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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:S1424-3903(24)00079-6. [PMID: 38584052 DOI: 10.1016/j.pan.2024.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [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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Bush N, Han S, Akshintala VS. Extra-Corporeal Shock Wave Lithotripsy for Pancreatic Duct Calculi: A Perspective From a Practice in the United States. Pancreas 2024; 53:e223-e224. [PMID: 38206656 DOI: 10.1097/mpa.0000000000002282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2024]
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Wong T, Pattarapuntakul T, Netinatsunton N, Ovartlarnporn B, Sottisuporn J, Yaowmaneerat T, Attasaranya S, Cattapan K, Sripongpun P. Predictive Factors Correlated with Successful Early Endoscopic Removal of Pancreaticolithiasis in Chronic Pancreatitis after Extracorporeal Shock Wave Lithotripsy. Diagnostics (Basel) 2024; 14:172. [PMID: 38248049 PMCID: PMC10814896 DOI: 10.3390/diagnostics14020172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Revised: 12/28/2023] [Accepted: 01/10/2024] [Indexed: 01/23/2024] Open
Abstract
BACKGROUND The treatment of chronic pancreatitis (CP) and symptomatic pancreatic duct (PD) calculi often involves techniques like endoscopic retrograde cholangiopancreatography (ERCP), extracorporeal shock wave lithotripsy (ESWL), or a combination of both. However, identifying predictive factors for the successful removal of these calculi remains variable. This study aimed to determine the factors predicting successful ESWL and endoscopic removal in CP and PD calculi patients. METHODS We examined data from CP patients who underwent complete PD calculi removal via ESWL combined with ERCP between July 2012 and 2022, and assessed baseline characteristics, imaging findings, and treatment details. Patients were categorized into early- and late-endoscopic complete removal groups (EER and LER groups, respectively). RESULTS Of the 27 patients analyzed, 74.1% were male with an average age of 44 ± 9.6 years. EER was achieved in 74% of the patients. Patients in the EER group exhibited smaller PD calculi diameter (8.5 vs. 19 mm, p = 0.012) and lower calculus density (964.6 vs. 1313.3 HU, p = 0.041) compared to the LER group. Notably, PD stricture and the rate of PD stent insertion were not different between the groups. A calculus density threshold of 1300 HU on non-contrast CT demonstrated 71% sensitivity and 80% specificity in predicting EER. CONCLUSIONS Smaller and low-density PD calculi may serve as predictors for successful EER, potentially aiding in the management of CP patients with PD calculi.
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Affiliation(s)
- Thanawin Wong
- Gastroenterology and Hepatology Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai 90110, Songkhla, Thailand
- NKC Institute of Gastroenterology and Hepatology, Songklanagarind Hospital, Faculty of Medicine, Prince of Songkla University, Hat Yai 90110, Songkhla, Thailand
| | - Tanawat Pattarapuntakul
- Gastroenterology and Hepatology Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai 90110, Songkhla, Thailand
- NKC Institute of Gastroenterology and Hepatology, Songklanagarind Hospital, Faculty of Medicine, Prince of Songkla University, Hat Yai 90110, Songkhla, Thailand
| | - Nisa Netinatsunton
- NKC Institute of Gastroenterology and Hepatology, Songklanagarind Hospital, Faculty of Medicine, Prince of Songkla University, Hat Yai 90110, Songkhla, Thailand
| | - Bancha Ovartlarnporn
- NKC Institute of Gastroenterology and Hepatology, Songklanagarind Hospital, Faculty of Medicine, Prince of Songkla University, Hat Yai 90110, Songkhla, Thailand
| | - Jaksin Sottisuporn
- NKC Institute of Gastroenterology and Hepatology, Songklanagarind Hospital, Faculty of Medicine, Prince of Songkla University, Hat Yai 90110, Songkhla, Thailand
| | - Thanapon Yaowmaneerat
- NKC Institute of Gastroenterology and Hepatology, Songklanagarind Hospital, Faculty of Medicine, Prince of Songkla University, Hat Yai 90110, Songkhla, Thailand
| | - Siriboon Attasaranya
- NKC Institute of Gastroenterology and Hepatology, Songklanagarind Hospital, Faculty of Medicine, Prince of Songkla University, Hat Yai 90110, Songkhla, Thailand
| | - Kamonwon Cattapan
- Department of Radiology, Faculty of Medicine, Prince of Songkla University, Hat Yai 90110, Songkhla, Thailand
| | - Pimsiri Sripongpun
- Gastroenterology and Hepatology Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai 90110, Songkhla, Thailand
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Yi JH, Li ZS, Hu LH. Adverse events of pancreatic extracorporeal shock wave lithotripsy: a literature review. BMC Gastroenterol 2023; 23:360. [PMID: 37853330 PMCID: PMC10585860 DOI: 10.1186/s12876-023-02992-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Accepted: 10/10/2023] [Indexed: 10/20/2023] Open
Abstract
Pancreatic stones are the result of pathophysiologic changes in chronic pancreatitis with an incidence of more than 90%. At present, pancreatic extracorporeal shock wave lithotripsy (P-ESWL) can be used as the first-line treatment for large or complex stones. Although a large number of studies have proven the safety and effectiveness of P-ESWL, we should also pay attention to postoperative adverse events, mainly due to the scattering of shock waves in the conduction pathway. Adverse events can be classified as either complications or transient adverse events according to the severity. Because the anatomic location of organs along the shock wave conducting pathway differs greatly, adverse events after P-ESWL are varied and difficult to predict. This paper outlines the mechanism, definition, classification, management and risk factors for adverse events related to P-ESWL. It also discusses the technique of P-ESWL, indications and contraindications of P-ESWL, and adverse events in special populations.
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Affiliation(s)
- Jin-Hui Yi
- Department of Gastroenterology, Shanghai Changhai Hospital, 168 Changhai Road, Shanghai, 200433, China
| | - Zhao-Shen Li
- Department of Gastroenterology, Shanghai Changhai Hospital, 168 Changhai Road, Shanghai, 200433, China.
| | - Liang-Hao Hu
- Department of Gastroenterology, Shanghai Changhai Hospital, 168 Changhai Road, Shanghai, 200433, China.
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Gerges C, Beyna T, Neuhaus H. Management of Pancreatic Duct Stones: Nonextracorporeal Approach. Gastrointest Endosc Clin N Am 2023; 33:821-829. [PMID: 37709413 DOI: 10.1016/j.giec.2023.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Abstract
Chronic pancreatitis (CP) is an ongoing inflammatory disease with most patients developing pancreatic calculi during their course of disease. Extracorporeal shock wave lithotripsy (ESWL) is a first-line treatment option in patients with large lumen obstructing pancreatic duct (PD) stones. In patients with CP and PD dilatation, digital single-operator pancreatoscopy (DSOP)-guided lithotripsy seems to be an appealing option to ESWL and surgery. DSOP-guided lithotripsy for the treatment of large symptomatic PD-stones has been demonstrated to be safe, technically, and clinically effective, and should be regarded as an alternative endoscopic treatment of certain patients.
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Affiliation(s)
- Christian Gerges
- University Hospital Essen, Essen, North Rhine-Westphalia, Germany.
| | - Torsten Beyna
- EVLK Duesseldorf, Kirchfeldstr. 40, 40489, Duesseldorf, Germany
| | - Horst Neuhaus
- RKM 740 Clinic, Pariserstr. 98, 40549, Duesseldorf, Germany
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Kalayarasan R, Shukla A. Changing trends in the minimally invasive surgery for chronic pancreatitis. World J Gastroenterol 2023; 29:2101-2113. [PMID: 37122602 PMCID: PMC10130972 DOI: 10.3748/wjg.v29.i14.2101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Revised: 02/21/2023] [Accepted: 03/23/2023] [Indexed: 04/13/2023] Open
Abstract
Chronic pancreatitis is a debilitating pancreatic inflammatory disease characterized by intractable pain resulting in poor quality of life. Conventional management of pancreatic pain consists of a step-up approach with medications and lifestyle modifications followed by endoscopic intervention. Traditionally surgery is reserved for patients who do not improve with other interventions. However, recent studies suggest that early surgical intervention is more beneficial as it can mitigate the progression of the pathological process and prevent loss of pancreatic function. Despite the widespread adoption of minimally invasive approaches in various gastrointestinal surgical disorders, minimally invasive surgery for chronic pancreatitis is slow to evolve. Technical difficulty due to severe inflammatory changes has been the major impediment to the widespread usage of minimally invasive surgery in chronic pancreatitis. With this background, the present review aimed to critically analyze the available evidence on the minimally invasive treatment of chronic pancreatitis. A Pub Med search of all relevant articles was performed using the appropriate keywords, parentheses, and Boolean operators. Most initial laparoscopic series have reported the feasibility of lateral pancreaticojejunostomy, considered an adequate procedure only in a small proportion of patients. The pancreatic head is the pacemaker of pain, so adequate decompression is critical for long-term pain relief. Recent studies have documented the feasibility of minimally invasive duodenum-preserving pancreatic head resection. With improvements in laparoscopic instrumentation and technological advances, minimally invasive surgery for chronic pancreatitis is gaining momentum. However, more high-quality evidence is required to document the superiority of minimally invasive surgery for chronic pancreatitis.
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Affiliation(s)
- Raja Kalayarasan
- Surgical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry 605006, India
| | - Ankit Shukla
- Surgical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry 605006, India
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Kaushik N, Dasari V, Jain D. Management of Pancreatic Calculi in Chronic Pancreatitis: A Review Article. Cureus 2023; 15:e35788. [PMID: 37025704 PMCID: PMC10072785 DOI: 10.7759/cureus.35788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 03/05/2023] [Indexed: 03/07/2023] Open
Abstract
Chronic pancreatitis is a slow, irreversible, and progressive inflammatory condition with abdominal pain, loss of parenchyma, fibrosis, and calculus formation. It also causes loss of exocrine and endocrine function. Gallstones and alcohol is the most frequent cause of chronic pancreatitis. It is also caused by other factors, including oxidative stress, fibrosis, and repeated incidence of acute pancreatitis. Chronic pancreatitis is followed by several sequelae, one of them being formation of calculi in the pancreas. The formation of calculi can occur in the main pancreatic duct, branches of the duct, and parenchyma. The cardinal sign of chronic pancreatitis is pain caused by obstruction of pancreatic ducts and its branches leading to ductal hypertension resulting in pain. The main aim of endotherapy includes pancreatic duct decompression. The management options vary based on the type and size of the calculus. The treatment of choice for small-sized pancreatic calculi is endoscopic retrograde cholangiopancreatography (ERCP) followed by sphincterotomy and extraction. The large-sized calculi need fragmentation before extraction, which is done by extracorporeal shock wave lithotripsy (ESWL). Surgery can be an option for patients having severe pancreatic calculi if endoscopic therapy fails. For diagnostic purposes, imaging plays a very important role. The treatment options remain complex if the radiological and laboratory findings overlap. Due to advancements in diagnostic imaging, treatment options have become precise and helpful. It can significantly lower the quality of life along with immediate and long-term problems that pose a serious risk to life. This review comprises the various management options available for removing calculi following chronic pancreatitis, including surgical, endoscopic, and medical therapy.
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Gnecco J, Brown LK, Boregowda U, Abidali H, Saligram S, Rosenkranz L, Patel S, Haluskza O, Sayana H. Pancreatic Stones and Extracorporeal Shockwave Lithotripsy: A Review of the Literature. Pancreas 2022; 51:916-22. [PMID: 36607935 DOI: 10.1097/MPA.0000000000002129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [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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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Geusens D, van Malenstein H. The role of extracorporeal shock wave lithotripsy in the treatment of chronic pancreatitis. Acta Gastroenterol Belg 2021; 84:620-6. [PMID: 34965044 DOI: 10.51821/84.4.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [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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Bick BL, Patel F, Easler JJ, Tong Y, Watkins JL, McHenry L, Lehman G, Fogel EL, Gromski MA, Sherman S. A comparative study between single-operator pancreatoscopy with intraductal lithotripsy and extracorporeal shock wave lithotripsy for the management of large main pancreatic duct stones. Surg Endosc 2021; 36:3217-3226. [PMID: 34264399 PMCID: PMC10153763 DOI: 10.1007/s00464-021-08631-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 07/05/2021] [Indexed: 01/27/2023]
Abstract
BACKGROUND AND AIMS Endoscopic management of large main pancreatic ductal (MPD) stones often require treatment with lithotripsy. Extracorporeal shock wave lithotripsy (ESWL) has been the mainstay therapy, and single-operator pancreatoscopy with intraductal (intracorporeal) lithotripsy (SOPIL) is an emerging technique. However, no comparative studies between these techniques exist. We therefore aimed to compare ESWL to SOPIL for the treatment of large MPD stones. METHODS This is a retrospective cohort study comparing patients who were treated with ESWL or SOPIL from September 2013 to September 2019 at a single tertiary center. Logistic regression was performed to identify factors associated with technical success and efficient stone clearance (≤ 2 procedures to clear stones). RESULTS There were 240 patients who were treated with ESWL and 18 treated with SOPIL. The overall technical success rate of stone clearance was 224/258 (86.8%), which was similar between the ESWL and SOPIL groups (86.7% vs 88.9%, p = 1.000). A SOPIL approach required fewer total procedures (1.6 ± 0.6 vs 3.1 ± 1.5, p < 0.001) and less aggregate procedure time (101.6 ± 68.2 vs 191.8 ± 111.6 min, p = 0.001). Adverse event rates were similar between the groups (6.3% vs 5.6%, p = 1.000). The use of SOPIL was independently associated with greater efficiency compared to ESWL (OR 5.241 [1.348-20.369], p = 0.017). Stone size > 10 mm was associated with less efficient stone clearance (OR 0.484 [0.256-0.912], p = 0.025). CONCLUSION Both ESWL and SOPIL are safe and effective endoscopic adjunct modalities for treating large pancreatic duct stones. SOPIL is an emerging alternative to ESWL that is potentially more efficient for lithotripsy and MPD stone clearance.
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Affiliation(s)
- Benjamin L Bick
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, 550 University Blvd, Suite UH1602, Indianapolis, IN, USA.
| | - Feenalie Patel
- Department of Internal Medicine and Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Jeffrey J Easler
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, 550 University Blvd, Suite UH1602, Indianapolis, IN, USA
| | - Yan Tong
- Department of Biostatistics, Indiana University School of Public Health, Indianapolis, IN, USA
| | - James L Watkins
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, 550 University Blvd, Suite UH1602, Indianapolis, IN, USA
| | - Lee McHenry
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, 550 University Blvd, Suite UH1602, Indianapolis, IN, USA
| | - Glen Lehman
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, 550 University Blvd, Suite UH1602, Indianapolis, IN, USA
| | - Evan L Fogel
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, 550 University Blvd, Suite UH1602, Indianapolis, IN, USA
| | - Mark A Gromski
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, 550 University Blvd, Suite UH1602, Indianapolis, IN, USA
| | - Stuart Sherman
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, 550 University Blvd, Suite UH1602, Indianapolis, IN, USA
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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15
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Sundaram S, Choksi D, Kale A, Giri S, Patra B, Bhatia S, Shukla A. Outcomes of Dilation of Recalcitrant Pancreatic Strictures Using a Wire-Guided Cystotome. Clin Endosc 2021; 54:903-908. [PMID: 33657781 PMCID: PMC8652154 DOI: 10.5946/ce.2020.297] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 01/05/2021] [Indexed: 11/29/2022] Open
Abstract
Background/Aims Pancreatic strictures in chronic pancreatitis are treated using endoscopic retrograde cholangiopancreatography (ERCP) with plastic stent placement. The management of recalcitrant strictures remains a challenge, with the use of a Soehendra stent retriever or a needle knife described in case reports. Here, we discuss our experience with dilation of dominant pancreatic strictures with a 6-Fr cystotome.
Methods A retrospective review of an endoscopy database was performed to search for patients with pancreatic strictures recalcitrant to conventional methods of dilation in which a cystotome was used. Technical success was defined as the successful dilation of the stricture with plastic stent placement. Functional success was defined as substantial pain relief or resolution of pancreatic fistulae.
Results Ten patients (mean age, 30.8 years) underwent dilation of a dominant pancreatic stricture secondary to chronic pancreatitis, with a 6-Fr cystotome. Seven patients presented with pain. Three patients had pancreatic fistulae (two had pancreatic ascites and one had a pancreaticopleural fistula). The median stricture length was 10 mm (range, 5–25 mm). The head of the pancreas was the most common location of the stricture (60%). Technical and functional success was achieved in all patients. One patient had self-limiting bleeding, whereas another patient developed mild post-ERCP pancreatitis.
Conclusions The use of a 6-Fr cystotome (diathermy catheter) can be an alternative method for dilation of recalcitrant pancreatic strictures after the failure of conventional modalities.
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Affiliation(s)
- Sridhar Sundaram
- Department of Gastroenterology, Seth GS Medical College and King Edward Memorial Hospital, Mumbai, India
| | - Dhaval Choksi
- Department of Gastroenterology, Seth GS Medical College and King Edward Memorial Hospital, Mumbai, India
| | - Aditya Kale
- Department of Gastroenterology, Seth GS Medical College and King Edward Memorial Hospital, Mumbai, India
| | - Suprabhat Giri
- Department of Gastroenterology, Seth GS Medical College and King Edward Memorial Hospital, Mumbai, India
| | - Biswaranjan Patra
- Department of Gastroenterology, Seth GS Medical College and King Edward Memorial Hospital, Mumbai, India
| | - Shobna Bhatia
- Department of Gastroenterology, Seth GS Medical College and King Edward Memorial Hospital, Mumbai, India
| | - Akash Shukla
- Department of Gastroenterology, Seth GS Medical College and King Edward Memorial Hospital, Mumbai, India
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Abstract
OBJECTIVES Data regarding the safety of endoscopic retrograde pancreatography (ERP) are limited compared with biliary endoscopic retrograde cholangiopancreatography. The aim of this study was to determine adverse events (AEs) associated with therapeutic ERP. METHODS This single-center retrospective study examined consecutive therapeutic ERPs with the primary intention of cannulating the pancreatic duct. Multivariate logistic regression was performed to identify risk factors for AEs. RESULTS A total of 3023 ERPs were performed in 1288 patients (mean age, 50.3 years; 57.8% female) from January 2000 to January 2017. Overall AE rate was 18.9% with abdominal pain requiring admission (9.8%) and post-ERP pancreatitis (5.7%) being most common. On multivariate analysis, female sex (adjusted odds ratio [aOR], 2.3; 95% confidence interval [CI], 1.9-2.9), acute recurrent pancreatitis (aOR, 5.0; 95% CI, 1.7-15.3), chronic pancreatitis (aOR, 1.8; 95% CI, 1.3-2.6), and pancreatic sphincter of Oddi dysfunction (aOR, 2.1; 95% CI, 1.4-3.3) were associated with an increased risk of overall AEs. Pancreatic sphincterotomy (aOR, 1.9; 95% CI, 1.5-2.4) and therapeutic stenting (aOR, 1.6; 95% CI, 1.2-2.2) also increased the risk of AEs. CONCLUSIONS Nearly 1 in 5 patients who undergo therapeutic ERP will experience an AE; however, the rates of major AEs, including post-ERP pancreatitis, bleeding, and perforation, are low.
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Affiliation(s)
- Samuel Han
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Augustin R. Attwell
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Philip Tatman
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Steven A. Edmundowicz
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Hazem T. Hammad
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Mihir S. Wagh
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Raj J. Shah
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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18
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Abstract
MRI and MRCP play an important role in the diagnosis of chronic pancreatitis (CP) by imaging pancreatic parenchyma and ducts. MRI/MRCP is more widely used than computed tomography (CT) for mild to moderate CP due to its increased sensitivity for pancreatic ductal and gland changes; however, it does not detect the calcifications seen in advanced CP. Quantitative MR imaging offers potential advantages over conventional qualitative imaging, including simplicity of analysis, quantitative and population-based comparisons, and more direct interpretation of detected changes. These techniques may provide quantitative metrics for determining the presence and severity of acinar cell loss and aid in the diagnosis of chronic pancreatitis. Given the fact that the parenchymal changes of CP precede the ductal involvement, there would be a significant benefit from developing MRI/MRCP-based, more robust diagnostic criteria combining ductal and parenchymal findings. Among cross-sectional imaging modalities, multi-detector CT (MDCT) has been a cornerstone for evaluating chronic pancreatitis (CP) since it is ubiquitous, assesses primary disease process, identifies complications like pseudocyst or vascular thrombosis with high sensitivity and specificity, guides therapeutic management decisions, and provides images with isotropic resolution within seconds. Conventional MDCT has certain limitations and is reserved to provide predominantly morphological (e.g., calcifications, organ size) rather than functional information. The emerging applications of radiomics and artificial intelligence are poised to extend the current capabilities of MDCT. In this review article, we will review advanced imaging techniques by MRI, MRCP, CT, and ultrasound.
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20
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Chen G, You Y, Yan H, He J, Gong J, Wei S. Drainage procedure for pancreatolithiasis: re-examination of the pancreatic duct diameter standard. Ann Surg Treat Res 2020; 98:190-198. [PMID: 32274367 PMCID: PMC7118322 DOI: 10.4174/astr.2020.98.4.190] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 01/10/2020] [Accepted: 02/07/2020] [Indexed: 12/16/2022] Open
Abstract
Purpose Pancreatic duct decompression relieves pancreatic duct stone (PDS)-associated abdominal pain, though a consensus indication for the drainage procedure of the main pancreatic duct (MPD) is lacking. Moreover, major prognostic factors for postsurgical long-term pain relief and recurrence are largely unknown. Methods The clinical outcomes of 65 consecutive PDS patients undergoing surgery from 2008–2012 with 3+ years of follow-up were assessed. Results At postsurgical follow-up (median, 4.5 years; range, 3–7 years; procedure: Partington, n = 32; Frey, n = 27; pancreatoduodenectomy, n = 3; distal pancreatectomy, n = 3), the early complication and complete stone clearance rates were 29.2% and 97%, respectively. Long-term, complete and partial pain relief were 93.9%, 83.1%, and 10.8%, respectively. The risk of pancreatic fistula was higher in the <8 mm group than in the >8 mm group (P < 0.05), and 80% of the pancreatic fistula cases occurred in the <8 mm group. A shorter pain duration (P = 0.007), smaller MPD diameter (P = 0.04), and lower Izbicki pain score (P < 0.001) predicted long-term pain relief. Pain recurrence after initial remission occurred in 5 patients and was only related to pain duration (P = 0.02). Stone recurrence and pancreatic exocrine functional and endocrine functional deterioration occurred in 2, 5, and 11 patients, respectively. Conclusion Surgery provides excellent stone clearance, long-term pain relief, and acceptable postoperative morbidity. Using 8 mm as the criterion for drainage surgery can minimize the postoperative pancreatic fistula risk. Individualized and timely surgical treatment may improve the effect of surgery.
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Affiliation(s)
- Guoyong Chen
- Department of Hepatobiliary Surgery, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, People's Hospital of Henan University, Zhengzhou, China
| | - Yu You
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Hongxian Yan
- Department of Hepatobiliary Surgery, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, People's Hospital of Henan University, Zhengzhou, China
| | - Junchuang He
- Department of Hepatobiliary Surgery, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, People's Hospital of Henan University, Zhengzhou, China
| | - Jianping Gong
- Department of Hepatobiliary Surgery, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, People's Hospital of Henan University, Zhengzhou, China
| | - Sidong Wei
- Department of Hepatobiliary Surgery, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, People's Hospital of Henan University, Zhengzhou, China
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Tandan M, Nageshwar Reddy D, Talukdar R, Vinod K, Kiran SVVS, Santosh D, Gupta R, Ramchandani M, Lakhtakia S, Rakesh K, Manohar Reddy P, Basha J, Nabi Z, Jagtap N, Rao GV. ESWL for large pancreatic calculi: Report of over 5000 patients. Pancreatology 2019; 19:916-921. [PMID: 31447280 DOI: 10.1016/j.pan.2019.08.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Revised: 07/17/2019] [Accepted: 08/02/2019] [Indexed: 12/11/2022]
Abstract
INTRODUCTION The primary aim of this study was to evaluate efficacy, safety and short-term pain relief after ESWL for large pancreatic calculi in over 5000 patients at a single center. METHODS This is a retrospective analysis of prospectively collected data. Patients with painful calculi >5 mm, located in the head, neck and body region in the MPD, who were not amenable for extraction by the standard procedure of endoscopic pancreatic sphincterotomy were subjected to ESWL using a third generation dual focus lithotripter. Patients were followed up at 6 months for outcome evaluation. RESULTS A total of 5124 patients (66% males) were subjected to ESWL. Majority of stones (79.2%) were radiopaque. Single calculi were seen in 3851 (75.1%).The majority of stones were located in head region of MPD in 2824 (55.1%) patients. 4386 (85.5%) patients required 3 or less sessions for fragmentation and complete stone clearance was achieved in 3722 (72.6%). EPS was performed in 5022 (98%) while PD stenting was required in 3536 (69%) patients. Of the 4280 patients followed up for 6 months, 3529 (82.6%) patients were pain free. Another 512 (11.9%) patients had significant reduction in VAS score. In 229 (5.3%) there was no decrease in pain intensity. Minor and self-limiting complications were reported in 1153 (22.5%). DISCUSSION Our study confirms the safety and efficacy and short-term pain relief of ESWL for large calculi in the MPD. In properly selected patients, this should be offered as the first line of therapy for all large MPD calculi not amenable to the standard techniques of stone extraction.
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Affiliation(s)
- Manu Tandan
- Asian Institute of Gastroenterology, Hyderabad, India.
| | | | | | - K Vinod
- Asian Institute of Gastroenterology, Hyderabad, India
| | - S V V S Kiran
- Asian Institute of Gastroenterology, Hyderabad, India
| | - D Santosh
- Asian Institute of Gastroenterology, Hyderabad, India
| | - Rajesh Gupta
- Asian Institute of Gastroenterology, Hyderabad, India
| | | | | | - K Rakesh
- Asian Institute of Gastroenterology, Hyderabad, India
| | | | | | - Zaheer Nabi
- Asian Institute of Gastroenterology, Hyderabad, India
| | - Nitin Jagtap
- Asian Institute of Gastroenterology, Hyderabad, India
| | - G V Rao
- Asian Institute of Gastroenterology, Hyderabad, India
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Liu Y, Wang D, Li ZS, Hu LH. Re: quantitative factors of unenhanced CT for predicting fragmenting efficacy of extracorporeal shock wave lithotripsy on pancreatic duct stones. Clin Radiol 2019; 74:729. [PMID: 31253422 DOI: 10.1016/j.crad.2019.04.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Accepted: 04/24/2019] [Indexed: 11/16/2022]
Affiliation(s)
- Y Liu
- Gongli Hospital, The Second Military Medical University, Shanghai, China
| | - D Wang
- Gongli Hospital, The Second Military Medical University, Shanghai, China
| | - Z-S Li
- Gongli Hospital, The Second Military Medical University, Shanghai, China
| | - L-H Hu
- Gongli Hospital, The Second Military Medical University, Shanghai, China.
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23
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Zou WB, Ru N, Wu H, Hu LH, Ren X, Jin G, Wang Z, Du YQ, Cao YN, Zhang L, Chang XY, Zhang RC, Li XB, Shen Y, Li P, Li ZS, Liao Z. Guidelines for the diagnosis and treatment of chronic pancreatitis in China (2018 edition). Hepatobiliary Pancreat Dis Int 2019; 18:103-109. [PMID: 30922816 DOI: 10.1016/j.hbpd.2019.02.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 02/02/2019] [Indexed: 02/05/2023]
Affiliation(s)
- Wen-Bin Zou
- Department of Gastroenterology, Digestive Endoscopy Center, Changhai Hospital, Naval Medical University, Shanghai 200433, China; Shanghai Institute of Pancreatic Diseases, Shanghai 200433, China
| | - Nan Ru
- Department of Gastroenterology, Digestive Endoscopy Center, Changhai Hospital, Naval Medical University, Shanghai 200433, China
| | - Hao Wu
- Department of Gastroenterology, Digestive Endoscopy Center, Changhai Hospital, Naval Medical University, Shanghai 200433, China; Shanghai Institute of Pancreatic Diseases, Shanghai 200433, China
| | - Liang-Hao Hu
- Department of Gastroenterology, Digestive Endoscopy Center, Changhai Hospital, Naval Medical University, Shanghai 200433, China
| | - Xu Ren
- Department of Gastroenterology, Heilongjiang Provincial Hospital, Harbin 150030, China
| | - Gang Jin
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital, Naval Medical University, Shanghai 200433, China
| | - Zheng Wang
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710061, China
| | - Yi-Qi Du
- Department of Gastroenterology, Digestive Endoscopy Center, Changhai Hospital, Naval Medical University, Shanghai 200433, China
| | - Ya-Nan Cao
- Shanghai Clinical Center for Endocrine and Metabolic Diseases, Ruijin Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai 200025, China
| | - Lei Zhang
- Department of Radiology, Shanghai First People's Hospital, Shanghai 200080, China
| | - Xiao-Yan Chang
- Department of Pathology, Peking Union Medical College Hospital, Beijing 100730, China
| | - Rong-Chun Zhang
- Department of Gastroenterology, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China
| | - Xiao-Bin Li
- Department of General Surgery, Peking Union Medical College Hospital, Beijing 100730, China
| | - Yan Shen
- Department of Hepatobiliary Pancreatic Surgery, First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Peng Li
- Department of Digestive Endoscopy, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Zhao-Shen Li
- Department of Gastroenterology, Digestive Endoscopy Center, Changhai Hospital, Naval Medical University, Shanghai 200433, China; Shanghai Institute of Pancreatic Diseases, Shanghai 200433, China.
| | - Zhuan Liao
- Department of Gastroenterology, Digestive Endoscopy Center, Changhai Hospital, Naval Medical University, Shanghai 200433, China; Shanghai Institute of Pancreatic Diseases, Shanghai 200433, China.
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Liu R, Su W, Wang J, Gong J, Lu J. Quantitative factors of unenhanced CT for predicting fragmenting efficacy of extracorporeal shock wave lithotripsy on pancreatic duct stones. Clin Radiol 2019; 74:408.e1-408.e7. [PMID: 30808501 DOI: 10.1016/j.crad.2019.01.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 01/23/2019] [Indexed: 10/27/2022]
Abstract
AIM To find potential predictors at unenhanced computed tomography (CT) to evaluate the stone clearance rate (SCR) of pancreatic duct stones (PDS) by extracorporeal shock wave lithotripsy (ESWL). MATERIALS AND METHODS A total of 106 consecutive patients with multiple stones of maximal transverse length (MTL) 0.3-3.6 cm in pancreatic head region were enrolled. Unenhanced CT was performed both before and after ESWL therapy. All patients underwent ESWL therapy using an electromagnetic lithotripter, and were divided into three groups with threshold values of >90%, 50-90% and <50% of SCR. Factors including sex, age, MTL, mean stone density (MSD), standard deviation of stone density (SDSD), variation coefficient of stone density (VCSD), attenuation density (AD), pancreatic duct diameter (PDD), skin-to-stone distance (SSD), and number of ESWL sessions were analysed, and their impact on SCR was evaluated by univariate and multivariate analyses. The diagnostic threshold of the independent predicting index was further calculated, and its relationship with SCR and ESWL was analysed by drawing a trend line. RESULTS The only significant predictor of SCR by ESWL was MSD (p<0.05). More courses of ESWL therapy are required in PDS patients with an MSD higher than the cut-off value of 375.4 HU (mean, 2.6 versus 1.8), but with a relatively lower SCR (mean, 43.96 versus 88.68%) . CONCLUSION MSD on pre-treatment unenhanced CT is an independent predictor for SCR of PDS patients treated with ESWL. Using a cut-off value of 375.4 HU, patients with low MSD are good candidates for ESWL therapy.
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Affiliation(s)
- R Liu
- Department of Radiology, Changhai Hospital Affiliated to the Second Military Medical University, Changhai Road 168, Yangpu District, Shanghai, 200433 PR China
| | - W Su
- Department of Nuclear Medicine, Changhai Hospital Affiliated to the Second Military Medical University, Changhai Road 168, Yangpu District, Shanghai, 200433 PR China
| | - J Wang
- Department of Radiology, Changhai Hospital Affiliated to the Second Military Medical University, Changhai Road 168, Yangpu District, Shanghai, 200433 PR China
| | - J Gong
- Department of Radiology, Changhai Hospital Affiliated to the Second Military Medical University, Changhai Road 168, Yangpu District, Shanghai, 200433 PR China.
| | - J Lu
- Department of Radiology, Changhai Hospital Affiliated to the Second Military Medical University, Changhai Road 168, Yangpu District, Shanghai, 200433 PR China.
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Xu ZL, Yao J, Wang LS. Computed tomography prediction of pancreatic extracorporeal shock wave lithotripsy outcomes could be improved. Abdom Radiol (NY) 2019; 44:389-390. [PMID: 30003272 DOI: 10.1007/s00261-018-1699-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Zheng-Lei Xu
- Department of Gastroenterology, Shenzhen People's Hospital, Jinan University, 1017 North Dongmen Road, Shenzhen, China
| | - Jun Yao
- Department of Gastroenterology, Shenzhen People's Hospital, Jinan University, 1017 North Dongmen Road, Shenzhen, China
| | - Li-Sheng Wang
- Department of Gastroenterology, Shenzhen People's Hospital, Jinan University, 1017 North Dongmen Road, Shenzhen, China.
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Abstract
RATIONALE Mesenteric hematoma after extracorporeal shock wave lithotripsy (ESWL) for pancreatic stones is a very rare complication which has never been reported before. PRESENTING CONCERNS We reported a case of a 36-year-old male diagnosed as chronic pancreatitis with pancreatic stones and a large pancreatic pseudocyst. He underwent 3 repeated sessions of pancreatic ESWL (P-ESWL). After the last session of P-ESWL, he complained of dizziness. Physical examination revealed a large mass in the right abdomen. DIAGNOSIS Emergent upper abdominal computerized tomography (CT) revealed this mass is a mesenteric hematoma with the size of 8.2 cm × 11.7 cm in the right abdominal cavity after P-ESWL and there was no sign of intestinal obstruction. INTERVENTIONS With close monitoring of vital signs, the patient received conservative treatment for several days. Dynamic abdominal ultrasound monitoring revealed the mesenteric hematoma had organized. OUTCOMES Vital signs of the patient were stable after fluid transfusion. Three-month follow-up CT showed the mesenteric hematoma had absorbed completely. LESSONS Mesenteric hematoma rarely occurs after P-ESWL and it alerts us the importance of considering uncommon complications after P-ESWL. If mesenteric hematoma occurs after P-ESWL, conservative treatment could be the first choice while surgery can also be considered.
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Affiliation(s)
- Yu Liu
- Department of Gastroenterology, Gongli Hospital
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai
| | - Lu Hao
- Department of Gastroenterology, Hainan Branch of Chinese PLA General Hospital, Sanya
- Digestive Endoscopy Center, Changhai Hospital, The Second Military Medical University, Shanghai
| | - Li-Sheng Wang
- Department of Gastroenterology, The Second Clinical Medical College (Shenzhen People's Hospital), Jinan University, Guangdong, China
| | - Teng Wang
- Department of Gastroenterology, Gongli Hospital
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai
| | - Zhao-Shen Li
- Department of Gastroenterology, Gongli Hospital
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai
| | - Liang-Hao Hu
- Department of Gastroenterology, Gongli Hospital
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai
| | - Zheng-Lei Xu
- Department of Gastroenterology, The Second Clinical Medical College (Shenzhen People's Hospital), Jinan University, Guangdong, China
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Gerges C, Pullmann D, Schneider M, Siersema P, van Geenen E, Neuhaus H, Beyna T. Pancreatoscopy in endoscopic treatment of pancreatic duct stones: a systematic review. MINERVA CHIR 2018; 74:334-347. [PMID: 30371042 DOI: 10.23736/s0026-4733.18.07932-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Treatment of chronic calcifying pancreatitis is challenging and requires an interdisciplinary approach including endoscopist, surgeon and radiologist. With advances in endoscopic technology therapeutic interventions in the pancreatic duct became available. Extracorporeal shock wave lithotripsy (ESWL) is still recommended to be first line treatment, hence peroral pancreatoscopy- (POP) -guided intracorporal lithotripsy is a promising supplement in endoscopic therapy especially if ESWL is unsuccessful or not available. EVIDENCE AQUISITION Evidence from published trials, abstracts and case reports on direct pancreatoscopic treatment of main pancreatic duct (MPD) stones was reviewed with focus on efficiency and safety of available technologies, endoscopes and lithotripsy devices. A systematic Medline and Cochrane Database search for relevant studies was performed. EVIDENCE SYNTHESIS Seventeen relevant publications meeting the inclusion criteria have been identified (two prospective series, seven retrospective trials, six case reports, two abstracts, for a total of 225 patients). Successful ductal clearance for POP-guided treatment was reported between 37.5% and 100%. Clinical success was reported between 74% and 100%. Adverse event (AE) rate for POP-guided therapy is reported with 0-30%. There is no reported mortality following POP treatment. Three ongoing trials found to be registered. CONCLUSIONS POP-guided lithotripsy seems to be a promising alternative in a very selected patient cohort. Good powered randomized controlled trials are needed to prove efficiency and safety of the new technique also for large numbers of patients before it can be recommended as general practice. The focus of future studies should not only be on technical success, but also clinical success and patient-reported outcomes (quality of life).
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Affiliation(s)
- Christian Gerges
- Department of General Internal Medicine and Gastroenterology, Evangelical Hospital Düsseldorf, Düsseldorf, Germany
| | - David Pullmann
- Department of General Internal Medicine and Gastroenterology, Evangelical Hospital Düsseldorf, Düsseldorf, Germany
| | - Markus Schneider
- Department of General Internal Medicine and Gastroenterology, Evangelical Hospital Düsseldorf, Düsseldorf, Germany
| | - Peter Siersema
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Erwin van Geenen
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Horst Neuhaus
- Department of General Internal Medicine and Gastroenterology, Evangelical Hospital Düsseldorf, Düsseldorf, Germany
| | - Torsten Beyna
- Department of General Internal Medicine and Gastroenterology, Evangelical Hospital Düsseldorf, Düsseldorf, Germany -
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Bi YW, Wang D, Du TT, Liao Z, Li ZS, Hu LH. Hepatic subcapsular hematoma breaking into the abdominal cavity after extracorporeal shock wave lithotripsy for pancreatic stones. J Dig Dis 2018; 19:314-317. [PMID: 28749071 DOI: 10.1111/1751-2980.12510] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Revised: 06/21/2017] [Accepted: 07/24/2017] [Indexed: 12/11/2022]
Affiliation(s)
- Ya Wei Bi
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Dan Wang
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Ting Ting Du
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Zhuan Liao
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai, China.,Digestive Endoscopy Center, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Zhao Shen Li
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai, China.,Digestive Endoscopy Center, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Liang Hao Hu
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai, China.,Digestive Endoscopy Center, Changhai Hospital, Second Military Medical University, Shanghai, China
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Wang D, Ji JT, Xin L, Bi YW, Pan J, Liao Z, Du TT, Lin JH, Zhang D, Zeng XP, Ye B, Zou WB, Chen H, Xie T, Li BR, Zheng ZH, Li ZS, Hu LH. Extracorporeal Shock Wave Lithotripsy for Chronic Pancreatitis Patients With Stones After Pancreatic Surgery. Pancreas 2018; 47:609-16. [PMID: 29683971 DOI: 10.1097/MPA.0000000000001042] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [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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Beyna T, Neuhaus H, Gerges C. Endoscopic treatment of pancreatic duct stones under direct vision: Revolution or resignation? Systematic review. Dig Endosc 2018; 30:29-37. [PMID: 28656688 DOI: 10.1111/den.12909] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Accepted: 06/22/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIM The main treatment aim in chronic pancreatitis (CP) is symptom control and especially pain relief. Management of stone-predominant CP is challenging and requires a multidisciplinary approach. Extracorporeal shock wave lithotripsy (ESWL) has emerged as the cornerstone of non-surgical treatment as a result of disappointing results of available endoscopic treatment options during the last decades. With new developments in the field of direct peroral pancreatoscopy (POP) and intracorporeal lithotripsy, direct intraluminal treatment of main pancreatic duct (MPD) stones returns to the spotlight. METHODS Herein, we reviewed the current data on direct pancreatoscopic treatment of MPD stones with a focus on efficiency and safety of available technologies, endoscopes and lithotripsy devices. A systematic Medline search for relevant studies was done. RESULTS Ten relevant publications meeting the inclusion criteria were identified (two prospective series, six retrospective trials, two case reports, n = 87 patients). Successful ductal clearance for POP-guided treatment was reported as between 43% and 100% compared to ESWL with 59% to 80%. Adverse event rate for POP-guided therapy was reported as 0-13.5%. One study showed a noticeable higher adverse event rate of 43%. In this trial, POP was carried out after ESWL. There is no reported mortality following POP treatment. CONCLUSION Available results are promising in terms of ductal clearance and pain relief compared to standard endoscopic techniques and ESWL as the current gold standard for lithotripsy. Interpretation of this data is limited by the small number of cases for POP and the lack of prospective randomized controlled trials.
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Affiliation(s)
- Torsten Beyna
- Evangelisches Krankenhaus Düsseldorf, Department of Gastroenterology, Düsseldorf, Germany
| | - Horst Neuhaus
- Evangelisches Krankenhaus Düsseldorf, Department of Gastroenterology, Düsseldorf, Germany
| | - Christian Gerges
- Evangelisches Krankenhaus Düsseldorf, Department of Gastroenterology, Düsseldorf, Germany
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Bansal RK, Patil GK, Puri R, Choudhary NS, Patle SR, Sharma ZD, Sud R. Endoscopic pancreatic balloon sphincteroplasty for difficult to treat pancreatic stones and strictures: experience in 80 patients. Endosc Int Open 2017; 5:E1229-E1234. [PMID: 29218314 PMCID: PMC5718908 DOI: 10.1055/s-0043-119752] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Accepted: 07/24/2017] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND AND AIM There is paucity of data about endoscopic pancreatic sphincteroplasty (EPS) after endoscopic pancreatic sphincterotomy (EPST) in the treatment of chronic pancreatitis. The aim of this study was to establish the indications for EPS, complications related to it, and to examine its effectiveness in managing chronic pancreatitis after a year of follow-up. METHODS We evaluated the safety and efficacy of pancreatic balloon dilation coupled with sphincterotomy for the treatment of chronic pancreatitis. The technical success rate of balloon dilation, stone clearance, frequency of pancreatic stenting, and procedure-related adverse events were recorded. RESULTS Out of 580 patients who underwent pancreatic endotherapy between July 2014 and February 2016, 80 patients underwent EPS. The mean age of these 80 patients was 34 ± 11 years, and 80 % (n = 64) were males. The common indications were removal of large radiolucent stones in 31 patients; unyielding radiopaque stones post extracorporeal shock wave lithotripsy (ESWL) in 20 patients, and pancreatic duct stricture combined with stones in 29 patients. EPS could be successfully completed in 98.75 % of patients. Complete ductal clearance in a single session was achieved in only 25 patients, while 26 patients required two sessions. There were two adverse events of pain requiring admission for more than 24 hours and one procedure related bleeding, all of which were managed conservatively. The patients had an average follow-up of 8 months (6 - 12 months) and all the patients were pain free. CONCLUSIONS Endoscopic pancreatic sphincteroplasty is a relatively safe procedure with a low incidence of complications and a high rate of treatment success.
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Affiliation(s)
- Rinkesh Kumar Bansal
- Institute of Digestive and Hepatobiliary Sciences, Medanta – The Medicity, Gurugram, Haryana, India
| | - Gaurav Kumar Patil
- Institute of Digestive and Hepatobiliary Sciences, Medanta – The Medicity, Gurugram, Haryana, India
| | - Rajesh Puri
- Institute of Digestive and Hepatobiliary Sciences, Medanta – The Medicity, Gurugram, Haryana, India,Corresponding author Rajesh Puri, MD DNB Institute of Digestive and Hepatobiliary SciencesMedanta – The MedicitySector 38GurugramDelhi NCRIndiaPIN 122001+91-12-44834445
| | - Narendra S. Choudhary
- Institute of Digestive and Hepatobiliary Sciences, Medanta – The Medicity, Gurugram, Haryana, India
| | - Saurabh R. Patle
- Institute of Digestive and Hepatobiliary Sciences, Medanta – The Medicity, Gurugram, Haryana, India
| | - Zubin D. Sharma
- Institute of Digestive and Hepatobiliary Sciences, Medanta – The Medicity, Gurugram, Haryana, India
| | - Randhir Sud
- Institute of Digestive and Hepatobiliary Sciences, Medanta – The Medicity, Gurugram, Haryana, India
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Qian YY, Chen H, Tang XY, Jiang X, Qian W, Zou WB, Xin L, Li B, Qi YF, Hu LH, Zou DW, Jin ZD, Wang D, Du YQ, Wang LW, Liu F, Li ZS, Liao Z. Rectally administered indomethacin to prevent post-ESWL-pancreatitis (RIPEP): study protocol for a randomized controlled trial. Trials 2017; 18:513. [PMID: 29096689 DOI: 10.1186/s13063-017-2250-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2017] [Accepted: 10/10/2017] [Indexed: 12/22/2022] Open
Abstract
Background Pancreatic extracorporeal shock wave lithotripsy (P-ESWL) is the first-line therapy for large pancreatic duct stones. Although it is a highly effective and safe procedure for the fragmentation of pancreatic stones, it is still not complication-free. Just like endoscopic retrograde cholangiopancreatography (ERCP), pancreatitis is the most common complication. To date, nonsteroidal anti-inflammatory drugs (NSAIDs) have proven to be the only effective prophylactic medication for post-ERCP pancreatitis and the European, American and Japanese Society for Gastrointestinal Endoscopy guidelines have recommended prophylactic rectally administered indomethacin for all patients undergoing ERCP. Given the little research about effective prevention for post P-ESWL pancreatitis, we aim to determine whether rectally administered indomethacin can reduce post-ESWL-pancreatitis. Methods/design The RIPEP study is a prospective, randomized, double-blinded, placebo-controlled trial. One thousand three hundred and seventy patients with chronic pancreatitis and pancreatic stones (>5 mm in diameter) treated with P-ESWL at Changhai Hospital will be randomly allocated to rectally administered indomethacin or placebo therapy before the procedure. The primary endpoint is the incidence of post-ESWL pancreatitis. Secondary endpoints include the severity of pancreatitis, occurrence rate of asymptomatic hyperamylasemia and other complications. Discussion The RIPEP trial is designed to show that rectally administered indomethacin reduces the development and severity of post-ESWL pancreatitis and benefits patients treated with P-ESWL. Trial registration ClinicalTrials.gov, ID: NCT02797067. Registered on 17 November 2016. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-2250-7) contains supplementary material, which is available to authorized users.
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Issa Y, van Santvoort HC, Fockens P, Besselink MG, Bollen TL, Bruno MJ, Boermeester MA. Diagnosis and treatment in chronic pancreatitis: an international survey and case vignette study. HPB (Oxford) 2017; 19:978-985. [PMID: 28821411 DOI: 10.1016/j.hpb.2017.07.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Revised: 05/03/2017] [Accepted: 07/02/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND The aim of the study was to evaluate the current opinion and clinical decision-making process of international pancreatologists, and to systematically identify key study questions regarding the diagnosis and treatment of chronic pancreatitis (CP) for future research. METHODS An online survey, including questions regarding the diagnosis and treatment of CP and several controversial clinical case vignettes, was send by e-mail to members of various international pancreatic associations: IHPBA, APA, EPC, ESGE and DPSG. RESULTS A total of 288 pancreatologists, 56% surgeons and 44% gastroenterologists, from at least 47 countries, participated in the survey. About half (48%) of the specialists used a classification tool for the diagnosis of CP, including the Mayo Clinic (28%), Mannheim (25%), or Büchler (25%) tools. Overall, CT was the preferred imaging modality for evaluation of an enlarged pancreatic head (59%), pseudocyst (55%), calcifications (75%), and peripancreatic fat infiltration (68%). MRI was preferred for assessment of main pancreatic duct (MPD) abnormalities (60%). Total pancreatectomy with auto-islet transplantation was the preferred treatment in patients with parenchymal calcifications without MPD abnormalities and in patients with refractory pain despite maximal medical, endoscopic, and surgical treatment. In patients with an enlarged pancreatic head, 58% preferred initial surgery (PPPD) versus 42% initial endoscopy. In patients with a dilated MPD and intraductal stones 56% preferred initial endoscopic ± ESWL treatment and 29% preferred initial surgical treatment. CONCLUSION Worldwide, clinical decision-making in CP is largely based on local expertise, beliefs and disbeliefs. Further development of evidence-based guidelines based on well designed (randomized) studies is strongly encouraged.
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Affiliation(s)
- Yama Issa
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands.
| | | | - Paul Fockens
- Department of Gastroenterology, Academic Medical Center, Amsterdam, The Netherlands
| | - Marc G Besselink
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Thomas L Bollen
- Department of Radiology, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Marco J Bruno
- Department of Gastroenterology, Erasmus Medical Center, Rotterdam, The Netherlands
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Tantau A, Mandrutiu A, Leucuta DC, Ciobanu L, Tantau M. Prognostic factors of response to endoscopic treatment in painful chronic pancreatitis. World J Gastroenterol 2017; 23:6884-6893. [PMID: 29085231 PMCID: PMC5645621 DOI: 10.3748/wjg.v23.i37.6884] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Revised: 08/13/2017] [Accepted: 09/05/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate the endoscopic treatment efficacy and prognostic factors of long-term response to treatment for painful chronic pancreatitis.
METHODS This retrospective analysis identified 168 patients with painful chronic pancreatitis hospitalized during January 2010-January 2015 in a Romanian tertiary referral center. Data on demographics, medical history, alcohol consumption, smoking habit, clinical parameters, type and number of endoscopic procedures and hospital admissions number were collected from the medical charts and analyzed. The absence or substantial reduction of pain (mild pain) at the end of the follow-up associated with the technical success of endotherapy was considered as clinical success.
RESULTS Among the 168 patients with painful chronic pancreatitis admitted to our department during the study period, 39 (23.21%) had optimal response to the medical therapy. One hundred and twenty-nine patients required endoscopic treatment. The median follow-up period was 15 mo (range, 0-60 mo). Overall, technical success of endotherapy was achieved in 105 patients (81.39%). More than two-thirds of patients (82.78%) had substantial improvement of pain after the endoscopic treatment, including frequency and severity of the pain attacks. Patients younger than 40 years had significantly more successful endoscopic procedures (P = 0.041). Clinical success was higher in non-smoking patients (P = 0.003). The hospital admission rate was higher in patients with recognized alcohol consumption (P = 0.03) and in smokers (P = 0.027). The number and location of pancreatic stones and locations of strictures did not significantly influence the technical success (P > 0.05) or the clinical success (P > 0.05).
CONCLUSION Younger age than 40 years can be considered an important factor positively influencing endoscopic treatment outcome in patients with painful chronic pancreatitis.
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Affiliation(s)
- Alina Tantau
- Department of Internal Medicine and Gastroenterology, “Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj-Napoca City, 400012 Cluj, Romania
- Department of Internal Medicine and Gastroenterology, 4th Medical Clinic, Cluj-Napoca City, 400015 Cluj, Romania
| | - Alina Mandrutiu
- Department of Gastroenterology, Gastroenterology and Hepatology Medical Center, Cluj-Napoca City, 400132 Cluj, Romania
| | - Daniel-Corneliu Leucuta
- Medical Informatics and Biostatistics Department, “Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj-Napoca City, 400012 Cluj, Romania
| | - Lidia Ciobanu
- Department of Internal Medicine and Gastroenterology, “Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj-Napoca City, 400012 Cluj, Romania
- Department of Internal Medicine and Gastroenterology, “Prof. Dr. Octavian Fodor“ Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca City, 400158 Cluj, Romania
| | - Marcel Tantau
- Department of Internal Medicine and Gastroenterology, “Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj-Napoca City, 400012 Cluj, Romania
- Department of Internal Medicine and Gastroenterology, “Prof. Dr. Octavian Fodor“ Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca City, 400158 Cluj, Romania
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Abstract
Pancreatolithiasis, or pancreatic calculi (PC), is a sequel of chronic pancreatitis (CP) and may occur in the main ducts, side branches or parenchyma. Calculi are the end result, irrespective of the etiology of CP. PC contains an inner nidus surrounded by successive layers of calcium carbonate. These calculi obstruct the pancreatic ducts and produce ductal hypertension, which leads to pain, the cardinal feature of CP. Both endoscopic therapy and surgery aim to clear these calculi and decrease ductal hypertension. In small PC, endoscopic retrograde cholangiopancreatography (ERCP) followed by sphincterotomy and extraction is the treatment of choice. Large calculi require fragmentation by extracorporeal shock wave lithotripsy (ESWL) prior to their extraction or spontaneous expulsion. In properly selected cases, ESWL followed by ERCP is the standard of care for the management of large PC. Long-term outcomes following ESWL have demonstrated good pain relief in approximately 60% of patients. However, ESWL has limitations. Per oral pancreatoscopy and intraductal lithotripsy represent techniques in evolution, and in current practice their use is limited to centers with considerable expertise. Surgery should be offered to all patients with extensive PC, associated multiple ductal strictures or following failed endotherapy.
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Affiliation(s)
- Manu Tandan
- Asian Institute of Gastroenterology, Hyderabad, India
| | - Rupjyoti Talukdar
- Asian Institute of Gastroenterology, Hyderabad, India.,Asian Healthcare Foundation, Hyderabad, India
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Vaysse T, Boytchev I, Antoni G, Croix DS, Choury AD, Laurent V, Pelletier G, Buffet C, Bou-Farah R, Carbonnel F. Efficacy and safety of extracorporeal shock wave lithotripsy for chronic pancreatitis. Scand J Gastroenterol 2016; 51:1380-5. [PMID: 27595309 DOI: 10.1080/00365521.2016.1209688] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION There is still uncertainty regarding the efficacy and optimal modalities of extracorporeal shock wave lithotripsy (ESWL) in the treatment of chronic pancreatitis. The aims of the present study were to assess the safety and the efficacy of ESWL, either alone or followed by therapeutic endoscopic retrograde cholangiopancreatography (adjuvant ERCP) and to determine predictive factors of efficacy, in a real-life setting. PATIENTS AND METHODS This study included all consecutive patients who underwent an ESWL in a single University Hospital between 2001 and 2012. The indication for ESWL was obstructive stone(s) of the main pancreatic duct resulting in either painful chronic pancreatitis or recurrent acute pancreatitis. Success was defined by resolution of pain, no analgesic treatment, no acute pancreatitis and no surgical treatment for chronic pancreatitis 6 months after the ESWL. RESULTS One hundred and forty-six patients were studied; 6/146 (4%) had a complication of ESWL. Among the 132 patients in whom follow-up was completed, 91 (69%) had an adjuvant ERCP. After 6 months of follow-up, 100/132 (76%) patients achieved success. In multivariate analysis, the single significant predictive factor of the success of the ESWL treatment was chronic pain (p = 0.03). Patients who had chronic pain and needed opioid treatment had less chance of success than patients without chronic pain (OR 95%CI 0.31 [0.07-1.14]). We found no difference in the success rates between patients who underwent adjuvant ERCP and those who had ESWL only (p = 0.93). CONCLUSION This study shows that the ESWL is a safe and effective treatment for patients with chronic pancreatitis and obstructive stones within the main pancreatic duct. Systematic association with therapeutic ERCP appears to provide no additional benefit and is therefore not recommended.
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Affiliation(s)
- Thibaut Vaysse
- a Service de Gastroentérologie, University Hospital of Bicêtre, Assistance Publique-Hôpitaux de Paris, Université Paris Sud , Le Kremlin Bicêtre , France
| | - Isabelle Boytchev
- a Service de Gastroentérologie, University Hospital of Bicêtre, Assistance Publique-Hôpitaux de Paris, Université Paris Sud , Le Kremlin Bicêtre , France
| | - Guillemette Antoni
- a Service de Gastroentérologie, University Hospital of Bicêtre, Assistance Publique-Hôpitaux de Paris, Université Paris Sud , Le Kremlin Bicêtre , France
| | - Damien Sainte Croix
- a Service de Gastroentérologie, University Hospital of Bicêtre, Assistance Publique-Hôpitaux de Paris, Université Paris Sud , Le Kremlin Bicêtre , France
| | - André Daniel Choury
- a Service de Gastroentérologie, University Hospital of Bicêtre, Assistance Publique-Hôpitaux de Paris, Université Paris Sud , Le Kremlin Bicêtre , France
| | - Valérie Laurent
- a Service de Gastroentérologie, University Hospital of Bicêtre, Assistance Publique-Hôpitaux de Paris, Université Paris Sud , Le Kremlin Bicêtre , France
| | - Gilles Pelletier
- a Service de Gastroentérologie, University Hospital of Bicêtre, Assistance Publique-Hôpitaux de Paris, Université Paris Sud , Le Kremlin Bicêtre , France
| | - Catherine Buffet
- a Service de Gastroentérologie, University Hospital of Bicêtre, Assistance Publique-Hôpitaux de Paris, Université Paris Sud , Le Kremlin Bicêtre , France
| | - Rita Bou-Farah
- a Service de Gastroentérologie, University Hospital of Bicêtre, Assistance Publique-Hôpitaux de Paris, Université Paris Sud , Le Kremlin Bicêtre , France
| | - Franck Carbonnel
- a Service de Gastroentérologie, University Hospital of Bicêtre, Assistance Publique-Hôpitaux de Paris, Université Paris Sud , Le Kremlin Bicêtre , France
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Lapp RT, Wolf JS Jr, Faerber GJ, Roberts WW, McCarthy ST, Anderson MA, Wamsteker EJ, Elta GH, Scheiman JM, Kwon RS. Duct Diameter and Size of Stones Predict Successful Extracorporeal Shock Wave Lithotripsy and Endoscopic Clearance in Patients With Chronic Pancreatitis and Pancreaticolithiasis. Pancreas 2016; 45:1208-11. [PMID: 26967455 DOI: 10.1097/MPA.0000000000000622] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVES The need for endoscopic therapy before extracorporeal shock wave lithotripsy (SWL) to facilitate pancreatic duct stone removal is unclear. Predictive factors associated with successful fragmentation and subsequent complete duct clearance are variable. We hypothesize pancreatic duct strictures and large stones, but not pre-SWL endotherapy, correlate with successful fragmentation and complete duct clearance. METHODS A retrospective cohort study of patients with pancreaticolithiasis who underwent SWL and endoscopic retrograde cholangiopancreatography between January 2009 and June 2014 was evaluated. RESULTS Thirty-seven patients were treated. Technical success (TS) of fragmentation was achieved in 22 patients (60%). Technical success was associated with fewer stones and SWL sessions and smaller stone and duct size. By multivariate logistic regression, only duct dilation was associated with TS. Endoscopic success of complete duct clearance was achieved in 29 patients (80%). Endoscopic success was more frequent with stones 12 mm or less and with successful TS. By multivariate logistic regression, stones greater than 12 mm were associated with endoscopic failure. CONCLUSIONS Pre-SWL endotherapy does not affect stone fragmentation. Patients with a dilated duct (>8 mm) and pancreatic stones 12 mm or greater were associated with unsuccessful TS and endoscopic success, respectively, and may benefit from early referral for surgical decompression.
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Korpela T, Udd M, Tenca A, Lindström O, Halttunen J, Myrskysalo S, Mikkola A, Kylänpää L. Long-term results of combined ESWL and ERCP treatment of chronic calcific pancreatitis. Scand J Gastroenterol 2016; 51:866-71. [PMID: 26912383 DOI: 10.3109/00365521.2016.1150502] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Extracorporeal shock wave lithotripsy (ESWL) combined with endotherapy (ET) is the standard treatment for pancreatic duct stones (PDS) in chronic pancreatitis (CP). Our aim was to report the short- and long-term results of ESWL and ET. MATERIAL AND METHODS Consecutively treated 83 patients with symptomatic PDS using ESWL and ET. Success was defined (i) technically: PDS fragmentation and clearance obtained and (ii) clinically: improvement/resolution of pain. To get information on quality of life, we conducted a phone survey whereby we contacted 64 (89%) patients. The long-term results are presented in those patients with ≥2 years follow-up. RESULTS Treated PDS with median size of 10 (5-25) mm were located in the head, body, or the tail of the pancreas in 78, 4, and 1 patients, respectively. The primary results were that technical success was achieved in 69 patients (83%) and clinical success in 66 patients (80%). Fourteen patients had technical failure, but eight of them became free of pain. Thus, clinical success can be considered to have been achieved in 74 of 83 patients (89%). In patients with persistent pseudocyst (PC) at the time of ESWL (n = 19), the PC disappeared in a year in 14 patients (74%). The long-term results were obtained from 61 (73%) ESWL- and ET-treated patients. The median follow-up for them was 53 months (range: 24-124) and 57 patients (93%) became pain-free or had less pain. CONCLUSIONS For patients with CP and PDS ESWL combined with ET is an effective and safe treatment giving favorable long-term results.
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Affiliation(s)
- Taija Korpela
- a Department of Surgery , Helsinki University Hospital, University of Helsinki , Helsinki , Finland
| | - Marianne Udd
- a Department of Surgery , Helsinki University Hospital, University of Helsinki , Helsinki , Finland
| | - Andrea Tenca
- b Department of Gastroenterology , Helsinki University Hospital, University of Helsinki , Helsinki , Finland
| | - Outi Lindström
- a Department of Surgery , Helsinki University Hospital, University of Helsinki , Helsinki , Finland
| | - Jorma Halttunen
- a Department of Surgery , Helsinki University Hospital, University of Helsinki , Helsinki , Finland
| | - Sanna Myrskysalo
- c Department of Urology , Helsinki University Hospital, University of Helsinki , Helsinki , Finland
| | - Arto Mikkola
- c Department of Urology , Helsinki University Hospital, University of Helsinki , Helsinki , Finland
| | - Leena Kylänpää
- a Department of Surgery , Helsinki University Hospital, University of Helsinki , Helsinki , Finland
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Li BR, Liao Z, Du TT, Ye B, Chen H, Ji JT, Zheng ZH, Hao JF, Ning SB, Wang D, Lin JH, Hu LH, Li ZS. Extracorporeal shock wave lithotripsy is a safe and effective treatment for pancreatic stones coexisting with pancreatic pseudocysts. Gastrointest Endosc 2016; 84:69-78. [PMID: 26542375 DOI: 10.1016/j.gie.2015.10.026] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Accepted: 10/13/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS We aimed to investigate outcomes of pancreatic extracorporeal shock wave lithotripsy (P-ESWL) for the removal of large pancreatic stones coexisting with pancreatic pseudocysts (PPCs) in chronic pancreatitis (CP). METHODS This is a prospective study performed in CP patients with at least 1 stone (≥5 mm). Patients were divided into the PPC group (stones coexisting with PPCs) or the control group (stones alone). Patients were initially subjected to successive P-ESWL treatments, followed by ERCP. Primary outcomes were P-ESWL adverse events, and secondary outcomes were stone clearance, long-term pain relief, improved quality-of-life scores, and PPC regression. RESULTS A total of 849 patients (59 in the PPC group and 790 in the control group) was subjected to P-ESWL between March 2011 and October 2013. Occurrences of P-ESWL adverse events were similar between the PPC group and the control group (11.86% vs 12.41%, P = .940). After the treatment of initial P-ESWL combined with ERCP, the complete, partial, and nonclearance of stones occurred in 67.24%, 20.69%, and 12.07%, respectively, of patients in PPC group, with no significant difference from the control group (complete, partial, and nonclearance: 83.17%, 10.40%, and 11.39%, respectively; P = .106). Fifty-five of 59 patients (93.22%) with PPCs were followed for a median period of 21.9 months (range, 12.0-45.1). PPCs disappeared in 56.36% (31/55) and 76.36% (42/55) of patients after 3 months and 1 year of follow-up visits, respectively. Moreover, complete and partial pain relief were achieved in 63.64% (35/55) and 25.45% (14/55) of patients, respectively. The scores for quality of life (P < .001), physical health (P < .001), and weight loss (P < .001) improved. CONCLUSIONS In our multispecialty tertiary center, initial P-ESWL followed by ERCP was safe in patients with coexisting pancreatic stones and PPCs and effective for stone clearance, main pancreatic duct drainage, and pain relief.
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Affiliation(s)
- Bai-Rong 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; Department of Gastroenterology, Air Force General Hospital, Beijing, China
| | - Zhuan Liao
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China; Digestive Endoscopy Center, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Ting-Ting Du
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Bo Ye
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China; Digestive Endoscopy Center, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Hui Chen
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China; Digestive Endoscopy Center, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Jun-Tao Ji
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Zhao-Hong Zheng
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Jun-Feng Hao
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Shou-Bin Ning
- Department of Gastroenterology, Air Force General Hospital, Beijing, China
| | - Dan Wang
- Department of Gastroenterology, Changhai Hospital, The Second Military Medical University, Shanghai, China; Digestive Endoscopy Center, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Jin-Huan Lin
- 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; Digestive Endoscopy Center, 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
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Li BR, Pan J, Hu LH, Li ZS. Laser lithotripsy as a supplementary approach for the treatment of main pancreatic duct stones. Gastrointest Endosc 2016; 83:1300-1. [PMID: 27206592 DOI: 10.1016/j.gie.2016.01.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 01/05/2016] [Indexed: 12/11/2022]
Affiliation(s)
- Bai-Rong Li
- Department of Gastroenterology, Air Force General Hospital, Beijing, China; Department of Gastroenterology and Digestive Endoscopy Center, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Jun Pan
- Department of Gastroenterology and Digestive Endoscopy Center, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Liang-Hao Hu
- Department of Gastroenterology and Digestive Endoscopy Center, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Zhao-Shen Li
- Department of Gastroenterology and Digestive Endoscopy Center, Changhai Hospital, The Second Military Medical University, Shanghai, China
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Moole H, Jaeger A, Bechtold ML, Forcione D, Taneja D, Puli SR. Success of Extracorporeal Shock Wave Lithotripsy in Chronic Calcific Pancreatitis Management: A Meta-Analysis and Systematic Review. Pancreas 2016; 45:651-8. [PMID: 26580454 DOI: 10.1097/MPA.0000000000000512] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES This is a meta-analysis and systematic review to assess the overall utility and safety of Extracorporeal shock wave lithotripsy (ESWL) in chronic calcific pancreatitis. Primary outcomes are pain relief, narcotic usage, ductal clearance, quality of life, and pancreatic exocrine and endocrine function. METHODS Studies involving ESWL in chronic calcific pancreatitis with main pancreatic duct stones greater than 5 mm and patients that failed conservative pain management were included. Fixed and random effects models were used to calculate the pooled proportions. RESULTS Initial search identified 1471 reference articles, in which 184 articles were selected and reviewed. Data were extracted from 27 studies (N = 3189) which met the inclusion criterion. The pooled proportion of patients with absence of pain at follow-up was 52.7% (95% confidence interval [95% CI], 50.85-54.56) and mild to moderate pain at follow-up was 33.43% (95% CI, 31.40-35.50). Quality of life improved in 88.21% (95% CI, 85.43-90.73) and complete ductal clearance was 70.69% (95% CI, 68.97-72.38) in the pooled patients. CONCLUSIONS The ESWL is an effective and safe management option in patients with chronic calcific pancreatitis patients with main pancreatic duct stone size greater than 5 mm who did not get adequate pain relief with conservative management.
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Pujahari AK. Chronic Pancreatitis: A Review. Indian J Surg 2015; 77:1348-58. [PMID: 27011563 DOI: 10.1007/s12262-015-1221-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Accepted: 01/05/2015] [Indexed: 10/23/2022] Open
Abstract
This is to incorporate the recent trends in chronic pancreatitis. Extensive literature search was done from Pubmed and Ovid SP. Full text articles and abstracts related to chronic pancreatitis were reviewed and the article was prepared. Chronic pancreatitis is evolving fast on its etiology and treatment areas. The main etiological factors are pointing towards genetic, alcohol, and smoking. Autoimmune has also been added as a cause. Endoscopic ultra sound (EUS) becoming the standard diagnostic procedure. Surgery is becoming the treatment of choice for pain and mechanical complications and not the endotherapy in the long-term follow-up. The numbers of surgeries are getting narrowed down. The two etiological groups of chronic pancreatitis namely alcohol + smoking and genetic getting clearer, where the later group present at an early age. Endoscopic ultrasound and imaging with secretin is diagnostic of chronic pancreatitis before the structural changes. Endotherapy is found to be inferior to surgery in long-term pain relief. Diagnostic criteria for autoimmune pancreatitis are established. Pancreaticogenic diabetes (Type3c) and its problem associated with fat malabsorption are being understood.
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Abstract
Endoscopic retrograde cholangiopancreatography is an effective platform for a variety of therapies in the management of benign and malignant disease of the pancreas. Over the last 50 years, endotherapy has evolved into the first-line therapy in the majority of acute and chronic inflammatory diseases of the pancreas. As this field advances, it is important that gastroenterologists maintain an adequate knowledge of procedure indication, maintain sufficient procedure volume to handle complex pancreatic endotherapy, and understand alternate approaches to pancreatic diseases including medical management, therapy guided by endoscopic ultrasonography, and surgical options.
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Affiliation(s)
- Brian P Riff
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1069, New York, NY 10029, USA
| | - Vinay Chandrasekhara
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, 3400 Civic Center Boulevard, Perelman Center for Advanced Medicine South Pavilion, 7th Floor, Philadelphia, PA 19104, USA.
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Hu LH, Ye B, Yang YG, Ji JT, Zou WB, Du TT, Hao JF, Jiang YY, Liao Z, Li ZS. Extracorporeal Shock Wave Lithotripsy for Chinese Patients With Pancreatic Stones: A Prospective Study of 214 Cases. Pancreas 2016; 45:298-305. [PMID: 26418906 DOI: 10.1097/MPA.0000000000000464] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVES This study aims to evaluate prospectively the safety and efficacy of extracorporeal shock wave lithotripsy (ESWL) in Chinese patients. METHODS A total of 214 patients with painful chronic pancreatitis and pancreatic stones who underwent ESWL followed by endoscopic retrograde cholangiopancreatography from March 2011 to February 2012 in Changhai Hospital were enrolled. The main pancreatic duct clearance rate and complications were recorded prospectively. Symptoms, weight, quality of life, and pancreatic function were assessed before and after ESWL and endotherapy. RESULTS A total of 473 ESWL procedures were performed in 214 patients. Stones were fragmented in all cases. Complete clearance of main pancreatic duct stones and successful endoscopic decompression were achieved in 155 (72.4%) and 188 (90.8%) of 214 patients, respectively. Complications were observed after 20 sessions (20 of 473, 4.23%). Follow-up (n = 195) after 18.5 ± 3.3 months showed that complete and partial pain relief were achieved in 71.3% and 24.0% of the patients, respectively. The scores for the quality of life (5.8 ± 1.7 vs 8.1 ± 1.2, P < 0.05) and mental health from the Medical Outcomes Study 36-Item Short-Form General Health Survey questionnaire (62.2 ± 21.5 vs 68.5 ± 16.4, P < 0.05) improved after ESWL. CONCLUSIONS Thus, ESWL is a safe and effective method to treat Chinese patients with pancreatic stones. This procedure can significantly improve the success rate of endotherapy.
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Anderson MA, Akshintala V, Albers KM, Amann ST, Belfer I, Brand R, Chari S, Cote G, Davis BM, Frulloni L, Gelrud A, Guda N, Humar A, Liddle RA, Slivka A, Gupta RS, Szigethy E, Talluri J, Wassef W, Wilcox CM, Windsor J, Yadav D, Whitcomb DC. Mechanism, assessment and management of pain in chronic pancreatitis: Recommendations of a multidisciplinary study group. Pancreatology 2016; 16:83-94. [PMID: 26620965 PMCID: PMC4761301 DOI: 10.1016/j.pan.2015.10.015] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Revised: 10/29/2015] [Accepted: 10/31/2015] [Indexed: 12/11/2022]
Abstract
DESCRIPTION Pain in patients with chronic pancreatitis (CP) remains the primary clinical complaint and source of poor quality of life. However, clear guidance on evaluation and treatment is lacking. METHODS Pancreatic Pain working groups reviewed information on pain mechanisms, clinical pain assessment and pain treatment in CP. Levels of evidence were assigned using the Oxford system, and consensus was based on GRADE. A consensus meeting was held during PancreasFest 2012 with substantial post-meeting discussion, debate, and manuscript refinement. RESULTS Twelve discussion questions and proposed guidance statements were presented. Conference participates concluded: Disease Mechanism: Pain etiology is multifactorial, but data are lacking to effectively link symptoms with pathologic feature and molecular subtypes. Assessment of Pain: Pain should be assessed at each clinical visit, but evidence to support an optimal approach to assessing pain character, frequency and severity is lacking. MANAGEMENT There was general agreement on the roles for endoscopic and surgical therapies, but less agreement on optimal patient selection for medical, psychological, endoscopic, surgical and other therapies. CONCLUSIONS Progress is occurring in pain biology and treatment options, but pain in patients with CP remains a major problem that is inadequately understood, measured and managed. The growing body of information needs to be translated into more effective clinical care.
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Affiliation(s)
| | | | - Kathryn M Albers
- Department of Neurobiology, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Inna Belfer
- Department of Anesthesiology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Randall Brand
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Suresh Chari
- Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Greg Cote
- Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Brian M Davis
- Department of Neurobiology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Luca Frulloni
- Department of Medicine, University of Verona, Verona, Italy
| | - Andres Gelrud
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Nalini Guda
- Department of Gastroenterology, Aurora St. Luke's Medical Center, Milwaukee, WI, USA
| | - Abhinav Humar
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Adam Slivka
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Eva Szigethy
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jyothsna Talluri
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Wahid Wassef
- Department of Medicine, University of Massachusetts, Worcester, MA, USA
| | - C Mel Wilcox
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - John Windsor
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Dhiraj Yadav
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - David C Whitcomb
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Department of Cell Biology & Molecular Physiology, University of Pittsburgh, Pittsburgh, PA, USA; Department of Human Genetics, University of Pittsburgh, Pittsburgh, PA, USA.
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Yang YG, Hu LH, Chen H, Li B, Fan XH, Li JB, Wang JF, Deng XM. Target-controlled infusion of remifentanil with or without flurbiprofen axetil in sedation for extracorporeal shock wave lithotripsy of pancreatic stones: a prospective, open-label, randomized controlled trial. BMC Anesthesiol 2015; 15:161. [PMID: 26547293 PMCID: PMC4637145 DOI: 10.1186/s12871-015-0141-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Accepted: 11/04/2015] [Indexed: 01/23/2023] Open
Abstract
Background Extracorporeal shock wave lithotripsy (ESWL) is an effective therapeutic method used to treat patients with pancreatic stones. However, the anesthesia for this procedure has been underappreciated, with minimal reports of these procedures in certain case series with general or epidural anesthesia. Methods A cohort of 60 patients who elected to undergo ESWL in order to treat pancreatic stones for the first time were randomly selected and divided into two groups. One group of patients received target controlled infusion (TCI) of remifentanil, while the other group of patients received TCI of remifentanil plus a bolus of flurbiprofen axetil (a cyclooxygenase inhibitor) (Rem group and Rem + Flu group, n = 30 for each group). The Dixon’s up-and-down method was used to calculate the half maximum effective concentration (EC50) of remifentanil. Visual analogue scales of pain, Ramsay sedation scale, hemodynamic changes, and adverse events were also recorded. Results The EC50 of remifentanil was calculated to be 4.0 ng/ml (95 % confidential interval: 3.84 ng/ml, 4.16 ng/ml) and 2.76 ng/ml (95 % confidential interval: 2.63 ng/ml, 2.89 ng/ml) in the Rem group and Rem + Flu group respectively (p < 0.001). Pain score was comparable between the two groups, while the Ramsay sedation scale was higher in the Rem group. Hemodynamic data showed that patients in the Rem group experienced higher mean arterial pressures and higher heart rates across the procedures. Patients in Rem group demonstrated a lower respiratory rate (p < 0.001) and a lower SpO2 (p = 0.001). Less adverse events occurred in Rem + Flu group, including a reduced respiratory depression requiring wake-up as well as reduced postoperative nausea and vomiting. Conclusion Remifentanil plus flurbiprofen axetil provided satisfactory analgesia and sedation for ESWL of pancreatic stones with less adverse events. (Clinicaltrial.gov: NCT01998217; registered on November 19, 2013)
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Affiliation(s)
- Yu-Guang Yang
- Department of Anesthesiology and Intensive Care, Changhai Hospital, the Second Military Medical University, 168 Changhai Road, Shanghai, 200433, PR China
| | - Liang-Hao Hu
- Department of Gastroenterology, Changhai Hospital, the Second Military Medical University, Shanghai, 200433, PR China
| | - Hui Chen
- Department of Anesthesiology and Intensive Care, Changhai Hospital, the Second Military Medical University, 168 Changhai Road, Shanghai, 200433, PR China
| | - Bo Li
- Department of Anesthesiology and Intensive Care, Changhai Hospital, the Second Military Medical University, 168 Changhai Road, Shanghai, 200433, PR China
| | - Xiao-Hua Fan
- Department of Anesthesiology and Intensive Care, Changhai Hospital, the Second Military Medical University, 168 Changhai Road, Shanghai, 200433, PR China
| | - Jin-Bao Li
- Department of Anesthesiology and Intensive Care, Changhai Hospital, the Second Military Medical University, 168 Changhai Road, Shanghai, 200433, PR China
| | - Jia-Feng Wang
- Department of Anesthesiology and Intensive Care, Changhai Hospital, the Second Military Medical University, 168 Changhai Road, Shanghai, 200433, PR China.
| | - Xiao-Ming Deng
- Department of Anesthesiology and Intensive Care, Changhai Hospital, the Second Military Medical University, 168 Changhai Road, Shanghai, 200433, PR China.
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Abstract
Chronic pancreatitis is associated with varied morphological complications, including intraductal stones, main pancreatic ductal strictures, distal biliary strictures and pseudocysts. Endoscopic therapy provides a less invasive alternative to surgery. In addition, extracorporeal shockwave lithotripsy improves the success rate of endoscopic clearance of intraductal stones. However, recent data from randomised trials have shown better long-term outcomes with surgical drainage for obstructive pancreatic ductal disease. In patients with distal biliary strictures, stent insertion leads to good immediate drainage, but after stent removal, recurrent narrowing is common. Endoscopic drainage of pancreatic pseudocysts has excellent outcome and should be accompanied by pancreatic ductal stenting when a ductal communication is evident. In those who remain symptomatic, endoscopic ultrasonography-guided coeliac plexus block may provide effective but short-term pain relief. In this review, we present the current evidence for the role of endotherapy in the management of patients with chronic pancreatitis.
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Affiliation(s)
- Andrew Boon Eu Kwek
- Department of Gastroenterology and Hepatology, Changi General Hospital, 2 Simei Street 3, Singapore 529889.
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Abstract
Extracorporeal shock wave lithotripsy is recommended as the first-line therapy for large (>5-mm) obstructive pancreatic ductal stones. Dominant pancreatic duct strictures should be initially managed with a wide-bore single plastic stent with 3 monthly exchanges for a year, even in asymptomatic patients. Recent studies have evaluated multiple plastic and self-expanding covered metal stents for refractory pancreatic ductal stricture. Pancreatic pseudocysts should be treated endoscopically with or without endoscopic ultrasound guidance.
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Abstract
Endoscopic therapy in chronic pancreatitis (CP) aims to provide pain relief and to treat local complications, by using the decompression of the pancreatic duct and the drainage of pseudocysts and biliary strictures, respectively. This is the reason for using it as first-line therapy for painful uncomplicated CP. The clinical response has to be evaluated at 6-8 weeks, when surgery may be chosen. This article reviews the main possibilities of endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) therapies. Endotherapy for pancreatic ductal stones uses ultrasound wave lithotripsy and sometimes additional stone extractions. The treatment of pancreatic duct strictures consists of a single large stenting for 1 year. If the stricture persists, simultaneous multiple stents are applied. In case of unsuccessful ERCP, the EUS-guided drainage of the main pancreatic duct (MPD) or a rendezvous technique can solve the ductal strictures. EUS-guided celiac plexus block has limited efficiency in CP. The drainage of symptomatic or complicated pancreatic pseudocysts can be performed transpapillarily or transgastrically/transduodenally, preferably by EUS guidance. When the biliary stricture is symptomatic or progressive, multiple plastic stents are indicated. In conclusion, as in many fields of symptomatic treatment, endoscopy remains the first choice, either by using ERCP or EUS-guided procedures, after consideration of a multidisciplinary team with endoscopists, surgeons, and radiologists. However, what is crucial is establishing the right timing for surgery.
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Affiliation(s)
- Andrada Seicean
- Regional Institute of Gastroenterology and Hepatology Cluj-Napoca, University of Medicine and Pharmacy “Iuliu Hatieganu”, Cluj-Napoca, Romania
| | - Simona Vultur
- Regional Institute of Gastroenterology and Hepatology Cluj-Napoca, University of Medicine and Pharmacy “Iuliu Hatieganu”, Cluj-Napoca, Romania
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