseudocysts. Endoscopic treatment is recommended for bile duct obstruction and afterwards surgery if this fails or needs repeated endoscopy. Surgery may be offered if there is significant calcification and/or mass of the pancreatic head. Percutaneous endovascular treatment is preferred for hemosuccus pancreaticus. Surgical treatment is recommended for duodenal stenosis due to chronic pancreatitis. CONCLUSIONS This international expert consensus guideline provides evidenced-based statements concerning indications and key aspects for interventional endoscopy in the management of patients with chronic pancreatitis.
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Affiliation(s)
- Masayuki Kitano
- Second Department of Internal Medicine, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8509, Japan.
| | - Thomas M Gress
- Department of Gastroenterology, Endocrinology, Metabolism and Infectiology, University Hospital, Philipps-Universität Marburg, Marburg, Germany.
| | - Pramod K Garg
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India.
| | - Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan.
| | - Atsushi Irisawa
- Department of Gastroenterology, Dokkyo Medical University, Mibu, Tochigi, Japan.
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan.
| | - Atsushi Kanno
- Department of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan.
| | - Kei Takase
- Department of Diagnostic Radiology, Tohoku University Graduate School of Medicine, Sendai, Japan.
| | - Michael Levy
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA.
| | - Ichiro Yasuda
- Third Department of Internal Medicine, University of Toyama, Toyama, Japan.
| | - Phillipe Lévy
- Service de Pancréatologie-Gastroentérologie, Pôle des Maladies de l'Appareil Digestif, DHU UNITY, Hôpital Beaujon, APHP, Clichy Cedex, Université Paris 7, France.
| | - Shuiji Isaji
- Department of Surgery, Mie University Graduate School of Medicine, Tsu, Japan.
| | | | - Asbjørn M Drewes
- Centre for Pancreatic Diseases, Department of Gastroenterology, Aalborg University Hospital, Aalborg, Denmark.
| | - Andrea R G Sheel
- Department of Molecular and Clinical Cancer Medicine, Institute of Translational Medicine, University of Liverpool, Liverpool, UK.
| | - John P Neoptolemos
- Department of General Surgery, University of Heidelberg, Heidelberg, Germany.
| | - Tooru Shimosegawa
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan.
| | - Marja Boermeester
- Department of Surgery, Amsterdam University Medical Centers, location AMC, and Amsterdam Gastroenterology & Metabolism, Amsterdam, the Netherlands.
| | - C Mel Wilcox
- Division of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - David C Whitcomb
- Departments of Medicine, Cell Biology & Molecular Physiology and Human Genetics, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh and UPMC, Pittsburgh, PA, USA.
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van Huijgevoort NC, Veld JV, Fockens P, Besselink MG, Boermeester MA, Arvanitakis M, van Hooft JE. Success of extracorporeal shock wave lithotripsy and ERCP in symptomatic pancreatic duct stones: a systematic review and meta-analysis. Endosc Int Open 2020; 8:E1070-E1085. [PMID: 32743061 PMCID: PMC7373664 DOI: 10.1055/a-1171-1322] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 03/30/2020] [Indexed: 12/12/2022] Open
Abstract
Background and study aims Pain is the most frequent and dominant symptom of chronic pancreatitis. Currently, these patients are treated using a step-up approach, including analgesics and lifestyle adjustments, endoscopic, and eventually surgical treatment. Extracorporeal shock wave lithotripsy (ESWL) is indicated after failure of the first step in patients with symptomatic intraductal stones larger than 5 mm in the head or body of the pancreas. To assess the complete ductal clearance rate and pain relief after ESWL in patients with symptomatic chronic pancreatitis with pancreatic duct stones, a systematic review and meta-analysis was performed. Patients and methods A systematic literature search from January 2000 to December 2018 was performed in PubMed, the Cochrane Library, and EMBASE for studies on ductal clearance rate of ESWL in patients with symptomatic chronic pancreatitis with pancreatic duct stones. Results After screening 486 studies, 22 studies with 3868 patients with chronic pancreatitis undergoing ESWL for pancreatic duct stones were included. The pooled proportion of patients with complete ductal clearance was 69.8 % (95 % CI 63.8-75.5). The pooled proportion of complete absence of pain during follow-up was 64.2 % (95 % CI 57.5-70.6). Complete stone fragmentation was 86.3 % (95 % CI 76.0-94.0). Post-procedural pancreatitis and cholangitis occurred in 4.0 % (95 % CI 2.5-5.8) and 0.5 % (95 % CI 0.2-0.9), respectively. Conclusion Treatment with ESWL results in complete ductal clearance rate in a majority of patients, resulting in absence of pain during follow up in over half of patients with symptomatic chronic pancreatitis caused by obstructing pancreatic duct stones.
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Affiliation(s)
- Nadine C.M. van Huijgevoort
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, location AMC, Amsterdam, The Netherlands
| | - Joyce V. Veld
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, location AMC, Amsterdam, The Netherlands
| | - Paul Fockens
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, location AMC, Amsterdam, The Netherlands
| | - Marc G. Besselink
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, location AMC, Amsterdam, The Netherlands
| | - Marja A. Boermeester
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, location AMC, Amsterdam, The Netherlands
| | - Marianna Arvanitakis
- Department of Gastroenterology and Hepatology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Jeanin E. van Hooft
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, location AMC, Amsterdam, The Netherlands
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Shanbhogue KP, Pourvaziri A, Jeyaraj SK, Kambadakone A. Endoscopic and surgical treatment options for chronic pancreatitis: an imaging perspective. Abdom Radiol (NY) 2020; 45:1397-1409. [PMID: 31707437 DOI: 10.1007/s00261-019-02249-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Chronic pancreatitis is a chronic fibro-inflammatory syndrome characterized by chronic pancreatic inflammation leading to fibrosis and scarring. Patients with this multifactorial debilitating illness often require endoscopic or surgical intervention for treatment. Radiologists play a crucial role in pre-therapeutic workup as well as post-treatment imaging of chronic pancreatitis. This review summarizes the most common surgical and endoscopic treatment options that are currently available for chronic pancreatitis, including the implications on imaging.
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25
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Udd M, Kylänpää L, Kokkola A. The Role of Endoscopic and Surgical Treatment in Chronic Pancreatitis. Scand J Surg 2020; 109:69-78. [DOI: 10.1177/1457496920910009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Chronic pancreatitis is a long-term illness leading to hospital admissions and readmission. This disease is often caused by heavy alcohol consumption and smoking. Patients with chronic pancreatitis suffer from acute or chronic pain episodes, recurrent pancreatitis, and complications, such as pseudocysts, biliary duct strictures, and pancreatic duct fistulas. Pancreatic duct strictures and stones may increase intraductal pressure and cause pain. Endoscopic therapy is aiming at decompressing the pressure and relieving the pain, most commonly with pancreatic duct stents and pancreatic duct stone retrieval. Early surgery is another option to treat the pain. In addition, endotherapy has been successful in treating complications related to chronic pancreatitis. The therapy should be individually chosen in a multidisciplinary meeting. Endoscopic therapy and surgery as treatment options for chronic pancreatitis are discussed in this review.
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Affiliation(s)
- M. Udd
- Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - L. Kylänpää
- Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - A. Kokkola
- Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Abstract
PURPOSE OF REVIEW 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. RECENT FINDINGS 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.
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Affiliation(s)
- Kaveh Sharzehi
- Division of Gastroenterology & Hepatology, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA.
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27
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Ogura T, Okuda A, Imanishi M, Miyano A, Amano M, Nishioka N, Kamiyama R, Higuchi K. Electrohydraulic Lithotripsy for Pancreatic Duct Stones Under Digital Single-Operator Pancreatoscopy (with Video). Dig Dis Sci 2019; 64:1377-1382. [PMID: 30456448 DOI: 10.1007/s10620-018-5374-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 11/08/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND 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. AIMS The aim of this study was to evaluate the technical feasibility and efficacy of EHL for MPD stones under DSOC guidance. METHODS 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. RESULTS 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 12 mm, 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. CONCLUSIONS In conclusion, although additional case reports and prospective studies are needed, EHL under DSOC may be an option to treat MPD stones.
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Affiliation(s)
- Takeshi Ogura
- 2nd Department of Internal Medicine, Osaka Medical College, 2-7 Daigakuchou, Takatsukishi, Osaka, 569-8686, Japan.
| | - Atsushi Okuda
- 2nd Department of Internal Medicine, Osaka Medical College, 2-7 Daigakuchou, Takatsukishi, Osaka, 569-8686, Japan
| | - Miyuki Imanishi
- 2nd Department of Internal Medicine, Osaka Medical College, 2-7 Daigakuchou, Takatsukishi, Osaka, 569-8686, Japan
| | - Akira Miyano
- 2nd Department of Internal Medicine, Osaka Medical College, 2-7 Daigakuchou, Takatsukishi, Osaka, 569-8686, Japan
| | - Mio Amano
- 2nd Department of Internal Medicine, Osaka Medical College, 2-7 Daigakuchou, Takatsukishi, Osaka, 569-8686, Japan
| | - Nobu Nishioka
- 2nd Department of Internal Medicine, Osaka Medical College, 2-7 Daigakuchou, Takatsukishi, Osaka, 569-8686, Japan
| | - Rieko Kamiyama
- 2nd Department of Internal Medicine, Osaka Medical College, 2-7 Daigakuchou, Takatsukishi, Osaka, 569-8686, Japan
| | - Kazuhide Higuchi
- 2nd Department of Internal Medicine, Osaka Medical College, 2-7 Daigakuchou, Takatsukishi, Osaka, 569-8686, Japan
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A Comparison of Endoscopic Retrograde Pancreatography With or Without Pancreatoscopy for Removal of Pancreatic Duct Stones. Pancreas 2019; 48:690-697. [PMID: 31091217 DOI: 10.1097/mpa.0000000000001317] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVES Pancreatic duct stones contribute to pain in patients with chronic pancreatitis, and per-oral pancreatoscopy (POP) allows visualization, fragmentation, and removal of these stones. This study compared the safety and efficacy of endoscopic retrograde pancreatography (ERP) with and without POP. METHODS This single-center retrospective review compared ERP with and without POP for treatment of main-duct pancreatic duct stones. The primary outcome was technical success, defined as partial or complete stone removal, which was compared between the 2 groups. RESULTS In all, 223 patients underwent 549 ERPs with a technical success rate of 92.4% and complete stone clearance rate of 74.9%. Patients undergoing ERP with POP (n = 94) had higher technical success than patients undergoing ERP without POP (n = 129, 98.9% vs 87.6%, P < 0.001), but required more ERPs (3.1 vs 1.9, P = 0.02). Endoscopic retrograde pancreatography with POP was associated with larger stone size (8.9 vs 6.1 mm, P = 0.001), more stones per case (5+ stones: 33.8% vs 21.1%, P = 0.002), and more impacted stones (48.8% vs 10.3%, P < 0.001). CONCLUSIONS Per-oral pancreatoscopy-guided lithotripsy permits effective stone removal in cases not amenable to standard ERP techniques, including those with larger or more numerous stones.
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29
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Han S, Shah RJ. ERCP with Digital Pancreatoscopy-Guided Stone Fragmentation: Breaking Up Is Easy to Do. Dig Dis Sci 2019; 64:1059-1061. [PMID: 30788682 PMCID: PMC6499632 DOI: 10.1007/s10620-019-05502-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Samuel Han
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Colorado Anschutz Medical Center, 1635 Aurora Ct, Mail Stop F735, Rm. AIP 2.031, Aurora, CO, 80045, USA
| | - Raj J Shah
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Colorado Anschutz Medical Center, 1635 Aurora Ct, Mail Stop F735, Rm. AIP 2.031, Aurora, CO, 80045, USA.
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Haraldsson S, Roug S, Nøjgaard C, Novovic S, Gluud LL, Feldager E, Schmidt PN. Extracorporeal shock wave lithotripsy for pancreatic duct stones: an observational study. Scand J Gastroenterol 2019; 53:1399-1403. [PMID: 30353766 DOI: 10.1080/00365521.2018.1508611] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Previous studies suggest that fragmentation of pancreatic duct stones (PDS) using extracorporeal shock wave lithotripsy (ESWL) is associated with pain relief. However, the treatment may not be effective in certain subgroups. AIM To evaluate predictors of pain relief after ESWL in patients with chronic pancreatitis and PDS. METHODS Retrospective study including patients with chronic pancreatitis undergoing ESWL for painful PDS. Analgesic use before and after the ESWL procedure was registered. We defined adequate pain relief after ESWL as 'pain-free without analgesics or with use of weak analgesics as needed'. The study was approved by the Danish Data Protection Agency (approval number: AHH-2017-048). RESULTS We included 81 patients (median age 58 years; 63% men; 68% alcoholic pancreatitis). Patients underwent one to seven ESWL procedures (mean 1.7). A concurrent ERCP was performed in 17%. All patients used analgesics before the ESWL procedure (68 used opioids). After ESWL, 43 still used opioids. Thirty-two patients achieved adequate pain relief. Univariable regression analysis showed that older age predicted adequate pain relief (OR 1.09;1.03-1.16; p = .002) as did location of the stone in the head or neck (OR 2.59;1.04-6.45; p = .041). In multivariable analysis, we found that the only two predictors of adequate pain relief were age (p = .002) and the location of the stones (p = .039). CONCLUSION After the ESWL, about four out of ten patients are pain-free without medication or able to manage their pain with weak analgesics. Age and the location of the stones may be considered when evaluating if patients are eligible for referral to ESWL.
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Affiliation(s)
- Stefan Haraldsson
- a Department of Gastroenterology , Landspitali - University Hospital , Reykjavik , Iceland
| | - Stine Roug
- b Abdominal Center K, Bispebjerg Hospital , Copenhagen , Denmark
| | - Camilla Nøjgaard
- c Department of Gastroenterology and Gastrointestinal Surgery , Copenhagen University Hospital Hvidovre , Hvidovre , Denmark
| | - Srdan Novovic
- c Department of Gastroenterology and Gastrointestinal Surgery , Copenhagen University Hospital Hvidovre , Hvidovre , Denmark
| | - Lise Lotte Gluud
- c Department of Gastroenterology and Gastrointestinal Surgery , Copenhagen University Hospital Hvidovre , Hvidovre , Denmark
| | - Erik Feldager
- c Department of Gastroenterology and Gastrointestinal Surgery , Copenhagen University Hospital Hvidovre , Hvidovre , Denmark
| | - Palle Nordblad Schmidt
- c Department of Gastroenterology and Gastrointestinal Surgery , Copenhagen University Hospital Hvidovre , Hvidovre , Denmark
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Mayerle J, Anz D, D'Haese JG, Werner J. [Endoscopic and surgical treatment of chronic pancreatitis]. Internist (Berl) 2019; 60:235-246. [PMID: 30635667 DOI: 10.1007/s00108-018-0546-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
With an increasing number of hospital admissions, an average of 16-to 20 days in hospital per year, 34% of patients constantly taking pain medication, 57% in need of enzyme supplementation, and 29% with diabetes mellitus, chronic pancreatitis is a debilitating disease of high socio-economic relevance. In total, 33% of all patients suffering from chronic pancreatitis can no longer practice their original profession. The number of unemployed chronic pancreatitis patients due to prolonged stays in hospital or continued alcohol abuse is known to be as high as 40%. Continued alcohol abuse with a hazard ratio (HR) of 1.6, smoking with a HR of 1.4, and the presence of liver cirrhosis with a HR of 2.5 negatively affects the prognosis of chronic pancreatitis. In a patient cohort burdened with high co-morbidity, endoscopic therapy can provide short-term relief of symptoms. Endotherapy is the first line of management in chronic pancreatitis with symptomatic pancreatobiliary ductal obstruction. Further studies are required in certain key areas such as the use of fully covered self-expanding metallic stents for pancreatic ductal and biliary strictures. Long-term success rates can mainly be achieved by surgical procedures, which can be performed with acceptable morbidity in pancreatic centers. The current review focuses on the advantages and disadvantages of endoscopic and surgical treatment of chronic pancreatitis.
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Affiliation(s)
- J Mayerle
- Medizinische Klinik und Poliklinik II, Klinikum der Universität München, Ludwig-Maximilians-Universität München, Marchioninistr. 15, 81377, München, Deutschland.
| | - D Anz
- Medizinische Klinik und Poliklinik II, Klinikum der Universität München, Ludwig-Maximilians-Universität München, Marchioninistr. 15, 81377, München, Deutschland
| | - J G D'Haese
- Klinik für Allgemein‑, Viszeral- und Transplantationschirurgie, Klinikum der Universität München, Ludwig-Maximilians-Universität München, Marchioninistr. 15, 81377 München, Deutschland
| | - J Werner
- Klinik für Allgemein‑, Viszeral- und Transplantationschirurgie, Klinikum der Universität München, Ludwig-Maximilians-Universität München, Marchioninistr. 15, 81377 München, Deutschland
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Watson RR, Parsi MA, Aslanian HR, Goodman AJ, Lichtenstein DR, Melson J, Navaneethan U, Pannala R, Sethi A, Sullivan SA, Thosani NC, Trikudanathan G, Trindade AJ, Maple JT. Biliary and pancreatic lithotripsy devices. VIDEOGIE : AN OFFICIAL VIDEO JOURNAL OF THE AMERICAN SOCIETY FOR GASTROINTESTINAL ENDOSCOPY 2018; 3:329-338. [PMID: 30402576 PMCID: PMC6205352 DOI: 10.1016/j.vgie.2018.07.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND AIMS Lithotripsy is a procedure for fragmentation or destruction of stones to facilitate their removal or passage from the biliary or pancreatic ducts. Although most stones may be removed endoscopically using conventional techniques such as endoscopic sphincterotomy in combination with balloon or basket extraction, lithotripsy may be required for clearance of large, impacted, or irregularly shaped stones. Several modalities have been described, including intracorporeal techniques such as mechanical lithotripsy (ML), electrohydraulic lithotripsy (EHL), and laser lithotripsy, as well as extracorporeal shock-wave lithotripsy (ESWL). METHODS In this document, we review devices and methods for biliary and pancreatic lithotripsy and the evidence regarding efficacy, safety, and financial considerations. RESULTS Although many difficult stones can be safely removed using ML, endoscopic papillary balloon dilation (EPBD) has emerged as an alternative that may lessen the need for ML and also reduce the rate of adverse events. EHL and laser lithotripsy are effective at ductal clearance when conventional techniques are unsuccessful, although they usually require direct visualization of the stone by the use of cholangiopancreatoscopy and are often limited to referral centers. ESWL is effective but often requires coordination with urologists and the placement of stents or drains with subsequent procedures for extracting stone fragments and, thus, may be associated with increased costs. CONCLUSIONS Several lithotripsy techniques have been described that vary with respect to ease of use, generalizability, and cost. Overall, lithotripsy is a safe and effective treatment for difficult biliary and pancreatic duct stones.
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Key Words
- ASGE, American Society for Gastrointestinal Endoscopy
- C-APCS, Comprehensive Ambulatory Payment Classification
- CMS, Centers for Medicare and Medicaid Services
- CPT, Current Procedural Terminology (https://www.asge.org/docs/default-source/education/Technology_Reviews/doc-enteral-nutrition-access-devices.pdf?sfvrsn=4)
- EHL, electrohydraulic lithotripsy
- EPBD, endoscopic papillary balloon dilation
- ERCP, endoscopic retrograde cholangiopancreatography
- ES, endoscopic sphincterotomy
- ESWL, extracorporeal shock wave lithotripsy
- FDA, U.S. Food and Drug Administration
- FREDDY, frequency-doubled, double-pulse neodymium
- HCPCS, Healthcare Common Procedure Coding System
- MAUDE, Manufacturer and User Facility Device Experience
- ML, mechanical lithotripsy
- RCT, randomized controlled trial
- YAG, yttrium aluminum garnet
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Abstract
PURPOSE OF REVIEW Pain is the most common symptom of chronic pancreatitis, having a profound effect on patients and a broad socioeconomic impact. Endoscopy is guideline recommended as first-line management for chronic pancreatitis pain in certain clinical scenarios. Herein, we provide an evidence-based review of the endoscopic treatment of pain due to chronic pancreatitis while highlighting some important confounders in the measurement of this outcome in clinical practice and research. RECENT FINDINGS Multiple recent studies have reported on the efficacy of current endoscopic therapies for chronic pancreatitis pain. Despite the high technical success rates of these procedures, pain outcomes remain disappointing. Complex mechanisms beyond ductal hypertension, such as central sensitization, visceral hypersensitivity and inflammatory neuritis account for some of the discordance observed between the rates of technical and clinical success. In addition, the sham effect is increasingly recognized as a confounder when interpreting the procedural benefit. Nevertheless, there are multiple promising innovations in the field of pancreatic endoscopy that are aimed to improve technical and clinical outcomes, but rigorous investigation is necessary to establish their role in clinical practice. SUMMARY Endoscopic therapy for chronic pancreatitis pain appears to be safe and effective in certain contexts and recent innovations in the field will hopefully further improve outcomes. In addition to evaluating the technical success of endotherapy in chronic pancreatitis, methodologically rigorous research focusing on patient-centered outcomes and accounting for the sham effect is necessary to advance this field.
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Extracorporeal Shock Wave Lithotripsy for Chronic Pancreatitis Patients With Stones After Pancreatic Surgery. Pancreas 2018; 47:609-616. [PMID: 29683971 DOI: 10.1097/mpa.0000000000001042] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES The objective of this study was to evaluate the safety and efficacy of pancreatic extracorporeal shock wave lithotripsy (P-ESWL) in chronic pancreatitis (CP) patients with pancreatic stones after previous pancreatic surgery. METHODS This is a single-center study prospectively conducted in pained CP patients undergoing P-ESWL. Patients with a pancreatic surgery history (PSH) were included in the PSH group, and patients without a PSH during the same period were assigned to the control group. The primary outcomes included complications associated with P-ESWL and pain relief. Secondary outcomes included stone clearance and improved quality-of-life scores. RESULTS From March 2011 to October 2014, P-ESWLs were performed on 1017 patients (50 in the PSH group, 967 in the control group). No significant difference was observed in the frequency of occurrence of P-ESWL complications between the PSH group and control group (14.0% vs 13.2%, P = 0.877). At follow-up (2.6 years; range, 1.0-4.5 years), pain relief was achieved in 36 patients (75.0%), and 37 patients (77.1%) experienced complete stone clearance. No significant differences were observed between these patients and the matched controls. CONCLUSIONS For CP patients who develop painful stones after pancreatic surgery, P-ESWL safely achieves significant pain relief and stone clearance, preventing the need for a repeat surgery.
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35
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Bi YW, Wang D, Li ZS, Hu LH. Pancreatic sphincter precutting using a dual knife to relieve acute pancreatic duct obstruction. Dig Liver Dis 2018; 50:94. [PMID: 28844855 DOI: 10.1016/j.dld.2017.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Revised: 07/26/2017] [Accepted: 08/01/2017] [Indexed: 12/11/2022]
Affiliation(s)
- Ya-Wei Bi
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Dan Wang
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Zhao-Shen Li
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China; Digestive Endoscopy Center, Changhai Hospital, The Second Military Medical University, Shanghai, China.
| | - Liang-Hao Hu
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China.
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Drewes AM, Bouwense SAW, Campbell CM, Ceyhan GO, Delhaye M, Demir IE, Garg PK, van Goor H, Halloran C, Isaji S, Neoptolemos JP, Olesen SS, Palermo T, Pasricha PJ, Sheel A, Shimosegawa T, Szigethy E, Whitcomb DC, Yadav D. Guidelines for the understanding and management of pain in chronic pancreatitis. Pancreatology 2017; 17:720-731. [PMID: 28734722 DOI: 10.1016/j.pan.2017.07.006] [Citation(s) in RCA: 165] [Impact Index Per Article: 23.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Revised: 06/26/2017] [Accepted: 07/11/2017] [Indexed: 12/11/2022]
Abstract
Abdominal pain is the foremost complication of chronic pancreatitis (CP). Pain can be related to recurrent or chronic inflammation, local complications or neurogenic mechanisms with corresponding changes in the nervous systems. Both pain intensity and the frequency of pain attacks have been shown to reduce quality of life in patients with CP. Assessment of pain follows the guidelines for other types of chronic pain, where the multidimensional nature of symptom presentation is taken into consideration. Quantitative sensory testing may be used to characterize pain, but is currently used in a research setting in advanced laboratories. For pain relief, current guidelines recommend a simple stepwise escalation of analgesic drugs with increasing potency until pain relief is obtained. Abstinence from alcohol and smoking should be strongly advised. Pancreatic enzyme therapy and antioxidants may be helpful as initial treatment. Endoscopic treatment can be used in patients with evidence of ductal obstruction and may be combined with extracorporeal shock wave lithothripsy. The best candidates are those with distal obstruction of the main pancreatic duct and in early stage of disease. Behavioral interventions should be part of the multidisciplinary approach to chronic pain management particularly when psychological impact is experienced. Surgery should be considered early and after a maximum of five endoscopic interventions. The type of surgery depends on morphological changes of the pancreas. Long-term effects are variable, but high success rates have been reported in open studies and when compared with endoscopic treatment. Finally, neurolytical interventions and neuromodulation can be considered in difficult patients.
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Affiliation(s)
- Asbjørn M Drewes
- Centre for Pancreatic Diseases, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Denmark.
| | - Stefan A W Bouwense
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Claudia M Campbell
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Güralp O Ceyhan
- Department of Surgery, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Myriam Delhaye
- Department of Gastroenterology, Erasme University Hospital, Brussels, Belgium
| | - Ihsan Ekin Demir
- Department of Surgery, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Pramod K Garg
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Harry van Goor
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Shuiji Isaji
- Department of Surgery, Mie University Graduate School of Medicine, Japan
| | - John P Neoptolemos
- Institute of Translational Medicine, University of Liverpool, United Kingdom
| | - Søren S Olesen
- Centre for Pancreatic Diseases, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Denmark
| | - Tonya Palermo
- Seattle Children's Hospital Research Institute, Washington School of Medicine, USA
| | - Pankaj Jay Pasricha
- Center for Neurogastroenterology, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Andrea Sheel
- Institute of Translational Medicine, University of Liverpool, United Kingdom
| | - Tooru Shimosegawa
- Department of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
| | - Eva Szigethy
- Visceral Inflammation and Pain Center, Division of Gastroenterology, University of Pittsburgh and UPMC, Pittsburgh, PA, USA
| | - David C Whitcomb
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh and UPMC, Pittsburgh, PA, USA
| | - Dhiraj Yadav
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh and UPMC, Pittsburgh, PA, USA
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37
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Adler JM, Gardner TB. Endoscopic Therapies for Chronic Pancreatitis. Dig Dis Sci 2017; 62:1729-1737. [PMID: 28258377 DOI: 10.1007/s10620-017-4502-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2016] [Accepted: 02/11/2017] [Indexed: 12/14/2022]
Abstract
Chronic pancreatitis is a fibroinflammatory disease of the pancreas leading to varying degrees of endocrine and exocrine dysfunction. Treatment options are generally designed to control the pain of chronic pancreatitis, and endoscopic therapy is one of the main treatment modalities. Herein, we describe the endoscopic management of pancreatic duct calculi and strictures, entrapment of the intrapancreatic bile duct, celiac plexus interventions, and drainage of pancreatic pseudocysts.
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Affiliation(s)
- Jeffrey M Adler
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH, 03756, USA
| | - Timothy B Gardner
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH, 03756, USA.
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Specific Radiological Imaging Findings in Patients With Hereditary Pancreatitis During a Long Follow-up of Disease. Pancreas 2017; 46:372-379. [PMID: 28129231 DOI: 10.1097/mpa.0000000000000764] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Hereditary pancreatitis (HP) is characterized by recurrent episodes of inflammation of the pancreas. Radiological imaging is used to diagnose HP and to monitor complications. The aim of this study was to describe specific imaging findings in HP. METHODS We retrospectively collected data of HP patients with serial imaging and reviewed all radiological imaging studies (transabdominal ultrasonography, computed tomography, and magnetic resonance imaging). RESULTS We included 15 HP patients, with a mean age of 32.5 years (range, 9-61 years) and mean disease duration of 24.1 years (range, 6-42 years). In total, 152 imaging studies were reviewed. Seventy-three percent of patients had a dilated main pancreatic duct (MPD) (width 3.5-18 mm). The MPD varied in size during disease course, with temporary reduction in diameter after drainage procedures. A severe dilated MPD (>10 mm) often coincided with presence of intraductal calcifications (size, 1-12 mm). In 73% of patients, pancreatic parenchyma atrophy occurred, which did not correlate with presence of exocrine or endocrine insufficiency. CONCLUSIONS In HP, the MPD diameter increases with time, mostly without dilated side branches, and is often accompanied by large intraductal calcifications. The size of the MPD is independent of disease state. Atrophy of pancreatic parenchyma is not correlated with exocrine or endocrine insufficiency.
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Bhandari S, Maydeo A. Extracorporeal shock wave lithotripsy: the cornerstone of pancreatic endotherapy. Gastrointest Endosc 2016; 84:79-80. [PMID: 27315735 DOI: 10.1016/j.gie.2016.03.1494] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Accepted: 03/26/2016] [Indexed: 02/05/2023]
Affiliation(s)
| | - Amit Maydeo
- Baldota Institute of Digestive Sciences, Mumbai, India
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