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

Technical success, clinical efficacy, and safety of endoscopic minor papilla interventions for symptomatic pancreatic diseases

BACKGROUND

Endoscopic minor papilla intervention (EMPI) is an option for diagnosing or treating symptomatic pancreatic diseases in cases with failed pancreatic duct deep cannulation via the major papilla, pancreas divisum with obstruction of the minor papilla, or an abnormal patulous orifice of the minor papilla during endoscopic retrograde cholangiopancreatography (ERCP). However, the relatively low patency and small opening of the minor papillae pose technical challenges.

AIM

To evaluate the technical success, clinical success, stone clearance, and safety profile of EMPI for diagnosis and treatment of symptomatic pancreatic diseases.

METHODS

Patients diagnosed with symptomatic pancreatic diseases and EMPI between February 1996 and February 2023 were included. The primary outcomes were the initial technical success, defined as successful deep cannulation via the minor papilla (DCMP; access of the guidewire to the upstream pancreatic duct via the minor papilla) alone, overall technical success, defined as successful DCMP alone and successful DCMP with additional needle-knife precut minor papillotomy (NKPMP), and immediate clinical success, defined as > 50% improvement in abdominal pain after therapeutic EMPI. Secondary outcomes included long-term clinical success at 1, 3, and 7 years, pancreatic stone clearance, and procedure-related early and late adverse events (AEs).

RESULTS

Overall, 43 patients, 32 with obstructive chronic pancreatitis, 8 with pancreatic divisum, and 3 with intraductal papillary mucinous neoplasm were included. The initial and overall technical success rates were 74.4% (32/43) and 88.4% (38/43), respectively. The immediate clinical success rate was 79.1% (34/43), and the long-term clinical success rates at 1, 3, and 7 years were 74.7%, 55.3%, and 41.5%, respectively, among the 22 patients with a follow-up period of 57.5 (7-266) months. Complete and partial success of pancreatic stone clearance was achieved in 53.9% (7/13) and 15.4% (2/13), respectively. Early AEs included post-ERCP pancreatitis (PEP, n = 5) and self-limiting bleeding (n = 1); surgery therapy was required for 1 case with severe PEP and conservative management for the other 4 with mild PEP. Late AEs included minor papilla stricture (n = 1) after endoscopic minor papillotomy and pancreatic duct stricture (n = 1) after double pancreatic stent placement; no specific treatment was implemented for these events.

CONCLUSION

EMPI is feasible, effective, and safe for symptomatic pancreatic diseases, in terms of the technical and clinical success, stone clearance, and incidence and severity of AEs. NKPMP appears to enhance technical success. However, potential risks of developing PEP and late AEs should be kept in mind.

Current status and future perspectives for endoscopic treatment of local complications in chronic pancreatitis

Chronic pancreatitis is a progressive disease characterized by irregular fibrosis, cellular infiltration, and parenchymal loss within the pancreas. Chronic pancreatitis treatment includes lifestyle modifications based on disease etiology, dietary adjustments appropriate for each stage and condition, drug therapy, endoscopic treatments, and surgical treatments. Although surgical treatments of symptomatic chronic pancreatitis provide good pain relief, endoscopic therapies are recommended as the first-line treatment because they are minimally invasive. In recent years, endoscopic therapy has emerged as an alternative treatment method to surgery for managing local complications in patients with chronic pancreatitis. For pancreatic stone removal, a combination of extracorporeal shock wave lithotripsy and endoscopic extraction is used. For refractory pancreatic duct stones, intracorporeal fragmentation techniques, such as pancreatoscopy-guided electrohydraulic lithotripsy and laser lithotripsy, offer additional options. Interventional endoscopic ultrasound has become the primary treatment modality for pancreatic pseudocysts, except in the absence of disconnected pancreatic duct syndrome. This review focuses on the current status of endoscopic therapies for common local complications of chronic pancreatitis, including updated information in the past few years.

Chronic and Idiopathic Pancreatitis-A Personalized Treatment Approach

Chronic pancreatitis is a fibroinflammatory disease of the pancreas with heterogeneous clinical features and a significant socioeconomic burden. Assessing its aetiology and early diagnosis of associated complications remain challenging. Personalized therapy necessitates precise knowledge of the genetic, biological, and clinical differences within a patient population. In this context, the identification of the underlying aetiology represents an essential cornerstone. This review elucidates current standards for identifying underlying aetiologies and the diagnostic work-up for idiopathic cases. It provides an overview of general therapeutic approaches and highlights individual treatment options. Additionally, the follow-up management of pancreatitis-associated complications, namely exocrine pancreatic insufficiency, post-pancreatitis diabetes mellitus, pain management, pancreatic fluid collections, and pancreatic cancer risk, is summarized.

The impact of pancreatic endotherapy on quality of life in chronic pancreatitis

BACKGROUND AND AIMS

Pancreatic endotherapy (PET) offers a treatment option for adverse events of chronic pancreatitis (CP) such as pancreatic duct (PD) strictures, stones, and pseudocysts. Previous studies have primarily focused on how PET affects pain, so the primary aim of this study was to evaluate the effect of PET on quality of life.

METHODS

This single-center prospective study assessed quality of life before the initiation of endotherapy using a validated CP-specific quality of life instrument. Quality of life, pain levels, and opiate use were also measured at 1, 3, 6, and 12 months' follow-up. PET modalities included therapeutic PD stent placement, PD stone lithotripsy, endoscopic ultrasound (EUS)-guided pseudocyst drainage, and celiac plexus block (EUS-CPB). A repeated-measures mixed effects model was used to compare pre- and post-PET changes in quality of life at each follow-up point.

RESULTS

A total of 120 subjects with CP (mean age 52.3 years, 58.3% female) were included in this study. PET modalities consisted primarily of therapeutic PD stenting (49.2%), EUS-CPB (32.5%), and PD stone lithotripsy (16.7%). Significant improvements in quality of life scores were seen at 1, 3, 6, and 12 months after PET completion, with the greatest improvement seen at 6 months (mean increase of 15.5 points). Significant improvements in pain levels were seen at 1 and 6 months, but not at 12 months. Decrease in opiate use was seen at all follow-up points.

CONCLUSIONS

PET is associated with improvement in quality of life up to 1 year after treatment, but pain improvement was seen only to 6 months, reflecting the complexity of pain management in this difficult patient population. Further studies are needed to predict responders to endotherapy.

Endoscopic Retrograde Cholangiopancreatography: Pancreatic Endoscopy

The evolution of pancreatic endoscopic retrograde cholangiopancreatography (ERCP) has transformed from a diagnostic tool to now a primarily therapeutic modality. Mainly utilized within the spectrum of pancreatitis, pancreatic ERCP can help resolve pancreatic duct (PD) leaks, disruptions, and pancreatic fluid collections. In chronic pancreatitis, ERCP is effective for the treatment of PD strictures and stones with the improvement of pancreatoscopy greatly facilitating targeted therapy. Pancreatoscopy also allows for accurate mapping of main duct intraductal papillary mucinous neoplasms, which can help guide surgical resection.

Long-term clinical outcomes of extracorporeal shockwave lithotripsy and endoscopic retrograde cholangiopancreatography for pancreatic duct stone treatment in patients with chronic pancreatitis

BACKGROUND AND AIMS

Extracorporeal shock wave lithotripsy for pancreatic stones (P-ESWL) and endoscopic retrograde cholangiopancreatography (ERCP) are the preferred therapeutic approaches for painful chronic pancreatitis (CP) with pancreatic stones. This study aimed to report the short- and long-term outcomes following P-ESWL and ERCP in a large cohort with CP.

METHODS

Patients with painful CP and pancreatic stones >5 mm in size, who underwent P-ESWL and subsequent ERCP between March 2011 and June 2018, were included in this retrospective-prospective mixed observational study. The total stone clearance rates were recorded. All patients were followed up until the end of March 2024, with the visual analogue scale (VAS) for pain, pain type, quality-of-life scores and other relevant information recorded.

RESULTS

A total of 2071 patients underwent P-ESWL, and 93.1% of them subsequently underwent ERCP during the study period. Patients were followed up for an average of 11.8 years from the onset of CP and 6.7 years from the first P-ESWL procedure. Complete stone clearance was achieved in 73.7% of the patients. At the end of the follow-up period, 70.1% of the patients achieved complete pain remission. Significant pain type conversion and lower VAS scores were observed in the patients after treatment. Quality-of-life scores and body mass indices increased after P-ESWL and ERCP.

CONCLUSIONS

P-ESWL and ERCP are effective and minimally invasive treatments for pancreatic stones in patients with painful CP. Most patients achieved complete pain relief, and pain-type conversion was common after treatment. (ClinicalTrials.gov: NCT05916547).

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.

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.

Management of chronic pancreatitis: recent advances and future prospects

As a progressive fibroinflammatory disease, chronic pancreatitis (CP) often manifests as recurrent bouts of abdominal pain with or without complications, causing a heavy burden of health care. In recent years, some meaningful insights into the management of CP have been obtained from randomized controlled trials, systematic reviews, and meta-analyses, which were of great importance. Based on this research, it is shown that there are various treatments for CP. Therefore, it is of great importance to choose a suitable strategy for patients with CP individually. Relevant evidence on the management of CP was summarized in this review, including nutrition supplements, medication, endoscopy, surgery, exploration of novel therapies as well as evaluation and prediction of treatment response.

Endotherapy in pediatric pancreatitis

PURPOSE OF REVIEW

Some children with acute recurrent and chronic pancreatitis stand to benefit from therapeutic endoscopic interventions. The purpose of this review is to summarize specific endoscopic therapies used for these conditions and highlight areas of future research.

RECENT FINDINGS

Multicenter collaboration and consortium efforts have provided more data now than ever on the technical outcomes and safety of therapeutic endoscopic procedures for pancreatitis in children. Indications are growing but more research is needed to help guide patient selection.

SUMMARY

Advanced endoscopic procedures including endoscopic retrograde cholangiopancreatography, endoscopic-ultrasound guided therapies, and single-operator pancreatoscopy may be used in patients with acute recurrent or chronic pancreatitis to manage pancreatic duct obstruction or local complications including pseudocysts and walled-off necrosis. Patient and procedural factors differ between adults and children. Access to these procedures for younger children is growing, and technical outcomes and adverse event rates appear similar between adults and children.

Long-term outcomes of pancreatoscopy-guided electrohydraulic lithotripsy for the treatment of obstructive pancreatic duct stones

Background and study aims  Pancreatoscopy-guided electrohydraulic lithotripsy (EHL) has proven to be an effective first-line therapy in symptomatic chronic pancreatitis (CP) patients with obstructing pancreatic duct (PD) stones 1 . However, long-term outcomes of endoscopic EHL remain unknown. The aim of the present study was to evaluate the long-term treatment effects of EHL as first-line therapy and to compare with those obtained in a historical cohort of patients who underwent extracorporeal shockwave lithotripsy (ESWL) as primary treatment.

Patients and methods  An observational retrospective single-center long-term follow-up study was performed including 19 consecutive patients who previously underwent endoscopic EHL compared to 18 patients who underwent ESWL followed by endoscopic retrograde pancreatography (ERP). The primary endpoint was long-term treatment success after EHL or ESWL defined as no recurrence of symptomatic intraductal stones confirmed on imaging. Secondary endpoints for the EHL-population included long-term clinical success (i. e., a similar or lower Izbicki Pain Score or reduction in opiate usage as compared to 6-month follow-up), quality of life (QoL), pancreatic function and hospital re-admission rate.

Results  In the EHL group, 37 % of the patients developed recurrent symptomatic PD stones versus 61 % in the ESWL group after a median follow-up of 35.0 and 76.5 months. Of the patients with recurrence, 71 % versus 100 % underwent a reintervention. Median time to recurrence was 12.0 versus 13.0 months. Clinical success sustained in 58 % of the EHL patients. QoL was not significantly different compared with 6-month follow-up and baseline.

Conclusions  Also at long-term follow-up, endoscopic EHL as first-line treatment is moderately effective for symptomatic CP patients with treatment success rates that seems at least equally effective as ESWL.