ERCP with per-oral pancreatoscopy-guided laser lithotripsy for calcific chronic pancreatitis: a multicenter U.S. experience

Use of pancreatic endotherapy in patients with chronic pancreatitis: results from a multicenter cohort study in the United States

BACKGROUND AND AIMS

Although pancreatic endotherapy (PET) is commonly used for treating adverse events of chronic pancreatitis, data on the frequency and factors associated with the use of PET are limited. Our aim was to define the use of and factors predictive for receiving PET in a well-characterized chronic pancreatitis cohort.

METHODS

This is a cross-sectional analysis of data from PROCEED, a multicenter U.S. cohort study of chronic pancreatitis. PET modalities primarily consisted of ERCP. A treatment course was defined as the number of sessions performed for a specific indication. A repeat course was defined as PET >1 year after completion of the last course. Multivariable logistic regression identified predictive factors for receiving PET, and proportional rates model assessed risk factors for repeat PET.

RESULTS

Of 681 subjects, 238 (34.9%) received PET. Factors associated with receiving PET included female sex (odds ratio [OR], 1.26; 95% confidence interval [CI], 1.03-1.53), lower education (OR, 1.30; 95% CI, 1.04-1.62), income ≤$50,000 per year (OR, 1.35; 95% CI, 1.07-1.71), and prior acute pancreatitis (OR, 1.74; 95% CI, 1.31-2.32). Of 238 subjects, 103 (43.3%) underwent repeat PET at a median duration of 2 years, with 23.1% receiving 2 courses, 9.7% receiving 3 courses, and 10.4% receiving ≥4 courses.

CONCLUSIONS

Nearly half of patients with chronic pancreatitis who undergo PET received 1 or more repeat courses within 2 to 3 years. In addition to a prior history of acute pancreatitis, demographic and socioeconomic factors were associated with receiving PET.

Endoscopic Retrograde Cholangiopancreatography for Management of Chronic Pancreatitis

Management of symptomatic chronic pancreatitis (CP) has shifted its approach from surgical procedures to minimally invasive endoscopic procedures. Increased experience and advanced technology have led to the use of endoscopic retrograde cholangiopancreatography (ERCP) as a therapeutic tool to provide pain relief and treat CP complications including pancreatic stones, strictures, and distal biliary strictures, pseudocysts, and pancreatic duct fistulas. In this article the authors will discuss the use of ERCP for the management of CP, its complications, recent advancements, and techniques from the most up to date literature available.

Pancreatoscopy-Guided Endotherapies for Pancreatic Diseases

Per-oral pancreatoscopy (POP) is a pancreas-preserving modality that allows for targeted pancreatic duct interventions, particularly in cases where standard techniques fail. POP specifically has an emerging role in the diagnosis, risk stratification, and disease extent determination of main duct intraductal papillary mucinous neoplasms (IPMNs). It has also been successfully used for laser ablation of IPMNs in poor surgical candidates, lithotripsy for complex stone disease, and laser stricturoplasty. As experience with POP increases beyond select referral center practices, further studies validating POP efficacy with long-term follow-up will help clarify when POP-guided intervention is most beneficial in relation to surgical intervention.

Peroral Pancreatoscopy-Guided Lithotripsy Compared with Extracorporeal Shock Wave Lithotripsy in the Management of Pancreatic Duct Stones in Chronic Pancreatitis: A Multicenter Retrospective Cohort Study

BACKGROUND

Extracorporeal shock wave lithotripsy (ESWL) is a common treatment for pancreatic stones in chronic pancreatitis. In contrast, peroral pancreatoscopy-guided lithotripsy (POPS-L) remains underexplored, with limited comparative studies to ESWL. This study compared the treatment outcomes of disposable POPS-L tools and ESWL for pancreatic stones.

METHODS

A retrospective analysis was conducted on 66 patients who had undergone pancreatic stone treatment at three institutions between 2006 and 2022. The treatment outcomes of POPS-L and ESWL were compared.

RESULTS

This study included 19 and 47 patients who had undergone POPS-L and ESWL, respectively. In a comparison between POPS-L and ESWL, the stone clearance rates were 78.9% vs. 70.2% (p = 0.55), while the procedure-related complication rates were 21% vs. 6.3% (p = 0.09). The median total session counts were 1 vs. 5 (p < 0.01). The cumulative stone recurrence rates were comparable in both groups. Multivariate analysis revealed no significant factors influencing the stone clearance rates, and the choice between POPS-L and ESWL did not affect the stone clearance rates.

CONCLUSIONS

POPS-L and ESWL exhibited comparable treatment outcomes in terms of stone clearance, complications, and recurrence rates. Furthermore, POPS-L is advantageous due to the need for fewer sessions to achieve pancreatic stone clearance.

Predictive Factors Correlated with Successful Early Endoscopic Removal of Pancreaticolithiasis in Chronic Pancreatitis after Extracorporeal Shock Wave Lithotripsy

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.

Per-oral pancreatoscopy-guided lithotripsy vs. extracorporeal shock wave lithotripsy for treating refractory main pancreatic duct stones in chronic pancreatitis: Protocol for an open-label multi-center randomized clinical trial

BACKGROUNDS/OBJECTIVES

Patients with chronic pancreatitis may develop pancreatic duct stones that can obstruct outflow leading to ductal hypertension and pain. Both endoscopic retrograde pancreatography (ERP) with per-oral pancreatoscopy (POP) and intraductal lithotripsy and extracorporeal shock wave lithotripsy (ESWL) are feasible options to attempt ductal stone clearance. This study aims to compare POP-guided lithotripsy with ESWL in the management of refractory symptomatic main pancreatic duct stones.

METHODS

This is an open-label, multi-center, parallel, randomized clinical trial. Patients with chronic pancreatitis and main pancreatic duct stones ≥5 mm who fail standard ERP methods for stone removal will be eligible for this study. In total, 150 subjects will be randomized 1:1 to either ESWL or POP. A maximum of 4 sessions of either ESWL or POP will be allowed in each arm, with crossover permitted thereafter. The primary outcome is complete stone clearance and secondary outcomes include quality of life, pain scores, number of interventions, and daily opiate requirements.

CONCLUSIONS

This study aims to answer the question of which lithotripsy method is superior in removing refractory pancreatic duct stones while addressing the effects of lithotripsy on quality of life and pain in patients with chronic calcific pancreatitis (ClinicalTrials.gov NCT04115826).

Open-source algorithm and software for computed tomography-based virtual pancreatoscopy and other applications

Pancreatoscopy plays a significant role in the diagnosis and treatment of pancreatic diseases. However, the risk of pancreatoscopy is remarkably greater than that of other endoscopic procedures, such as gastroscopy and bronchoscopy, owing to its severe invasiveness. In comparison, virtual pancreatoscopy (VP) has shown notable advantages. However, because of the low resolution of current computed tomography (CT) technology and the small diameter of the pancreatic duct, VP has limited clinical use. In this study, an optimal path algorithm and super-resolution technique are investigated for the development of an open-source software platform for VP based on 3D Slicer. The proposed segmentation of the pancreatic duct from the abdominal CT images reached an average Dice coefficient of 0.85 with a standard deviation of 0.04. Owing to the excellent segmentation performance, a fly-through visualization of both the inside and outside of the duct was successfully reconstructed, thereby demonstrating the feasibility of VP. In addition, a quantitative analysis of the wall thickness and topology of the duct provides more insight into pancreatic diseases than a fly-through visualization. The entire VP system developed in this study is available at https://github.com/gaoyi/VirtualEndoscopy.git.

Pancreatic Stones and Extracorporeal Shockwave Lithotripsy: A Review of the Literature

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.

Pancreatoscopy-guided electrohydraulic lithotripsy for the treatment of obstructive pancreatic duct stones: a prospective consecutive case series

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.).

Endoscopic management of chronic pancreatitis

Chronic pancreatitis (CP) is an inflammatory process characterized by irreversible morphological changes in the pancreas. Pain is the predominant symptom observed during the course of CP. The etiopathogenesis of pain in CP is multifactorial and includes ductal hypertension due to obstruction of the pancreatic duct (PD), neuropathic causes, and extrapancreatic complications of CP like pseudocyst and distal biliary obstruction. A sizeable proportion of patients with CP are amenable to endoscopic treatment. The mainstay of endotherapy includes decompression of PD with one or more plastic stents in those with stricture, and fragmentation of PD calculi using extracorporeal shock wave lithotripsy. Nearly two-thirds of the patients achieve pain relief in the long term with endotherapy. Upfront assessment for the suitability of endotherapy is paramount to achieve the best outcomes. The predictors of poor response to endotherapy include multifocal disease, like those with multifocal strictures or multiple calculi throughout the pancreas, or a combination of both PD strictures and stones. With the emerging use of covered metal stents, the outcomes are likely to improve in cases with refractory PD strictures as well as CP-related distal biliary obstruction. The optimum stent design and indwell time of metal stents in cases with refractory PD strictures need further evaluation. Endoscopic ultrasonography has emerged as a complementary endoscopic modality in the management of CP as well as associated complications like pseudocysts, refractory pain, and vascular complications.

Per-oral pancreatoscopy-guided lithotripsy for the endoscopic management of pancreatolithiasis: A systematic review and meta-analysis

OBJECTIVE

Pancreatic stones result from chronic pancreatitis and can occur in the main pancreatic duct, pancreatic branches or parenchyma. Although extracorporeal shock wave lithotripsy (ESWL) is considered the first-line treatment, per-oral pancreatoscopy (POP) has emerged as a useful method for treating pancreatic stones. The aim of this systematic review and meta-analysis was to determine the efficacy and safety of POP-guided lithotripsy, electrohydraulic lithotripsy (EHL) and laser lithotripsy (LL), in patients with pancreatolithiasis.

METHODS

Literature review was conducted in PubMed, OVID, MEDLINE and Cochrane Library databases for studies published up to August 2020.

RESULTS

Altogether 15 studies were analyzed, of which 11 were retrospective and four were prospective. The studies comprised 370 patients, of whom 66.4% were male. The patients underwent 218 EHL and 155 LL. The pooled technical and clinical success rate of the overall POP was 88.1% and 87.1%. For EHL-POP, the pooled technical success rate was 90.9% (95% CI 87.2%-95.2%) and the pooled clinical success rate was 89.8% (95% CI 87.2%-95.2%). While for LL-POP, the pooled technical and clinical success rate was 88.4% (95% CI 85.9%-95.1%) and 85.8% (95% CI 80.6%-91.6%). In total 43 adverse events occurred (12.1%; 95% CI 8.7%-15.5%).

CONCLUSION

POP-guided lithotripsy has a high rate of technical and clinical success for managing pancreatolithiasis with a low complication rate. Both EHL-POP and LL-POP achieve similar efficacy in the endoscopic therapy of pancreatolithiasis. Further large randomized controlled trials are needed to compare EHL-POP and LL-POP with ESWL and evaluate whether POP may replace ESWL as the first-line management of pancreatolithiasis.

Long-term outcome of endotherapy for pancreatic stones by using a dedicated pancreatic basket catheter

BACKGROUND AND AIM

Although endotherapy for pancreatic stones is less invasive compared with surgical interventions, its recurrence rate is high and residual pancreatic stones can be a cause of recurrence. We previously reported usefulness of a novel basket catheter with nitinol fine reticular structure for pancreatic stone retraction. In this retrospective study, we aimed to evaluate the long-term outcomes of endotherapy for pancreatic stones with and without the use of this dedicated basket catheter.

METHODS

We retrospectively compared patients with symptomatic pancreatic stones who underwent the initial endotherapy between 2008 and 2019. The primary outcome was the symptomatic recurrence after complete stone clearance. Secondary outcomes were the rate of complete stone clearance, complications, risk factors for recurrences, and the treatment cost.

RESULTS

A total of 101 patients who underwent endotherapy for pancreatic stones were analyzed: 41 patients by using the dedicated basket catheter and 60 patients by only the conventional devices. The complete stone clearance was achieved in 87.8% in the dedicated basket group and 88.3% in the conventional device group. Symptomatic recurrence was observed in 16.7% of the dedicated basket group and 47.2% of the conventional device group (P < 0.01). In the multivariate analysis, the use of the dedicated basket catheter was significantly associated with the reduced risk of symptomatic recurrence (hazard ratio, 0.40; 95% confidence interval, 0.15-0.92, P = 0.031). The complication rate and the cost were comparable between the two groups.

CONCLUSION

The use of this dedicated pancreatic basket catheter significantly reduced symptomatic recurrence after complete pancreatic stone removal.

Adverse Events Associated With Therapeutic Endoscopic Retrograde Pancreatography

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.

Incidence and Significance of Biliary Stricture in Chronic Pancreatitis Patients Undergoing Extracorporeal Shock Wave Lithotripsy for Obstructing Pancreatic Duct Stones

Background/Aims

This study assessed the significance of biliary stricture in symptomatic chronic pancreatitis patients requiring extracorporeal shock wave lithotripsy (ESWL) and endoscopic retrograde cholangiopancreatography (ERCP) to remove obstructing pancreatic calculi.

Methods

A total of 97 patients underwent ESWL followed by ERCP to remove pancreatic calculi between October 2014 and October 2017 at Virginia Mason Medical Center. Significant biliary stricture (SBS) was defined as a stricture with upstream dilation on computed tomography scan or magnetic resonance cholangiopancreatography scans accompanied by cholestasis and/or cholangitis. SBS was initially managed by either a plastic stent or fully covered self-expandable metallic stent (fcSEMS). If the stricture did not resolve, the stent was replaced with either multiple plastic stents or another fcSEMS. Data were collected by retrospectively reviewing the medical records.

Results

Biliary strictures were noted in approximately one-third of patients (34/97, 35%) undergoing ESWL for pancreatic calculi. Approximately one-third of the biliary strictures (11/34, 32%) were SBS. Pseudocysts were more frequently found in those with SBS (36% vs 8%, p=0.02), and all pseudocysts in the SBS group were located in the pancreatic head. The initial stricture resolution rates with fcSEMSs and plastic prostheses were 75% and 29%, respectively. The overall success rate for stricture resolution was 73% (8/11), and the recurrence rate after initial stricture resolution was 25% (2/8).

Conclusions

Although periductal fibrosis is the main mechanism underlying biliary stricture development in chronic pancreatitis, inflammation induced by obstructing pancreatic calculi, including pseudocysts, is an important contributing factor to SBS formation during the acute phase.

Per-oral pancreatoscopy with intraductal lithotripsy for difficult pancreatic duct stones: a systematic review and meta-analysis

Background and study aims  Per-oral pancreatoscopy (POP) with intraductal lithotripsy via electrohydraulic lithotripsy (EHL) or laser lithotripsy (LL) facilitates optically-guided stone fragmentation of difficult pancreatic stones refractory to conventional endoscopic therapy. The aim of this study was to perform a systematic review and meta-analysis to evaluate the efficacy and safety of POP with intraductal lithotripsy for difficult pancreatic duct stones. Methods  Individualized search strategies were developed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Meta-analysis of Observational Studies in Epidemiology guidelines. This was a cumulative meta-analysis performed by calculating pooled proportions with rates estimated using random effects models. Measured outcomes included pooled technical success, complete or partial stone fragmentation success, complete duct clearance after initial lithotripsy session, and adverse events (AEs). Results  Ten studies (n = 302 patients; 67.72 % male; mean age 55.10 ± 3.22 years) were included with mean stone size of 10.66 ± 2.19 mm. The most common stone location was in the pancreatic head (66.17 %). Pooled technical success was 91.18 % with an overall fragmentation success of 85.77 %. Single lithotripsy session stone fragmentation and pancreatic duct clearance occurred in 62.05 % of cases. Overall, adverse events were reported in 14.09 % of patients with post-procedure pancreatitis developing in 8.73 %. Of these adverse events, 4.84 % were classified as serious. Comparing POP-EHL vs POP-LL, there was no significant difference in technical success, fragmentation success, single session duct clearance, or AEs ( P  > 0.0500). Conclusions  Based on this systematic review and meta-analysis, POP with intraductal lithotripsy appears to be an effective and relatively safe procedure for patients with difficult to remove pancreatic duct stones.

Do available data support the widespread adoption of pancreatoscopy guided-lithotripsy?

Peroral pancreatoscopy (POPS) is a demanding endoscopic procedure that can be used to perform intracanal lithotripsy in obstructing pancreatic stones but the experience is limited. Most stones can be removed successfully by endoscopic retrograde cholangio-pancreatography but patients with large stones require advanced therapeutic approaches, such as extracorporeal shock wave lithotripsy (alone or followed by endoscopic retrograde cholangio-pancreatography), currently the mainstay of treatment. Unfortunately, in about 10% of cases, extracorporeal shock wave lithotripsy can fail; moreover, it is not be available in many institutions. For this subgroup of patients, POPS guided-lithotripsy can play a role and have benefits. The most consistent study concerns a retrospective multicenter analysis that enrolled few patients per center. Considering the epidemiological scenario and the scant volume of skilled endoscopists, POPS must be developed in very few high-volume referral centers with standardized pathways and capable of performing multi-modality treatment. In addition, we could reasonably assume that POPS-guided-lithotripsy should be used as rescue therapy in special situations, identifying the ideal candidate who can achieve the maximum clinical result, and carefully balancing risk/benefits ratio.

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

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.

Cholangiopancreatoscopy-guided laser dissection and ablation for pancreas and biliary strictures and neoplasia

Background and study aims  Cholangiopancreatoscopy-guided laser dissection or ablation (CPL) is a novel therapeutic modality for refractory benign strictures. Our aim was to describe the safety and efficacy of CPL for pancreaticobiliary disorders. Patients and methods  Patients who underwent CPL using holmium or thulium laser between February 2017 and September 2019 were included. For stricture dissection, gentle strokes of the laser fiber from a distal to proximal approach were applied until luminal patency permitted advancement of the cholangiopancreatoscope. Immediate technical success was defined as ability to traverse the stricture with the cholangiopancreatoscope after CPL. Short-term technical success was defined as > 90 % resolution of the stricture on follow-up pancreatogram. Results  Eleven patients underwent a mean of 3.6 ERCPs (mean total diameter of 14.2 Fr of stenting) prior to CPL. Indications included pancreatic duct stricture (n = 8), pancreaticojejunostomy anastomotic stricture (n = 1), bile duct stricture (n = 1) and pancreatic intraductal papillary mucinous neoplasm ablation (n = 1). Immediate technical success was 94.1 % and short-term technical success rates was 88.2 %. At a mean follow-up of 12.1 months, there have been no stricture recurrences. Conclusions  CPL may be an effective therapy for strictures refractory to conventional dilation and multiple stenting.

Endoscopic intervention in pancreatitis: perspectives from a gastroenterologist

The last decade has seen a dramatic paradigm shift for the treatment of pancreatitis and its related complications away from surgery to minimally invasive endoscopic approaches. In this review, we provide an overview of the indications, techniques and outcomes of endoscopic interventions in the management of acute and chronic pancreatitis. Emphasis is placed on drainage of pancreatic pseudocysts and treatment of pain in chronic pancreatitis.

The Expansion of Cholangioscopy: Established and Investigational Uses of SpyGlass in Biliary and Pancreatic Disorders

Direct visualization of bile and pancreatic duct pathology is proving to be beneficial in patients where previous techniques have failed. Recent advancements in technology and the development of the SpyGlass system have led to an increased use of cholangioscopy. It is already known that SpyGlass is beneficial in patients with difficult bile duct stones and indeterminate biliary lesions through the use of targeted lithotripsy and visually guided biopsy. Cholangioscopy allows the visualization of hidden stone and guide wire placement across difficult strictures and selective cannulation of the intrahepatic and cystic ducts. It is also demonstrating its utility in investigational applications such as post-liver transplant and primary sclerosing cholangitis stricture treatment, evaluation of hemobilia, and guided radiofrequency ablation of ductal tumors. In addition to having clinical utility, cholangioscopy may also be cost-effective by limiting the number of repeat procedures. Cholangioscopy overall has similar complication rates compared to other standard endoscopic retrograde cholangioscopy (ERCP) techniques, but there may be higher rates of cholangitis. This could be mitigated with prophylactic antibiotic use, and overall, cholangioscopy has similar complication rates compared to other techniques.

ESWL for large pancreatic calculi: Report of over 5000 patients

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.

Low Serum Trypsin Levels Predict Deep Pancreatic Cannulation Failure During Endoscopic Retrograde Cholangiopancreatography in Patients With Symptomatic Obstructive Chronic Pancreatitis

OBJECTIVES

Deep pancreatic cannulation (DPC) failure during endoscopic retrograde cholangiopancreatography (ERCP) in patients with chronic pancreatitis (CP) can occur in the presence of ductal obstruction due to strictures and/or stones. There are currently no simple preprocedure clinical or laboratory tests that can predict DPC failure during ERCP.

METHODS

All adult patients with definite CP by M-ANNHEIM criteria referred to the pancreatitis clinic between 2010 and 2017 were evaluated. Serum trypsin levels were obtained to assess the morphologic severity of disease and/or exocrine insufficiency. Univariable and multivariable logistic regression analyses were performed to identify factors associated with DPC failure.

RESULTS

There were 346 patients, of whom 100 underwent trypsin measurements and ERCP for symptomatic CP. Deep pancreatic cannulation failure occurred in 32 (32%). There were no significant differences with regard to age, sex, etiology, smoking, and alcohol use. Deep pancreatic cannulation failure was more likely to occur in patients with low trypsin levels (53.1% vs 25%, P = 0.007) compared with those with successful DPC. Low trypsin levels were independently associated with DPC failure in adjusted analysis (odds ratio, 3.7; 95% confidence interval, 1.2-11; P = 0.02).

CONCLUSIONS

Low serum trypsin levels independently predict DPC failure during ERCP in patients with symptomatic obstructive CP.

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

Background and study aims The role of the digital single-operator pancreatoscopy (D-SOP) with electrohydraulic (EHL) or laser lithotripsy (LL) in treating pancreatic ductal stones is unclear. We investigated the safety and efficacy of D-SOP with EHL or LL in patients with obstructing pancreatic duct stones.

Patients and methods Retrospective analysis of 109 patients who underwent D-SOP for pancreatic stones at 17 tertiary centers in the United States and Europe from February 2015 to September 2017. Logistic regression was performed to identify factors associated with the need for more than one D-SOP with EHL/LL.

Results Most patients were males (70.6 %),mean age 54.7 years. Fifty-nine (54.1 %) underwent EHL and 50 (45.9 %) underwent LL. Mean procedure time was longer in the EHL group (74.4 min vs 53.8 min; P < 0.001). Ducts were completely cleared (technical success) in 89.9 % of patients (94.1 % in EHL vs 100 % in LL; P = 0.243), achieved in a single session in 73.5 % of patients (77.1 % by EHL and 70 % by LL; P= 0.5).D-SOP failed in 11 patients (10.1 %); 6 patients were treated with extracorporeal shockwave lithotripsy (ESWL), 1 with surgery,1 with combined treatment (ESWL + D-SOP EHL) and 3 with other. Fourteen adverse events occurred in 11 patients (10.1 %). Patients with more than three ductal stones were more likely to have technical failure compared to those with less than three stones (17 % vs. 4.8 %; P = 0.04). Having more than three stones was independently associated with the need for more than one D-SOC EHL/LL session (OR 2.94, 95 % CI 1.13 – 7.65).

Conclusion D-SOP with EHL or LL is effective and safe in patients with pancreatic ductal stones.

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

BACKGROUND

Recently, a digital single-operator cholangiopancreatoscope (DSOC) has become available. This system allows the performance of electrohydraulic lithotripsy (EHL) even within the main pancreatic duct (MPD). However, there are only few reports of EHL for MPD stones using SPY-DS.

AIMS

The aim of this study was to evaluate the technical feasibility and efficacy of EHL for MPD stones under DSOC guidance.

METHODS

Between October 2016 and August 2017, patients with MPD stones were retrospectively enrolled in this study. The presence of MPD stones was diagnosed by endoscopic ultrasound and MRCP. The patients' baseline characteristics and those of the stones, including their size, number, and site in the MPD, number of EHL procedures, and adverse events, were reviewed.

RESULTS

A total of 21 patients were retrospectively enrolled. The etiologies of chronic pancreatitis were idiopathic (n = 4) and alcohol induced (n = 17). The pancreatic stone was variously located in the head (n = 6), body (n = 11), tail (n = 1), head and body (n = 2), and body and tail (n = 1) of the pancreas. Median pancreatic stone size was 12 mm, and the mean number of ERCP sessions was 1.29 (range 1-3). EHL was successfully performed in 15 patients (85.7%, 18/21), and the rate of complete stone clearance was 88.2% (18/21). Severe adverse events were not seen in any of the patients, although one patient developed mild acute pancreatitis.

CONCLUSIONS

In conclusion, although additional case reports and prospective studies are needed, EHL under DSOC may be an option to treat MPD stones.

A Comparison of Endoscopic Retrograde Pancreatography With or Without Pancreatoscopy for Removal of Pancreatic Duct Stones

OBJECTIVES

Pancreatic duct stones contribute to pain in patients with chronic pancreatitis, and per-oral pancreatoscopy (POP) allows visualization, fragmentation, and removal of these stones. This study compared the safety and efficacy of endoscopic retrograde pancreatography (ERP) with and without POP.

METHODS

This single-center retrospective review compared ERP with and without POP for treatment of main-duct pancreatic duct stones. The primary outcome was technical success, defined as partial or complete stone removal, which was compared between the 2 groups.

RESULTS

In all, 223 patients underwent 549 ERPs with a technical success rate of 92.4% and complete stone clearance rate of 74.9%. Patients undergoing ERP with POP (n = 94) had higher technical success than patients undergoing ERP without POP (n = 129, 98.9% vs 87.6%, P < 0.001), but required more ERPs (3.1 vs 1.9, P = 0.02). Endoscopic retrograde pancreatography with POP was associated with larger stone size (8.9 vs 6.1 mm, P = 0.001), more stones per case (5+ stones: 33.8% vs 21.1%, P = 0.002), and more impacted stones (48.8% vs 10.3%, P < 0.001).

CONCLUSIONS

Per-oral pancreatoscopy-guided lithotripsy permits effective stone removal in cases not amenable to standard ERP techniques, including those with larger or more numerous stones.

Recent advances in the diagnosis and management of chronic pancreatitis

Chronic pancreatitis is a chronic condition characterized by pancreatic inflammation that causes fibrosis and the destruction of exocrine and endocrine tissues. Chronic pancreatitis is a progressive disease, and no physiological treatment is available to reverse its course. However, with advances in medical technology, the existing diagnostic and treatment methods for chronic pancreatitis are evolving. Managing patients with chronic pancreatitis is challenging and necessitates a multidisciplinary approach. In this review, we discuss the recent advances in the diagnosis and management of chronic pancreatitis and introduce future alternative modalities.

Role of pancreatoscopy in management of pancreatic disease: A systematic review

BACKGROUND

Per-oral pancreatoscopy (POP) plays a role in the diagnosis and therapy of pancreatic diseases. With recent technological advances, there has been renewed interest in this modality.

AIM

To evaluate the efficacy and safety of POP in management of pancreatic stone disease and pancreatic ductal neoplasia.

METHODS

To determine the safety and efficacy of POP in the management of pancreatic diseases, a systematic search was conducted in MEDLINE, EMBASE and Ovid. Articles in languages other than English and case reports were excluded. All published case series were eligible. Data specific to POP were extracted from studies, which combined cholangiopancreatoscopy. Ten studies were included in the analysis of POP therapy for pancreatic stone disease, and 15 case series satisfied the criteria for inclusion for the role of POP in the management of pancreatic ductal neoplasia. The examined data were subcategorized according to adjunctive modalities, such as direct tissue sampling, cytology, the role of intraoperative POP, intraductal ultrasound (IDUS) and POP combined with image-enhancing technology.

RESULTS

The success rate for complete ductal stone clearance ranged from 37.5%-100%. Factors associated with failure included the presence of strictures, multiple stones and the inability to visualize the target area. Although direct visualization can identify malignant and premalignant conditions, there is significant overlap with benign diseases. Visually-directed biopsies provide a high degree of accuracy, and represent a unique approach for tissue acquisition in patients with ductal abnormalities. Addition of pancreatic fluid cytology increases diagnostic yield for indeterminate lesions. Protrusions larger than 3 mm noted on IDUS are significantly more likely to be associated with malignancy. The rate of adverse events associated with POP ranged from 0%-35%.

CONCLUSION

Current evidence supports wider adoption of pancreatoscopy, as it is safe and effective. Improved patient selection and utilization of novel technologies may further enhance its role in managing pancreatic disease.

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

BACKGROUND AND AIMS

Per-oral pancreatoscopy (POP) permits direct evaluation of the pancreatic duct for the visualization and sampling of neoplastic lesions and treatment of pancreatic duct stones by using intraductal lithotripsy techniques. Pancreatic laser endotherapy of mucosa has been described in animal models for tumor ablation, but human experience is lacking. We describe 3 unique and challenging clinical situations that benefited from pancreatic laser dissection and ablation.

CASE DESCRIPTION

Case 1 was a 75-year-old woman with presumed divisum-associated chronic pancreatitis who had recurrent acute pancreatitis despite minor papilla sphincterotomy and therapeutic stent placement. POP showed a side-branch intraductal papillary mucinous neoplasm within the neck of the pancreas. POP-guided holmium laser ablation of neoplastic tissue was performed, followed by pancreatic stent placement every 6 months, with no further hospitalizations at 20 months of follow-up. Case 2 was a 69-year-old woman with divisum-associated chronic calcific pancreatitis and recalcitrant mid-body stenosis. Previous attempts at balloon dilation and stent placement failed to resolve the stenosis. POP-guided holmium laser dissection of the stenosis was pursued, with immediate radiographic resolution. Case 3 was a 65-year-old woman with chronic calcific pancreatitis and a large stone burden who underwent POP-guided electrohydraulic lithotripsy and partial stone extraction followed by stent placement. Unfortunately, the stent fractured during the subsequent removal attempt because the fragment was impacted in the pancreatic body. POP-guided laser dissection and lithotripsy were used to debulk dense fibrous tissue and stones surrounding the stent fragment, respectively, followed by removal.

CONCLUSIONS

Pancreatoscopy-guided laser endotherapy is a novel and potentially useful technique to manage difficult benign and neoplastic pancreatic disorders.

SpyGlass DS-guided lithotripsy for pancreatic duct stones in symptomatic treatment-refractory chronic calcifying pancreatitis

Background and study aims  Endoscopic retrograde cholangiopancreatography (ERCP) and/or extracorporeal shock wave lithotripsy are first-line therapies for draining an obstructed pancreatic duct (PD) in painful chronic calcifying pancreatitis (CCP). Pancreaticoscopy has shown promising success rates in small series. Materials and methods  This study was a retrospective analysis of a clinical database. Included were all digital single-operator digital video (SOV) pancreaticoscopy-guided interventions (n = 23) on CCP patients (n = 20) between 2015 and 2017. Success and complication rates were collected from the database. Clinical success was determined by assessing pain level score (NRS) and quality of life (QoL) using standardized questionnaires. Results  Overall technical success rate (successful SOV-pancreaticoscopy and PD drainage) was 95 %. Adverse events occurred in 7 of 23 procedures (30 %) and included extravasation from the PD (n = 1), self-limiting post-sphincterotomy bleeding (n = 1) and post-ERCP pancreatitis (PEP) (n = 6). At 3- to 6-month follow-up, 95 % of patients reported improvement in symptoms and reduction in intake of analgesics. Mean NRS decreased from 5.4 (±1.6) to 2.8 (± 1.8) ( P  < 0.01). Clinical success was achieved in 95 % of patients. Conclusions  Digital SOV-guided lithotripsy was found to be safe and effective in this highly selected population of CCP patients. PD decompression had a beneficial effect on pain reduction and QoL.

Pancreatoscopy: An update

Per-oral pancreatoscopy (POPS) is an endoscopic procedure to visualize the main pancreatic duct. POPS specifically has the advantage of direct visualization of the pancreatic duct, allowing tissue acquisition and directed therapies such as stones lithotripsy. The aim of this review is to analyze and summarize the literature around pancreatoscopy. Pancreatoscopy consists of the classic technique of the mother-baby method in which a mini-endoscope is passed through the accessory channel of the therapeutic duodenoscope. Pancreatoscopy has two primary indications for diagnostic purpose. First, it is used for visualization and histological diagnosis of intraductal papillary mucinous neoplasms. In these cases, POPS is very useful to assess the extent of malignancy and for the study of the intraductal papillary mucinous neoplasm in order to guide the surgery resection margins. Second, it is used to determine pancreatic duct strictures, particularly important in cases of chronic pancreatitis, which is associated with both benign and malignant strictures. Therefore POPS allows differentiation between benign and malignant disease and allows mapping the extent of the tumor prior to surgical resection. Also tissue sampling is possible, but it can be technically difficult because of the limited maneuverability of the biopsy forceps in the pancreatic ducts. Pancreatoscopy can also be used for therapeutic purposes, such as pancreatoscopy-guided lithotripsy in chronic painful pancreatitis with pancreatic duct stones. The available data for the moment suggests that, in selected patients, pancreatoscopy has an important and promising role to play in the diagnosis of indeterminate pancreatic duct strictures and the mapping of main pancreatic duct intraductal papillary mucinous neoplasms. However, further studies are necessary to elucidate and validate the pancreatoscopy role in the therapeutic algorithm of chronic pancreatitis.

Safety and efficacy of SpyGlass cholangiopancreatoscopy in routine clinical practice in a regional Singapore hospital

INTRODUCTION

This study examined the efficacy and safety of cholangiopancreatoscopy via the SpyGlass™ system in routine clinical practice.

METHODS

The clinical data of endoscopic retrograde cholangiopancreatography (ERCP) performed in a regional hospital from January 2013 to November 2016 was retrieved from an electronic database and reviewed. All patients who had undergone SpyGlass cholangiopancreatoscopy were enrolled. Patient demographics, procedure indication, technical success rates, clinical success rates and complication rates were analysed. A subanalysis of clinical outcomes was performed comparing the SpyGlass legacy (fibreoptic) and digital systems.

RESULTS

Out of 2,050 ERCP procedures performed, 47 patients underwent 50 cholangiopancreatoscopy procedures. Clinical indications were difficult common bile duct (CBD) stones (59.6%, n = 28), indeterminate CBD stricture (36.2%, n = 17), indeterminate pancreatic duct stricture (2.1%, n = 1) and proximally migrated CBD stent (2.1%, n = 1). Complete stone extraction was achieved in 26 (92.9%) out of 28 patients. Among patients with strictures, a correct diagnosis of malignancy based on image visualisation was achieved in all 11 cases. The sensitivity and specificity for SpyBite™ biopsies were 81.8% (95% confidence interval [CI] 48.2%-97.7%) and 100.0% (95% CI 15.8%-100.0%), respectively. The proximally migrated CBD stent was successfully extracted. Complications included pancreatitis (2.1%, n = 1), suspected sealed perforation after laser lithotripsy treated conservatively (2.1%, n = 1) and cholangitis (10.6%, n = 5). There was no difference in clinical outcomes between the SpyGlass legacy (n = 20) and digital (n = 30) systems.

CONCLUSION

SpyGlass cholangiopancreatoscopy is a safe and effective tool in routine clinical practice.

Biliary and pancreatic lithotripsy devices

BACKGROUND AND AIMS

Lithotripsy is a procedure for fragmentation or destruction of stones to facilitate their removal or passage from the biliary or pancreatic ducts. Although most stones may be removed endoscopically using conventional techniques such as endoscopic sphincterotomy in combination with balloon or basket extraction, lithotripsy may be required for clearance of large, impacted, or irregularly shaped stones. Several modalities have been described, including intracorporeal techniques such as mechanical lithotripsy (ML), electrohydraulic lithotripsy (EHL), and laser lithotripsy, as well as extracorporeal shock-wave lithotripsy (ESWL).

METHODS

In this document, we review devices and methods for biliary and pancreatic lithotripsy and the evidence regarding efficacy, safety, and financial considerations.

RESULTS

Although many difficult stones can be safely removed using ML, endoscopic papillary balloon dilation (EPBD) has emerged as an alternative that may lessen the need for ML and also reduce the rate of adverse events. EHL and laser lithotripsy are effective at ductal clearance when conventional techniques are unsuccessful, although they usually require direct visualization of the stone by the use of cholangiopancreatoscopy and are often limited to referral centers. ESWL is effective but often requires coordination with urologists and the placement of stents or drains with subsequent procedures for extracting stone fragments and, thus, may be associated with increased costs.

CONCLUSIONS

Several lithotripsy techniques have been described that vary with respect to ease of use, generalizability, and cost. Overall, lithotripsy is a safe and effective treatment for difficult biliary and pancreatic duct stones.

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

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).

Current role of endoscopic pancreatoscopy

PURPOSE OF REVIEW

To provide an overview of the field of pancreatoscopy and to summarize the data informing its clinical utility.

RECENT FINDINGS

Regarding the technological advance of pancreatoscopy, recent studies are the first to report the use of digital, single-operator pancreatoscopy (SpyGlass DS; Boston Scientific, Natick, MA). New data on the use of preoperative pancreatoscopy offer promising results for the potential to optimize treatment of intraductal papillary mucinous neoplasms and to differentiate between benign and malignant pancreatic strictures. Finally, there has been accumulating evidence for the use of pancreatoscopy-guided lithotripsy for the management of painful chronic calcific pancreatitis.

SUMMARY

Endoscopic pancreatoscopy offers the advantage of direct visualization of the pancreatic duct, allowing for optimal macroscopic assessment, targeted tissue acquisition and guided therapies such as lithotripsy of pancreatic duct stones. The data informing some aspects remain limited, but the accumulating literature forms our understanding of the current and future role of pancreatoscopy in the management of pancreatic disease.

Outcomes of Single-Operator Cholangioscopy-Guided Lithotripsy in Patients with Difficult Biliary and Pancreatic Stones

Background and Aims

Endoscopic retrograde cholangiopancreatography is the preferred strategy for the management of biliary and pancreatic duct stones. However, difficult stones occur, and electrohydraulic (EHL) and laser lithotripsy (LL) have emerged as treatment modalities for ductal clearance. Recently, single-operator cholangioscopy was introduced, permitting the routine use of these techniques. We aimed to evaluate the clinical effectiveness of cholangioscopy-guided lithotripsy using LL or EHL in patients with difficult biliary or pancreatic stones.

Methods

This is a prospective clinical study - conducted at two affiliated university hospitals - of 17 consecutive patients with difficult biliary and pancreatic stones who underwent single-operator cholangioscopy-guided lithotripsy using two techniques: holmium laser lithotripsy (HL) or bipolar EHL. We analyzed complete ductal clearance as well as the impact of the location and number of stones on clinical success and evaluated the efficacy of the two techniques used for cholangioscopy-guided lithotripsy and procedural complications.

Results

Twelve patients (70.6%) had stones in the common bile duct/common hepatic duct, 2 patients (17.6%) had a stone in the cystic stump, and 3 patients (17.6%) had stones in the pancreas. Sixteen patients (94.1%) were successfully managed in 1 session, and 1 patient (5.9%) achieved ductal clearance after 3 sessions including EHL, LL, and mechanical lithotripsy. Eleven patients were successfully submitted to HL in 1 session using a single laser fiber. Six patients were treated with EHL: 4 patients achieved ductal clearance in 1 session with a single fiber, 1 patient obtained successful fragmentation in 1 session using two fibers, and 1 patient did not achieve ductal clearance after using two fibers and was successfully treated with a single laser fiber in a subsequent session. Complications were mild and were encountered in 6/17 patients (35.2%), including fever (n = 3), pain (n = 1), and mild pancreatitis (n = 1). Conclusions: Cholangioscopy-guided lithotripsy using LL or EHL in patients with difficult biliary or pancreatic stones is highly effective with transient and minimal complications. There is a clear need to further compare EHL and HL in order to assess their role in the success of cholangioscopy-guided lithotripsy.

Advanced ERCP techniques for the extraction of complex biliary stones: a single referral center's 12-year experience

OBJECTIVES

Advanced ERCP techniques (AETs) for difficult biliary stones include peroral cholangioscopy (POC) with electrohydraulic/laser lithotripsy (EHL/LL), endoscopic papillary large balloon dilation (EPLBD) and mechanical lithotripsy (ML). We assess the efficacy of AETs.

METHODS

A retrospective query for AETs.

PRIMARY OUTCOME

Complete duct clearance. Secondary outcome: Complete duct clearance by technique. Statistical Analysis version 9.3 (SAS Inc., Cary, NC).

RESULTS

From 1/00 to 10/12, 349 patients were identified of which 222 (80% had prior ERCPs) had AETs. 211 with sufficient follow-up underwent 295 ERCPs; 280 of which were AET's. Index AETs: POC with EHL/LL (n = 46/211, 22%), ML (n = 84/211, 40%), EPLBD with mean balloon size of 11.5 ± 1.7 mm (n = 39/211, 18%) and combination AETs (n = 42/211, 20%). Stone characteristics: 76% had ≥1 stone, 81% extrahepatic and 32% had strictures. Number of stones (mean 2.5 and range 1-20) did not differ among groups. EPLBD had higher percentage (95%) of extrahepatic stones (p = .0003). The 'Combination' and 'POC' groups had larger stones (mean 17.7 mm ±6.4 and 16.8 mm ±6.1, respectively; p < .001). Complete clearance: 209/211 (99%) at index AET 167/211 (79%) or after mean of 2.5 ± 0.7 AETs in 42/211 (20%). Partial clearance: 2/211 (1%). Clearance at index AETs was higher with EPLBD (90%, p = .014). Adverse Events: 7/280 (2.5%).

CONCLUSIONS

AETs achieved clearance in 99%. EPLBD had higher clearance at index AET likely owing to higher extrahepatic stones. Larger stones, but not number, were associated with increased combination AETs and total ERCPs.

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

INTRODUCTION

Per-oral pancreatoscopy can be used for both evaluation and treatment of pancreatic duct stones during endoscopic retrograde cholangiopancreatography, evaluating and treating pancreatic duct strictures of indeterminate etiology, and visual inspection and direct biopsy of pancreatic duct mucosa for diagnosis of intraductal papillary mucinous neoplasm (IPMN). We aim to describe the efficacy, safety, and outcomes of pancreatoscopy in a large, multicenter series of patients.

MATERIALS AND METHODS

A multicenter retrospective review was conducted of all patients who underwent per-oral pancreatoscopy at 2 large tertiary-care medical centers. Review of relevant medical records, laboratory data, imaging studies, endoscopic procedure notes, telephone follow-up notes, and progress notes was performed.

RESULTS

Thirty-three patients underwent 41 pancreatoscopy procedures. Indications included: 20 (48.8%) for diagnosis and treatment of pancreatic duct stones, 16 (39%) for investigation of IPMN, and 5 (12.2%) for evaluation of pancreatic duct strictures.In 20 procedures performed for stone disease, complete pancreatic duct clearance was achieved in 17 of 20 (85%) cases. Strictures were successfully dilated in 5 of 5 (100%) procedures. Direct visualization and biopsy demonstrated IPMN in 11 of 11 (100%) cases. Adverse events occurred in 3 of 41 (7.3%) of procedures, all of which were mild.

CONCLUSIONS

In this large series, we demonstrate that in patients with difficult to manage stone disease, strictures and possible malignant ductal pathology, pancreatoscopy is an effective and safe tool that can facilitate both diagnosis and effective therapy. Adverse events in our study were mild and within acceptable limits, further demonstrating that this is a safe procedure that should be offered to appropriate patients.

Chronic pancreatitis

PURPOSE OF REVIEW

Summarize key clinical advances in chronic pancreatitis reported in 2016.

RECENT FINDINGS

Early diagnosis of chronic pancreatitis remains elusive. Recent studies suggest that endoscopic ultrasound may be less accurate than previously thought and new MRI techniques may be helpful. Genetic predisposition may independently affect the clinical course of chronic pancreatitis and the risk for pancreatic cancer. Cigarette smoking may have a greater negative impact on chronic pancreatitis than previously thought and moderate alcohol consumption may be protective. A multidisciplinary approach is necessary for the treatment of type 3 diabetes and nutritional deficiencies in chronic pancreatitis. Although endoscopic therapy remains a reasonable first-line option in treating chronic pancreatitis and its complications, early surgical intervention may be indicated for pain in select patients.

SUMMARY

Newer endoscopic ultrasound and MRI techniques are being evaluated to help with the early diagnosis of chronic pancreatitis. Both genetic predisposition and cigarette smoking are increasingly recognized as having a major impact in the course of the disease and the risk for pancreatic cancer. Endoscopic therapy is well tolerated and effective for the treatment of chronic pancreatitis and its complications although an early surgical approach for pain may be associated with improved clinical outcomes.

Management of Pancreatic Calculi: An Update

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.

Role of per-oral pancreatoscopy in the evaluation of suspected pancreatic duct neoplasia: a 13-year U.S. single-center experience

BACKGROUND AND AIMS

The role of per-oral pancreatoscopy (POP) in the evaluation of occult pancreatic duct (PD) lesions remains limited to case series. The aim of this study was to evaluate the ability of POP to differentiate malignant from benign diseases of the PD.

METHODS

Patients who underwent POP between 2000 and 2013 for the evaluation of indeterminate PD strictures, dilatations, or with suspected or known main duct intraductal papillary mucinous neoplasm were identified. Main outcome measurements were visual impression accuracy, POP tissue sampling, efficacy, and safety of POP.

RESULTS

During the study period, 79 patients who underwent POP for the evaluation of pancreatic stricture or dilatation were identified. Technical success was achieved in 78 (97%). In the PD neoplasia group (n = 33), the final diagnosis was based on index confirmatory POP-guided tissue sampling in 29 (88%). For the detection of PD neoplasia, POP visual impression had a sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 87%, 86%, 83%, 91%, and 87%, respectively. When combined with POP-guided tissue sampling, the values were 91%, 95%, 94%, 93%, and 94%, respectively. Of 102 POPs performed, adverse events were noted in 12 (12%) cases.

CONCLUSIONS

This study demonstrates a high technical success rate, visual impression accuracy, and tissue sampling capability of POP. Examinations were performed by endoscopists with expertise in pancreatoscopy interpretation, and the results may not be generalizable.

Pancreatoscopy-Directed Electrohydraulic Lithotripsy for Pancreatic Ductal Stones in Painful Chronic Pancreatitis Using SpyGlass

OBJECTIVE

Painful chronic pancreatitis is often associated with main duct obstruction due to stones. Approaches to management are challenging, including surgery, extracorporeal shock wave lithotripsy, or endoscopic approaches. Here, we report our experience of pancreatoscopy + electrohydraulic lithotripsy (EHL) for pancreatic duct (PD) stones using SpyGlass.

METHODS

We retrospectively audited the use of SpyGlass (Legacy and DS) + EHL. Indication, procedural details, and clinical outcomes were assessed.

RESULTS

A total of 118 SpyGlass + EHL procedures for stones were performed, of which 8 (7%) for pancreatic stones, in 6 patients (3 female; mean [standard deviation] age, 45 [7] years). All patients had painful chronic pancreatitis, with radiological evidence of a dilated PD, and main duct stone disease. Surgical options had been considered in all cases. Stone fragmentation and PD decompression were achieved in 83% (n = 5) without complications. Two patients required 2 EHL procedures to achieve clearance. In 1 patient with failed clearance, pancreatoscopy revealed a stone in the adjacent parenchyma and not in PD. All patients with successful EHL had pain relief/marked improvement at clinical review (mean [standard deviation] follow-up, 2.7 [1.1] years).

CONCLUSIONS

Pancreatoscopy + EHL may have a valuable role in treating obstructing PD stones, possibly avoiding the need for surgery in some patients.