Washington University experience with extracorporeal shock-wave lithotripsy of pancreatic duct calculi

Pancreatic extracorporeal shock wave lithotripsy: a key technology truly improves treatment model for pancreatic stones

Chronic pancreatitis (CP) is characterized by irreversible destruction of pancreatic parenchyma, inflammatory cell infiltration and progressive fibrosis of pancreatic tissue. Obstruction of pancreatic duct by pancreatic stone is the common pathological change in the course of CP with the incidence of over 50 % at the diagnosis of CP. These ductal stones would cause pancreatic parenchymal hypertension and local ischemia, which was eventually followed by recurrent episodes of painful pancreatitis or other manifestations of pancreatic exocrine and endocrine insufficiency. Removing pancreatic stones has been confirmed as the core to reduce pressure, improve drainage and lessen pain. Surgical therapy achieves satisfying pain relief with more complications, higher cost and less repeatability compared with endoscopic therapy. Endoscopic retrograde cholangiopancreatography, which used to be the standard endoscopic therapy for pancreatic stones, would fail if these stones are large or complex, while pancreatic extracorporeal shock wave lithotripsy (P-ESWL), which has been applied since 1987, could overcome this problem. Up to now, a large number of guidelines have recommended the P-ESWL as the first-line treatment strategy for radiopaque obstructive main pancreatic duct stones larger than 5 mm located in the head/body of the pancreas, and P-ESWL had completely changed the traditional treatment model for CP patients with pancreatic stones. In this article, we will focus on the technical progress, efficacy, safety and potential research areas of P-ESWL, we also give us suggestions for lithotripters improvement.

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).

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

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

Success of Extracorporeal Shock Wave Lithotripsy in Chronic Calcific Pancreatitis Management: A Meta-Analysis and Systematic Review

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.

Percutaneous treatment of complex biliary stone disease using endourological technique and literature review

Most biliary stone diseases need to be treated surgically. However, in special cases that traditional biliary tract endoscopic access is not allowed, a multidisciplinary approach using hybrid technique with urologic instrumental constitute a treatment option. We report a case of a patient with complex intrahepatic stones who previously underwent unsuccessful conventional approaches, and who symptoms resolved after treatment with hybrid technique using an endourologic technology. We conducted an extensive literature review until October 2012 of manuscripts indexed in PubMed on the treatment of complex gallstones with hybrid technique. The multidisciplinary approach with hybrid technique using endourologic instrumental represents a safe and effective treatment option for patients with complex biliary stone who cannot conduct treatment with conventional methods.

Endoscopic management of chronic pancreatitis

Chronic pancreatitis (CP) is a common gastrointestinal illness, which affects the quality of life with substantial morbidity and mortality. The management includes medical, endoscopic and surgical approaches with the need for interaction between various specialties, calling for a concerted multidisciplinary approach. However, at the time of this publication, guidelines to establish care of these patients are lacking. This review provides the reader with a comprehensive overview of the studies summarizing the various treatment options available, including medical, surgical and endoscopic options. In addition, technological advances such as endoscopic retrograde cholangiopancreatogrophy, endoscopic shock wave lithotripsy and endoscopic ultrasound can now be offered with reasonable success for pancreatic decompression, stricture dilatation with stent placement, stone fragmentation, pseudocyst drainage, and other endoscopic interventions such as celiac plexus block for pain relief. We emphasize the endoscopic options in this review, and attempt to extract the most up to date information from the current literature. The treatment of CP and its complications are discussed extensively. Complications such as biliary strictures. pancreatic pseudocysts, and chronic pain are common issues that arise as long-term complications of CP. These often require endoscopic or surgical management and possibly a combination of approaches, however choosing amongst the various therapeutic and palliative modalities while weighing the risks and benefits, makes the management of CP challenging. Treatment goals should be not just to control symptoms but also to prevent disease progression. Our aim in this paper is to advocate and emphasize an evidence based approach for the management of CP and associated long term complications.

Shock wave lithotripsy for renal stones is not associated with hypertension and diabetes mellitus

OBJECTIVES

To clarify the influences of shock wave lithotripsy (SWL) treatments for renal and ureteropelvic junction stones on new onsets of hypertension and diabetes mellitus (DM).

METHODS

We compared the new onsets of hypertension and DM after SWL in renal and ureteral stone groups. The renal stone group consisted of 772 patients treated with SWL, who had a possibility of renal and pancreatic shock wave damage. The ureteral stone group consisted of 505 patients treated with SWL, who were unlikely to have suffered SWL damage in the kidney and pancreas areas. Both treatment groups received SWL between 1984 and 1994.

RESULTS

The rates of new onset of hypertension in the renal stone and ureteral stone groups were 22.8% and 20.0% in men and 23.1% and 20.5% in women, respectively. The rates of new onset of DM in the renal stone and ureteral stone groups were 7.4% and 11.0% in men and 8.7% and 8.7% in women, respectively. There was no significant difference in the new onsets of hypertension and DM between renal and ureteral stone groups depending on each age decade or sex. Treatment for renal stone was not a significant risk factor for new onsets of hypertension and DM by logistic regression analysis.

CONCLUSIONS

Our findings suggest that SWL treatment for renal and UPJ stones might not be associated with new onset of hypertension or DM.

Extracorporeal shock wave lithotripsy of pancreatic duct stones using the Healthtronics LithoTron lithotriptor and the Dornier HM3 lithotripsy machine

PURPOSE

Pancreatic duct stones, which are most often a result of alcohol induced chronic pancreatitis, can lead to chronic abdominal pain, pseudocysts, and exocrine and endocrine failure of the pancreas. Others have reported success using extracorporeal shock wave lithotripsy (ESWL) (Dornier Medical Systems, Inc., Marietta, Georgia) for pancreatic stones. We report our experience with pancreatic ESWL using the LithoTron (Healthtronics, Marietta, Georgia) and HM3 (Dornier) lithotripsy machines.

MATERIALS AND METHODS

We performed pancreatic ESWL in 23 patients in 4 years, including in 12 with the LithoTron and in 11 with the HM3. After ESWL endoscopic retrograde cholangio-pancreatography (ERCP) was performed in all cases. Stone-free status was defined as no stone fragments visualized or the elimination of all post-ESWL stones by ERCP.

RESULTS

Stone-free status was documented in 83% and 82% of patients treated with the LithoTron and HM3, respectively, and 2 per group later required open surgical intervention. There were no changes in pancreatic enzymes and no cases of sepsis or fever after ERCP.

CONCLUSIONS

In association with post-procedure ERCP pancreatic ESWL is an effective and safe procedure that enables patients with obstructing pancreatic duct stones recalcitrant to primary endoscopic extraction to avoid a potentially morbid open procedure. The HM3 and LithoTron have comparable efficacy and safety. This modality is particularly effective for a stone aggregate of less than 20 mm., while a larger stone burden of greater than 20 mm. in aggregate and multiple stones are clear risk factors for treatment failure.

Contemporary "urologic" intervention in the pancreaticobiliary tree

OBJECTIVES

To evaluate the role of minimally invasive "urologic" interventional techniques for the treatment of pancreaticobiliary calculi in contemporary practice.

METHODS

Fourteen patients with retained cystic duct (n = 2), hepatic duct (n = 5), common duct (n = 2), pancreatic duct (n = 4), or gallbladder (n = 1) calculi were treated with 19 procedures, including shock wave lithotripsy (n = 9) and percutaneous flexible endoscopy with electrohydraulic or holmium laser lithotripsy (n = 10). Previous attempts using standard gastroenterologic or radiologic interventions before the urologic referral had failed in all 14 patients.

RESULTS

A successful result, defined by the resolution of stones and symptoms, was achieved in 12 patients (86%); 2 patients (14%) had residual calculi that ultimately required an open operative procedure. The hospital stay for each intervention was 0 to 2 nights, and no patients had any significant complications.

CONCLUSIONS

Even in this age of advanced gastroenterologic technology, including laparoscopic cholecystectomy, endoscopic retrograde cholangiopancreatoscopy, and percutaneous transhepatic cholangiography, the urologist can play a significant role in the minimally invasive treatment of patients with complicated biliary disease such that the need for open operative "salvage" procedures will be further minimized.

Prospective evaluation of morphology, function, and quality of life after extracorporeal shockwave lithotripsy and endoscopic treatment of chronic calcific pancreatitis

OBJECTIVE

Therapeutic endoscopy may be effective in selected patients with chronic calcific pancreatitis (CCP). We prospectively evaluated the early outcome of extracorporeal shockwave lithotripsy (ESWL) in combination with interventional endoscopy, using broad inclusion criteria.

METHODS

A total of 48 consecutive patients (35 male, 13 female) were recruited for ESWL and endoscopic therapy of symptomatic CCP. Symptoms, quality of life, pancreatic morphology and function were assessed before and after.

RESULTS

Multiple stones (n = 43), strictures (n = 34), and pancreas divisum (n = 11) were found. A median of 13 ESWL sessions (range 2-74) with a median of 22,100 shockwaves (1,700-150,900) were required. Endoscopic pancreatic sphincterotomy (n = 48), stricture dilation (n = 12), and/or stenting (n = 27) were performed. After therapy, drainage of the pancreatic duct system was achieved in 36, complete stone clearance in 21 patients. Follow-up (n = 38) at 7 months (range 5-9) showed a significant decrease in pancreatic duct diameter (p < 0.001) and pain score (p < 0.0001) whereas complete pain relief was observed in 45% of cases. Several quality of life scores improved significantly. Weight gain occurred in 68% of patients. Normalization of fasting blood glucose and HbA1c levels were observed in four patients, without modifying their treatment. Improvement in pain score correlated with weight gain and decrease in pancreatic duct diameter. Nonalcoholic etiology was associated with a better chance for improvement in pain score and decrease in pancreatic duct diameter. The presence of strictures did not deteriorate the clinical outcome.

CONCLUSIONS

Besides pain relief, ESWL in combination with interventional endoscopy resulted in pancreatic ductal decompression, weight gain, and improvement in quality of life in a considerable number of patients with advanced CCP.