1
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Sheth SG, Machicado JD, Chhoda A, Chalhoub JM, Forsmark C, Zyromski N, Sadeghirad B, Morgan RL, Thosani NC, Thiruvengadam NR, Ruan W, Pawa S, Ngamruengphong S, Marya NB, Kohli DR, Fujii-Lau LL, Forbes N, Elhanafi SE, Desai M, Cosgrove N, Coelho-Prabhu N, Amateau SK, Alipour O, Abidi W, Qumseya BJ. American Society for Gastrointestinal Endoscopy guideline on the role of endoscopy in the management of chronic pancreatitis: methodology and review of evidence. Gastrointest Endosc 2024:S0016-5107(24)03250-4. [PMID: 39243238 DOI: 10.1016/j.gie.2024.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2024] [Accepted: 05/29/2024] [Indexed: 09/09/2024]
Affiliation(s)
- Sunil G Sheth
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Jorge D Machicado
- Division of Gastroenterology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Ankit Chhoda
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Jean M Chalhoub
- Division of Gastroenterology and Hepatology, Staten Island University Hospital, Northwell Health, Staten Island, New York, USA
| | - Christopher Forsmark
- Division of Gastroenterology, Hepatology, and Nutrition, University of Florida, Gainesville, Florida, USA
| | - Nicholas Zyromski
- Department of Surgery, Indiana University, Indianapolis, Indiana, USA
| | - Behnam Sadeghirad
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada; Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
| | - Rebecca L Morgan
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada; School of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - Nirav C Thosani
- Center for Interventional Gastroenterology at UTHealth, McGovern Medical School, Houston, Texas, USA
| | - Nikhil R Thiruvengadam
- Department of Gastroenterology and Hepatology, Loma Linda University, Loma Linda, California, USA
| | - Wenly Ruan
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Swati Pawa
- Department of Gastroenterology, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - Saowanee Ngamruengphong
- Division of Gastroenterology and Hepatology, The Johns Hopkins University, Baltimore, Maryland, USA
| | - Neil B Marya
- Division of Gastroenterology, UMass Chan Medical School, Worcester, Massachusetts, USA
| | - Divyanshoo R Kohli
- Pancreas and Liver Clinic, Providence Sacred Heart Medical Center, Elon Floyd School of Medicine, Washington State University, Spokane, Washington, USA
| | | | - Nauzer Forbes
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Sherif E Elhanafi
- Division of Gastroenterology, Texas Tech University Health Sciences Center, El Paso, Texas, USA
| | - Madhav Desai
- Center for Interventional Gastroenterology at UTHealth, McGovern Medical School, Houston, Texas, USA
| | - Natalie Cosgrove
- Center for Interventional Endoscopy, AdventHealth, Orlando, Florida, USA
| | | | - Stuart K Amateau
- Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota Medical Center, Minneapolis, Minnesota, USA
| | - Omeed Alipour
- Division of Gastroenterology, University of Washington Medical Center, Seattle, Washington, USA
| | - Wasif Abidi
- Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, Texas, USA
| | - Bashar J Qumseya
- Division of Gastroenterology, Hepatology, and Nutrition, University of Florida, Gainesville, Florida, USA
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2
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Liu Y, Yin XY, Cui JH, Wang T, Feng XY, Yi JH, Xu JJ, Zhang SL, Han PD, Wang D, Liu RH, Wang FY, Li ZS, Hu LH. Long-term clinical outcomes of extracorporeal shockwave lithotripsy and endoscopic retrograde cholangiopancreatography for pancreatic duct stone treatment in patients with chronic pancreatitis. Aliment Pharmacol Ther 2024. [PMID: 39169663 DOI: 10.1111/apt.18224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2024] [Revised: 06/28/2024] [Accepted: 08/12/2024] [Indexed: 08/23/2024]
Abstract
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).
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Affiliation(s)
- Yu Liu
- Department of Gastroenterology, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu, China
- Department of Gastroenterology, Changhai Clinical Research Unit, Changhai Hospital, Naval Medical University, Shanghai, China
- National key Laboratory of Immunity and Inflammation, Naval Medical University, Shanghai, China
- Shanghai Institute of Pancreatic Diseases, Shanghai, China
- Department of Pharmacology, College of Pharmacy, Naval Medical University, Shanghai, China
| | - Xiao-Yi Yin
- Department of Hepatobiliary Pancreatic Surgery, Shanghai Changhai Hospital, Naval Medical University, Shanghai, China
| | - Jia-Hui Cui
- Department of Pharmacy, Shanghai Changhai Hospital, Naval Medical University, Shanghai, China
| | - Teng Wang
- Department of Gastroenterology, Changhai Clinical Research Unit, Changhai Hospital, Naval Medical University, Shanghai, China
- National key Laboratory of Immunity and Inflammation, Naval Medical University, Shanghai, China
- Shanghai Institute of Pancreatic Diseases, Shanghai, China
| | - Xiao-Yue Feng
- Department of Gastroenterology, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu, China
- Department of Gastroenterology and Hepatology, Jinling Clinical College of Nanjing Medical University, Jinling Hospital, Nanjing, Jiangsu, China
| | - Jin-Hui Yi
- Department of Gastroenterology, Changhai Clinical Research Unit, Changhai Hospital, Naval Medical University, Shanghai, China
- National key Laboratory of Immunity and Inflammation, Naval Medical University, Shanghai, China
- Shanghai Institute of Pancreatic Diseases, Shanghai, China
| | - Jin-Jie Xu
- Department of Gastroenterology, Changhai Clinical Research Unit, Changhai Hospital, Naval Medical University, Shanghai, China
- National key Laboratory of Immunity and Inflammation, Naval Medical University, Shanghai, China
- Shanghai Institute of Pancreatic Diseases, Shanghai, China
| | - Song-Ling Zhang
- Department of Gastroenterology, Changhai Clinical Research Unit, Changhai Hospital, Naval Medical University, Shanghai, China
- National key Laboratory of Immunity and Inflammation, Naval Medical University, Shanghai, China
- Shanghai Institute of Pancreatic Diseases, Shanghai, China
| | - Pei-Dong Han
- Department of Gastroenterology, Changhai Clinical Research Unit, Changhai Hospital, Naval Medical University, Shanghai, China
- National key Laboratory of Immunity and Inflammation, Naval Medical University, Shanghai, China
- Shanghai Institute of Pancreatic Diseases, Shanghai, China
| | - Dan Wang
- Department of Gastroenterology, Changhai Clinical Research Unit, Changhai Hospital, Naval Medical University, Shanghai, China
- National key Laboratory of Immunity and Inflammation, Naval Medical University, Shanghai, China
- Shanghai Institute of Pancreatic Diseases, Shanghai, China
| | - Run-Hui Liu
- Department of Pharmacology, College of Pharmacy, Naval Medical University, Shanghai, China
| | - Fang-Yu Wang
- Department of Gastroenterology, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu, China
- Department of Gastroenterology and Hepatology, Jinling Clinical College of Nanjing Medical University, Jinling Hospital, Nanjing, Jiangsu, China
| | - Zhao-Shen Li
- Department of Gastroenterology, Changhai Clinical Research Unit, Changhai Hospital, Naval Medical University, Shanghai, China
- National key Laboratory of Immunity and Inflammation, Naval Medical University, Shanghai, China
- Shanghai Institute of Pancreatic Diseases, Shanghai, China
| | - Liang-Hao Hu
- Department of Gastroenterology, Changhai Clinical Research Unit, Changhai Hospital, Naval Medical University, Shanghai, China
- National key Laboratory of Immunity and Inflammation, Naval Medical University, Shanghai, China
- Shanghai Institute of Pancreatic Diseases, Shanghai, China
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Bofill-Garcia A, Lupianez-Merly C. Endoscopic Retrograde Cholangiopancreatography for Management of Chronic Pancreatitis. Gastrointest Endosc Clin N Am 2024; 34:449-473. [PMID: 38796292 DOI: 10.1016/j.giec.2024.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2024]
Abstract
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.
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Affiliation(s)
- Aliana Bofill-Garcia
- Department of Gastroenterology and Hepatology, Mayo Clinic Rochester, 200 First Street Southwest, Rochester, MN 55905, USA.
| | - Camille Lupianez-Merly
- Department of Gastroenterology and Hepatology, Mayo Clinic Rochester, 200 First Street Southwest, Rochester, MN 55905, USA
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4
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Kundra A, Strand DS, Shami VM. Endoscopic Management of Pain due to Chronic Pancreatitis. Gastrointest Endosc Clin N Am 2024; 34:433-448. [PMID: 38796291 DOI: 10.1016/j.giec.2024.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2024]
Abstract
Pain secondary to chronic pancreatitis is a poorly understood and complex phenomenon. Current endoscopic treatments target pancreatic duct decompression secondary to strictures, stones, or inflammatory and neoplastic masses. When there is refractory pain and other treatments have been unsuccessful, one can consider an endoscopic ultrasound-guided celiac plexus block. Data on the latter are underwhelming.
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Affiliation(s)
- Arjun Kundra
- Department of Gastroenterology and Hepatology, University of Virginia, Charlottesville, VA, USA
| | - Daniel S Strand
- Department of Gastroenterology, University of Virginia, Charlottesville, VA, USA
| | - Vanessa M Shami
- Department of Medicine, University of Virginia, Charlottesville, VA, USA.
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5
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Gurav N, Jagtap N, Koppoju V, Sekhramantri K, Asif S, Tandan M, Lakhtakia S, Kalapala R, Ramchandani M, Talukdar R, Basha J, Nabi Z, Memon SF, Darisetty S, Rao GV, Reddy DN. Predictors of persistent pain after extracorporeal shockwave lithotripsy for painful chronic calcific pancreatitis. Endoscopy 2024; 56:406-411. [PMID: 38267001 DOI: 10.1055/a-2252-9920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2024]
Abstract
BACKGROUND Extracorporeal shockwave lithotripsy (ESWL) and/or endoscopic retrograde cholangiopancreatography (ERCP) are recommended as first-line therapy for painful uncomplicated chronic pancreatitis with obstructed main pancreatic duct (MPD) in the pancreas head/body. However, predictors of pain relief after ESWL are unknown. We evaluated independent predictors of persistent pain in patients who underwent ESWL for chronic pancreatitis. METHODS 640 consecutive adult patients with chronic pancreatitis, who underwent successful ESWL with ERCP and pancreatic duct (PD) stent placement, were followed for 12 months. The pain was assessed at baseline and at 12 months using the Izbicki Pain Score, with a score decrease of >50% considered pain relief. Independent predictors of pain relief were derived from logistic regression analysis. RESULTS Of 640 patients (mean age 36.71 [SD 12.19] years; 60.5% men), 436 (68.1%) had pain relief and 204 (31.9%) had persistent pain. On univariate analysis, older age, male sex, alcohol and tobacco intake, longer duration of symptoms, dilated MPD and MPD stricture were associated with persistent pain at 12 months (P<0.05). Consumption of alcohol (odds ratio [OR] 1.93, 95%CI 1.26-2.97), tobacco (OR 4.09, 95%CI 2.43-6.90), duration of symptoms (OR 1.02, 95%CI 1.01-1.04), MPD size (OR 1.22, 95%CI 1.11-1.33), and MPD stricture (OR 8.50, 95%CI 5.01-14.42) were independent predictors of persistent pain. CONCLUSIONS Alcohol, tobacco, duration of symptoms, MPD size and stricture were independent predictors of persistent pain after successful ESWL. A multidisciplinary team approach that includes behavioral therapy and surgical options should be considered for such patients.
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Affiliation(s)
- Nitish Gurav
- Department of Medical Gastroenterology, AIG Hospitals, Hyderabad, India
| | - Nitin Jagtap
- Department of Medical Gastroenterology, AIG Hospitals, Hyderabad, India
| | - Vinod Koppoju
- Department of Medical Gastroenterology, AIG Hospitals, Hyderabad, India
| | | | - Shujaath Asif
- Department of Medical Gastroenterology, AIG Hospitals, Hyderabad, India
| | - Manu Tandan
- Department of Medical Gastroenterology, AIG Hospitals, Hyderabad, India
| | - Sundeep Lakhtakia
- Department of Medical Gastroenterology, AIG Hospitals, Hyderabad, India
| | - Rakesh Kalapala
- Department of Medical Gastroenterology, AIG Hospitals, Hyderabad, India
| | - Mohan Ramchandani
- Department of Medical Gastroenterology, AIG Hospitals, Hyderabad, India
| | - Rupjyoti Talukdar
- Department of Medical Gastroenterology, AIG Hospitals, Hyderabad, India
| | - Jahangeer Basha
- Department of Medical Gastroenterology, AIG Hospitals, Hyderabad, India
| | - Zaheer Nabi
- Department of Medical Gastroenterology, AIG Hospitals, Hyderabad, India
| | - Sana Fatima Memon
- Department of Medical Gastroenterology, AIG Hospitals, Hyderabad, India
| | - Santosh Darisetty
- Department of Gastrointestinal Anaesthesia, AIG Hospitals, Hyderabad, India
| | - Guduru Venkat Rao
- Department of Surgical Gastroenterology, AIG Hospitals, Hyderabad, India
| | - D Nageshwar Reddy
- Department of Medical Gastroenterology, AIG Hospitals, Hyderabad, India
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Bush N, Chandragiri P, Gaurav NA, Sonaiya S, Lahooti I, Singh A, Gupta A, Afghani E, Papachristou G, Khashab MA, Lee PJ, Talukdar R, Lakhtakia S, Singh VK, Han S, Tandan M, Akshintala VS. Development of a novel CT-based index for predicting the number of extracorporeal shockwave lithotripsy (ESWL) sessions required for successful fragmentation of obstructing pancreatic duct stones. Pancreatology 2024; 24:643-648. [PMID: 38584052 DOI: 10.1016/j.pan.2024.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Revised: 03/19/2024] [Accepted: 03/26/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND & AIM Extracorporeal shock wave lithotripsy (ESWL) is used for the treatment of pancreatic duct stones (PDS) in patients with chronic pancreatitis (CP). We aimed to develop a CT based index to predict the required number of ESWL sessions for technical success. METHODS We retrospectively evaluated patients with PDS secondary to CP who underwent ESWL. Technical success was defined as the complete fragmentation of stones to <3 mm. CT features including PDS size, number, location, and density in Hounsfield units (HU) were noted. We analyzed the relationship between PDS characteristics and the number of ESWL sessions required for technical success. A multiple linear regression model was used to combine size and density into the pancreatic duct stone (PDS) index that was translated into a web-based calculator. RESULTS There were 206 subjects (mean age 38.6 ± 13.7 years, 59.2% male) who underwent ESWL. PDS size showed a moderate correlation with the number of ESWL sessions (r = 0.42, p < 0.01). PDS in the head required a fewer number of sessions in comparison to those in the body (1.4 ± 0.6 vs. 1.6 ± 0.7, p = 0.01). There was a strong correlation between PDS density and the number of ESWL sessions (r = 0.617, p-value <0.01). The PDS index {0.3793 + [0.0009755 x PDS density (HU)] + [0.02549 x PDS size (mm)]} could accurately predict the required number of ESWL sessions with an AUC of 0.872 (p < 0.01). CONCLUSION The PDS index is a useful predictor of the number of ESWL sessions needed for technical success that can help in planning and patient counseling.
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Affiliation(s)
- Nikhil Bush
- Pancreatitis Center, Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Praneeth Chandragiri
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Nitish Ashok Gaurav
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Sneh Sonaiya
- Pancreatitis Center, Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Ila Lahooti
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Anmol Singh
- Pancreatitis Center, Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Abhinav Gupta
- Pancreatitis Center, Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Elham Afghani
- Pancreatitis Center, Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Georgios Papachristou
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Mouen A Khashab
- Pancreatitis Center, Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Peter J Lee
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Rupjyoti Talukdar
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Sundeep Lakhtakia
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Vikesh K Singh
- Pancreatitis Center, Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Samuel Han
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Manu Tandan
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Venkata S Akshintala
- Pancreatitis Center, Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA.
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7
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Saleem N, Patel F, Watkins JL, McHenry L, Easler JJ, Fogel EL, Gromski MA, Lehman GA, Sherman S, Tong Y, Bick BL. Timing of ERCP after extracorporeal shock wave lithotripsy for large main pancreatic duct stones. Surg Endosc 2023; 37:9098-9104. [PMID: 37798530 DOI: 10.1007/s00464-023-10467-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 09/06/2023] [Indexed: 10/07/2023]
Abstract
BACKGROUND AND AIMS Extracorporeal shock wave lithotripsy (ESWL) is performed to fragment large main pancreatic duct (MPD) stones in symptomatic patients. Subsequent endoscopic retrograde cholangiopancreatography (ERCP) is often performed to clear the stone fragments. Edema of surrounding tissue after ESWL theoretically affects the ability to perform ERCP. However, the optimal timing of ERCP after ESWL is not clearly defined. The aim of this study is to determine the efficacy and safety of same-day ERCP after ESWL and to determine if the timing of ERCP after ESWL affects outcomes. METHODS This is a retrospective study of consecutive patients from January, 2013 to September, 2019 who received ESWL for MPD stones at our center. Included patients received subsequent same-day ERCP under the same general anesthesia session or later session ERCP (1-30 days after ESWL). Demographics, anatomical findings, history, and outcomes were collected. Success was defined as complete or near complete (> 80%) stone fragmentation with clearance. RESULTS 218 patients were treated with ESWL and subsequent ERCP. 133 (61.0%) received ERCP on the same day immediately after ESWL, while 85 (39.0%) returned for ERCP at a later day (median 3.0 days after ESWL). Baseline characteristics demonstrated patients who received same-day ERCP had a higher rate of pain at baseline (94.7% vs 87.1%, p = 0.045). Main outcomes demonstrated an overall successful MPD stone clearance rate of 90.4%, with similar rates between same-day ERCP and later session ERCP (91.7% vs 88.2%, p = 0.394). Additionally, successful cannulation at ERCP, adverse events, and post-procedure admission rates were similar. CONCLUSIONS Delaying ERCP to allow peripancreatic tissue recovery after ESWL does not affect outcomes. Same-day ERCP after ESWL is safe and effective.
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Affiliation(s)
- Nasir Saleem
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, 550 University Blvd, Suite UH1602, Indianapolis, IN, 46202-5250, USA.
| | - Feenalie Patel
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, 550 University Blvd, Suite UH1602, Indianapolis, IN, 46202-5250, USA
| | - James L Watkins
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, 550 University Blvd, Suite UH1602, Indianapolis, IN, 46202-5250, USA
| | - Lee McHenry
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, 550 University Blvd, Suite UH1602, Indianapolis, IN, 46202-5250, USA
| | - Jeffrey J Easler
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, 550 University Blvd, Suite UH1602, Indianapolis, IN, 46202-5250, USA
| | - Evan L Fogel
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, 550 University Blvd, Suite UH1602, Indianapolis, IN, 46202-5250, USA
| | - Mark A Gromski
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, 550 University Blvd, Suite UH1602, Indianapolis, IN, 46202-5250, USA
| | - Glen A Lehman
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, 550 University Blvd, Suite UH1602, Indianapolis, IN, 46202-5250, USA
| | - Stuart Sherman
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, 550 University Blvd, Suite UH1602, Indianapolis, IN, 46202-5250, USA
| | - Yan Tong
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Benjamin L Bick
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, 550 University Blvd, Suite UH1602, Indianapolis, IN, 46202-5250, USA
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8
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Yi JH, Li ZS, Hu LH. Adverse events of pancreatic extracorporeal shock wave lithotripsy: a literature review. BMC Gastroenterol 2023; 23:360. [PMID: 37853330 PMCID: PMC10585860 DOI: 10.1186/s12876-023-02992-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Accepted: 10/10/2023] [Indexed: 10/20/2023] Open
Abstract
Pancreatic stones are the result of pathophysiologic changes in chronic pancreatitis with an incidence of more than 90%. At present, pancreatic extracorporeal shock wave lithotripsy (P-ESWL) can be used as the first-line treatment for large or complex stones. Although a large number of studies have proven the safety and effectiveness of P-ESWL, we should also pay attention to postoperative adverse events, mainly due to the scattering of shock waves in the conduction pathway. Adverse events can be classified as either complications or transient adverse events according to the severity. Because the anatomic location of organs along the shock wave conducting pathway differs greatly, adverse events after P-ESWL are varied and difficult to predict. This paper outlines the mechanism, definition, classification, management and risk factors for adverse events related to P-ESWL. It also discusses the technique of P-ESWL, indications and contraindications of P-ESWL, and adverse events in special populations.
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Affiliation(s)
- Jin-Hui Yi
- Department of Gastroenterology, Shanghai Changhai Hospital, 168 Changhai Road, Shanghai, 200433, China
| | - Zhao-Shen Li
- Department of Gastroenterology, Shanghai Changhai Hospital, 168 Changhai Road, Shanghai, 200433, China.
| | - Liang-Hao Hu
- Department of Gastroenterology, Shanghai Changhai Hospital, 168 Changhai Road, Shanghai, 200433, China.
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Endo S, Kawaguchi S, Satoh T, Shirane N. Extracorporeal shock wave lithotripsy and endoscopic pancreatic stenting without pancreatic sphincterotomy for the treatment of pancreatolithiasis: a case series. Clin J Gastroenterol 2023:10.1007/s12328-023-01803-z. [PMID: 37087534 DOI: 10.1007/s12328-023-01803-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 04/12/2023] [Indexed: 04/24/2023]
Abstract
Endoscopic therapy and extracorporeal shock wave lithotripsy (ESWL) are recommended as the first choice in treating pancreatolithiasis. Endoscopic therapy is generally performed using endoscopic pancreatic sphincterotomy (EPST). Herein, we report our experience implementing a treatment protocol, combining endoscopic therapy and ESWL without EPST, for pancreatolithiasis. The inpatient treatment plan was performed every 3 months with a set number of sessions of ESWL with endoscopic pancreatic stenting (EPS) implanted or replaced. Finally, treatment was terminated when the stone was removed after implantation of a 10-Fr stent and crushed to approximately 3 mm or after spontaneous stone discharge. Eight patients were included in this study; the median time to stone disappearance was 208.5 days. The median number of inpatient treatment cycles, endoscopic retrograde cholangiopancreatography, and ESWL sessions was 2.5, 3, and 3, respectively. No serious adverse events were observed in all patients. Therefore, combining ESWL and EPS without EPST can safely treat pancreatolithiasis.
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Affiliation(s)
- Shinya Endo
- Department of Gastroenterology, Shizuoka General Hospital, 4-27-1, Kita-Ando, Aoi-Ku, Shizuoka-City, Shizuoka, 420-8527, Japan.
| | - Shinya Kawaguchi
- Department of Gastroenterology, Shizuoka General Hospital, 4-27-1, Kita-Ando, Aoi-Ku, Shizuoka-City, Shizuoka, 420-8527, Japan
| | - Tatsunori Satoh
- Department of Gastroenterology, Shizuoka General Hospital, 4-27-1, Kita-Ando, Aoi-Ku, Shizuoka-City, Shizuoka, 420-8527, Japan
| | - Naofumi Shirane
- Department of Gastroenterology, Shizuoka General Hospital, 4-27-1, Kita-Ando, Aoi-Ku, Shizuoka-City, Shizuoka, 420-8527, Japan
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10
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Pancreatic Stones and Extracorporeal Shockwave Lithotripsy: A Review of the Literature. Pancreas 2022; 51:916-922. [PMID: 36607935 DOI: 10.1097/mpa.0000000000002129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
ABSTRACT Pancreatic stones are sequelae of chronic pancreatitis, resulting in poor quality of life, frequent hospitalizations, and a significant economic burden. Extracorporeal shock wave lithotripsy (ESWL) can be used to treat pancreatic stones and is less invasive when compared to other modalities. In this review article, we have discussed the role of ESWL in the treatment of pancreatic stones and how it differs from other modalities. Databases were searched electronically for articles discussing the treatment of pancreatic ductal stones by ESWL or other modalities. Articles discussing or comparing treatment success rates were preferentially included. An inductive approach was used to identify articles related to the treatment of pancreatic stones with ESWL throughout the review process. Although laser lithotripsy and electrohydraulic lithotripsy appear to have higher success rates, the potential for ESWL to affect clinical outcomes is substantial, especially in individuals with a higher risk for invasive procedures. The decision to perform ESWL should be considered if the outcome will substantially alter the clinical management when performed by an experienced endoscopist. Further randomized controlled trials are needed to compare ESWL and peroral pancreatic lithotripsy methods.
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11
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Gholami R, Khan R, Ramkissoon A, Alabdulqader A, Gimpaya N, Bansal R, Scaffidi MA, Prasad V, Detsky AS, Baker JP, Grover SC. Recommendation Reversals in Gastroenterology Clinical Practice Guidelines. J Can Assoc Gastroenterol 2022; 5:98-99. [PMID: 35368318 PMCID: PMC8972276 DOI: 10.1093/jcag/gwab040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 09/28/2021] [Indexed: 11/23/2022] Open
Abstract
Background Recommendations in clinical practice guidelines (CPGs) may be reversed when evidence emerges to show they are futile or unsafe. In this study, we identified and characterized recommendation reversals in gastroenterology CPGs. Methods We searched CPGs published by 20 gastroenterology societies from January 1990 to December 2019. We included guidelines which had at least two iterations of the same topic. We defined reversals as when (a) the more recent iteration of a CPG recommends against a specific practice that was previously recommend in an earlier iteration of a CPG from the same body, and (b) the recommendation in the previous iteration of the CPG is not replaced by a new diagnostic or therapeutic recommendation in the more recent iteration of the CPG. The primary outcome was the number of recommendation reversals. Secondary outcomes included the strength of recommendations and quality of evidence cited for reversals. Results Twenty societies published 1022 CPGs from 1990 to 2019. Our sample for analysis included 129 unique CPGs. There were 11 recommendation reversals from 10 guidelines. New evidence was presented for 10 recommendation reversals. Meta-analyses were cited for two reversals, and randomized controlled trials (RCTs) for seven reversals. Recommendations were stronger after the reversal for three cases, weaker in two cases, and of similar strength in three cases. We were unable to compare recommendation strengths for three reversals. Conclusion Recommendation reversals in gastroenterology CPGs are uncommon but highlight low value or harmful practices.
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Affiliation(s)
- Reza Gholami
- Division of Gastroenterology, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Rishad Khan
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Anushka Ramkissoon
- Division of Gastroenterology, St. Michael’s Hospital, Toronto, Ontario, Canada
| | | | - Nikko Gimpaya
- Division of Gastroenterology, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Rishi Bansal
- Division of Gastroenterology, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Michael A Scaffidi
- Division of Gastroenterology, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Vinay Prasad
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California,USA
| | - Allan S Detsky
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, Mount Sinai Hospital and University Health Network, Toronto, Ontario, Canada
| | - Jeffrey P Baker
- Division of Gastroenterology, St. Michael’s Hospital, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Samir C Grover
- Division of Gastroenterology, St. Michael’s Hospital, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
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12
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Yamamoto S, Inui K, Katano Y, Miyoshi H, Kobayashi T, Tachi Y, Torii Y. Pancreatic Stones: Clinical Outcomes With Nonsurgical Treatment in a Japanese Single-Center Study. Pancreas 2022; 51:205-211. [PMID: 35404899 DOI: 10.1097/mpa.0000000000001996] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES While chronic pancreatitis associated with pancreatolithiasis presents with pain, exocrine and endocrine pancreatic functions worsen with time. We examined outcomes of nonsurgical treatment. METHODS Between 1992 and 2020, we treated pancreatolithiasis nonsurgically in 165 patients with chronic pancreatitis using extracorporeal shock wave lithotripsy alone or followed by endoscopic procedures. The mean follow-up duration was 49 months (standard deviation, 56 months) and the age was 56 years (standard deviation, 13 years). The male:female ratio was 5.1:1 (138 men, 27 women). We followed treatment results including relief of abdominal pain, stone clearance and recurrence, and pancreatic exocrine function (bentiromide-p-aminobenzoic acid testing). RESULTS Treatment relieved pain in 117 of 124 patients (94%). The overall stone clearance was achieved in 130 of 165 patients (79%). Stones recurred during follow-up in 50 of 130 patients (38%). One fifth of recurrences were early, often involving stricture of the main pancreatic duct. After 1 year, 65% of the patients had improved or stable exocrine function. CONCLUSIONS Nonsurgical stone removal usually improved symptoms and preserved pancreatic exocrine function. Nonsurgical treatment with extracorporeal shock wave lithotripsy followed by endoscopic treatment if needed is useful as initial management for pancreatolithiasis.
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Affiliation(s)
| | - Kazuo Inui
- Department of Gastroenterology, Yamashita Hospital, Ichinomiya
| | - Yoshiaki Katano
- From the Department of Gastroenterology, Fujita Health University Bantane Hospital, Nagoya, Japan
| | - Hironao Miyoshi
- From the Department of Gastroenterology, Fujita Health University Bantane Hospital, Nagoya, Japan
| | - Takashi Kobayashi
- From the Department of Gastroenterology, Fujita Health University Bantane Hospital, Nagoya, Japan
| | - Yoshihiko Tachi
- Department of Gastroenterology, Fujita Health University Okazaki Medical Center, Okazaki, Japan
| | - Yoshinori Torii
- From the Department of Gastroenterology, Fujita Health University Bantane Hospital, Nagoya, Japan
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13
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Nabi Z, Lakhtakia S. Endoscopic management of chronic pancreatitis. Dig Endosc 2021; 33:1059-1072. [PMID: 33687105 DOI: 10.1111/den.13968] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 03/02/2021] [Accepted: 03/05/2021] [Indexed: 02/05/2023]
Abstract
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.
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Affiliation(s)
- Zaheer Nabi
- Asian Institute of Gastroenterology, Hyderabad, India
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14
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The role of extracorporeal shock wave lithotripsy in the treatment of chronic pancreatitis. Acta Gastroenterol Belg 2021; 84:620-626. [PMID: 34965044 DOI: 10.51821/84.4.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Pain is the most frequent symptom in chronic pancreatitis (CP) and has an important impact on quality of life. One of its major pathophysiological mechanisms is ductal hypertension, caused by main pancreatic duct stones and/or strictures. In this article, we focus on extracorporeal shock wave lithotripsy (ESWL) as a treatment for main pancreatic duct stones, which have been reported in >50% of CP patients. ESWL uses acoustic pulses to generate compressive stress on the stones, resulting in their gradual fragmentation. In patients with radiopaque obstructive main pancreatic duct (MPD) stones larger than 5 mm, located in the pancreas head or body, ESWL improves ductal clearance, thereby relieving pain and improving quality of life. In case of insufficient ductal clearance or the presence of an MPD stricture, ESWL can be followed by endoscopic retrograde cholangiopancreatography (ERCP) to increase success rate. Alternatively, direct pancreaticoscopy with intracorporeal lithotripsy or surgery can be performed.
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15
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Bick BL, Patel F, Easler JJ, Tong Y, Watkins JL, McHenry L, Lehman G, Fogel EL, Gromski MA, Sherman S. A comparative study between single-operator pancreatoscopy with intraductal lithotripsy and extracorporeal shock wave lithotripsy for the management of large main pancreatic duct stones. Surg Endosc 2021; 36:3217-3226. [PMID: 34264399 PMCID: PMC10153763 DOI: 10.1007/s00464-021-08631-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 07/05/2021] [Indexed: 01/27/2023]
Abstract
BACKGROUND AND AIMS Endoscopic management of large main pancreatic ductal (MPD) stones often require treatment with lithotripsy. Extracorporeal shock wave lithotripsy (ESWL) has been the mainstay therapy, and single-operator pancreatoscopy with intraductal (intracorporeal) lithotripsy (SOPIL) is an emerging technique. However, no comparative studies between these techniques exist. We therefore aimed to compare ESWL to SOPIL for the treatment of large MPD stones. METHODS This is a retrospective cohort study comparing patients who were treated with ESWL or SOPIL from September 2013 to September 2019 at a single tertiary center. Logistic regression was performed to identify factors associated with technical success and efficient stone clearance (≤ 2 procedures to clear stones). RESULTS There were 240 patients who were treated with ESWL and 18 treated with SOPIL. The overall technical success rate of stone clearance was 224/258 (86.8%), which was similar between the ESWL and SOPIL groups (86.7% vs 88.9%, p = 1.000). A SOPIL approach required fewer total procedures (1.6 ± 0.6 vs 3.1 ± 1.5, p < 0.001) and less aggregate procedure time (101.6 ± 68.2 vs 191.8 ± 111.6 min, p = 0.001). Adverse event rates were similar between the groups (6.3% vs 5.6%, p = 1.000). The use of SOPIL was independently associated with greater efficiency compared to ESWL (OR 5.241 [1.348-20.369], p = 0.017). Stone size > 10 mm was associated with less efficient stone clearance (OR 0.484 [0.256-0.912], p = 0.025). CONCLUSION Both ESWL and SOPIL are safe and effective endoscopic adjunct modalities for treating large pancreatic duct stones. SOPIL is an emerging alternative to ESWL that is potentially more efficient for lithotripsy and MPD stone clearance.
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Affiliation(s)
- Benjamin L Bick
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, 550 University Blvd, Suite UH1602, Indianapolis, IN, USA.
| | - Feenalie Patel
- Department of Internal Medicine and Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Jeffrey J Easler
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, 550 University Blvd, Suite UH1602, Indianapolis, IN, USA
| | - Yan Tong
- Department of Biostatistics, Indiana University School of Public Health, Indianapolis, IN, USA
| | - James L Watkins
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, 550 University Blvd, Suite UH1602, Indianapolis, IN, USA
| | - Lee McHenry
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, 550 University Blvd, Suite UH1602, Indianapolis, IN, USA
| | - Glen Lehman
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, 550 University Blvd, Suite UH1602, Indianapolis, IN, USA
| | - Evan L Fogel
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, 550 University Blvd, Suite UH1602, Indianapolis, IN, USA
| | - Mark A Gromski
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, 550 University Blvd, Suite UH1602, Indianapolis, IN, USA
| | - Stuart Sherman
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, 550 University Blvd, Suite UH1602, Indianapolis, IN, USA
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16
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Mann R, Boregowda U, Vyas N, Gajendran M, Umapathy CP, Sayana H, Echavarria J, Patel S, Saligram S. Current advances in the management of chronic pancreatitis. Dis Mon 2021; 67:101225. [PMID: 34176572 DOI: 10.1016/j.disamonth.2021.101225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Chronic pancreatitis is characterized by irreversible destruction of pancreatic parenchyma and its ductal system resulting from longstanding inflammation, leading to fibrosis and scarring due to genetic, environmental, and other risk factors. The diagnosis of chronic pancreatitis is made based on a combination of clinical features and characteristic findings on computed tomography or magnetic resonance imaging. Abdominal pain is the most common symptom of chronic pancreatitis. The main aim of treatment is to relieve symptoms, prevent disease progression, and manage complications related to chronic pancreatitis. Patients who do not respond to medical treatment or not a candidate for surgical treatment are usually managed with endoscopic therapies. Endoscopic therapies help with symptoms such as abdominal pain and jaundice by decompression of pancreatic and biliary ducts. This review summarizes the risk factors, pathophysiology, diagnostic evaluation, endoscopic treatment of chronic pancreatitis, and complications. We have also reviewed recent advances in endoscopic retrograde cholangiopancreatography and endoscopic ultrasound-guided therapies for pancreatic duct obstruction due to stones, strictures, pancreatic divisum, and biliary strictures.
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Affiliation(s)
- Rupinder Mann
- Department of Internal Medicine, Saint Agnes Medical Center, 1303 E Herndon Ave, Fresno, CA 93720, USA
| | - Umesha Boregowda
- Department of Internal Medicine, Bassett Healthcare Network, Columbia Bassett Medical School, 1 Atwell Road, Cooperstown, NY 13326, USA
| | - Neil Vyas
- Department of Gastroenterology and Advanced endoscopy, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA
| | - Mahesh Gajendran
- Department of Internal Medicine, Texas Tech University Health Science Center El Paso, 2000B Transmountain Road, El Paso, TX 79911, USA
| | - Chandra Prakash Umapathy
- Department of Gastroenterology and Advanced endoscopy, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA
| | - Hari Sayana
- Department of Gastroenterology and Advanced endoscopy, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA
| | - Juan Echavarria
- Department of Gastroenterology and Advanced endoscopy, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA
| | - Sandeep Patel
- Department of Gastroenterology and Advanced endoscopy, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA
| | - Shreyas Saligram
- Department of Gastroenterology and Advanced endoscopy, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA.
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17
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van Huijgevoort NC, Veld JV, Fockens P, Besselink MG, Boermeester MA, Arvanitakis M, van Hooft JE. Success of extracorporeal shock wave lithotripsy and ERCP in symptomatic pancreatic duct stones: a systematic review and meta-analysis. Endosc Int Open 2020; 8:E1070-E1085. [PMID: 32743061 PMCID: PMC7373664 DOI: 10.1055/a-1171-1322] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 03/30/2020] [Indexed: 12/12/2022] Open
Abstract
Background and study aims Pain is the most frequent and dominant symptom of chronic pancreatitis. Currently, these patients are treated using a step-up approach, including analgesics and lifestyle adjustments, endoscopic, and eventually surgical treatment. Extracorporeal shock wave lithotripsy (ESWL) is indicated after failure of the first step in patients with symptomatic intraductal stones larger than 5 mm in the head or body of the pancreas. To assess the complete ductal clearance rate and pain relief after ESWL in patients with symptomatic chronic pancreatitis with pancreatic duct stones, a systematic review and meta-analysis was performed. Patients and methods A systematic literature search from January 2000 to December 2018 was performed in PubMed, the Cochrane Library, and EMBASE for studies on ductal clearance rate of ESWL in patients with symptomatic chronic pancreatitis with pancreatic duct stones. Results After screening 486 studies, 22 studies with 3868 patients with chronic pancreatitis undergoing ESWL for pancreatic duct stones were included. The pooled proportion of patients with complete ductal clearance was 69.8 % (95 % CI 63.8-75.5). The pooled proportion of complete absence of pain during follow-up was 64.2 % (95 % CI 57.5-70.6). Complete stone fragmentation was 86.3 % (95 % CI 76.0-94.0). Post-procedural pancreatitis and cholangitis occurred in 4.0 % (95 % CI 2.5-5.8) and 0.5 % (95 % CI 0.2-0.9), respectively. Conclusion Treatment with ESWL results in complete ductal clearance rate in a majority of patients, resulting in absence of pain during follow up in over half of patients with symptomatic chronic pancreatitis caused by obstructing pancreatic duct stones.
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Affiliation(s)
- Nadine C.M. van Huijgevoort
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, location AMC, Amsterdam, The Netherlands
| | - Joyce V. Veld
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, location AMC, Amsterdam, The Netherlands
| | - Paul Fockens
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, location AMC, Amsterdam, The Netherlands
| | - Marc G. Besselink
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, location AMC, Amsterdam, The Netherlands
| | - Marja A. Boermeester
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, location AMC, Amsterdam, The Netherlands
| | - Marianna Arvanitakis
- Department of Gastroenterology and Hepatology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Jeanin E. van Hooft
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, location AMC, Amsterdam, The Netherlands
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18
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Abstract
Chronic pancreatitis is characterized by progressive, irreversible morphologic and functional changes that are most commonly attributed to environmental insults, particularly when there is a genetic or anatomic predisposition. Heavy alcohol use and cigarette smoking are the most common environmental risk factors, but both may be absent. Antecedent episodes of acute pancreatitis occur in about half of patients. Abdominal pain is the most common symptom and requires a tailored approach depending on the anatomic changes in the pancreas. Other clinical manifestations include diabetes mellitus, exocrine pancreatic insufficiency, metabolic bone disease, pancreatic cancer, and anatomic complications. Current disease management is centered on risk factor reduction and screening for and treating disease complications. There are no current therapies to delay or retard disease progression, but there are ongoing efforts to more fully understand the natural history of chronic pancreatitis and underlying mechanisms of disease. These studies are expected to provide insights that will transform our approach to disease management and provide increased hope to patients.
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Abstract
PURPOSE OF REVIEW Pancreatic duct stones are sequela of chronic pancreatitis. They can cause pancreatic duct obstruction which is the most important cause of pain in chronic pancreatitis. Stone resolution has shown to improve pain. The goal of this review is to highlight recent endoscopic and surgical advancements in treatment of pancreatic duct stones. RECENT FINDINGS Stone fragmentation by extracorporeal shock wave lithotripsy has become first line and the mainstay of treatment for majority of patients with pancreatic duct stones. Introduction of digital video pancreatoscopy in the last few years with the capability of guided lithotripsy has provided a robust therapeutic option where extracorporeal shock wave lithotripsy is unsuccessful or unavailable. Historically, surgery has been considered a more reliable and durable option when feasible. However, it had not been compared with more effective endoscopic therapy. Lithotripsy (extracorporeal and pancreatoscopy guided) is evolving as a strong treatment modality for pancreatic stones.
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Affiliation(s)
- Kaveh Sharzehi
- Division of Gastroenterology & Hepatology, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA.
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20
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Haraldsson S, Roug S, Nøjgaard C, Novovic S, Gluud LL, Feldager E, Schmidt PN. Extracorporeal shock wave lithotripsy for pancreatic duct stones: an observational study. Scand J Gastroenterol 2019; 53:1399-1403. [PMID: 30353766 DOI: 10.1080/00365521.2018.1508611] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Previous studies suggest that fragmentation of pancreatic duct stones (PDS) using extracorporeal shock wave lithotripsy (ESWL) is associated with pain relief. However, the treatment may not be effective in certain subgroups. AIM To evaluate predictors of pain relief after ESWL in patients with chronic pancreatitis and PDS. METHODS Retrospective study including patients with chronic pancreatitis undergoing ESWL for painful PDS. Analgesic use before and after the ESWL procedure was registered. We defined adequate pain relief after ESWL as 'pain-free without analgesics or with use of weak analgesics as needed'. The study was approved by the Danish Data Protection Agency (approval number: AHH-2017-048). RESULTS We included 81 patients (median age 58 years; 63% men; 68% alcoholic pancreatitis). Patients underwent one to seven ESWL procedures (mean 1.7). A concurrent ERCP was performed in 17%. All patients used analgesics before the ESWL procedure (68 used opioids). After ESWL, 43 still used opioids. Thirty-two patients achieved adequate pain relief. Univariable regression analysis showed that older age predicted adequate pain relief (OR 1.09;1.03-1.16; p = .002) as did location of the stone in the head or neck (OR 2.59;1.04-6.45; p = .041). In multivariable analysis, we found that the only two predictors of adequate pain relief were age (p = .002) and the location of the stones (p = .039). CONCLUSION After the ESWL, about four out of ten patients are pain-free without medication or able to manage their pain with weak analgesics. Age and the location of the stones may be considered when evaluating if patients are eligible for referral to ESWL.
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Affiliation(s)
- Stefan Haraldsson
- a Department of Gastroenterology , Landspitali - University Hospital , Reykjavik , Iceland
| | - Stine Roug
- b Abdominal Center K, Bispebjerg Hospital , Copenhagen , Denmark
| | - Camilla Nøjgaard
- c Department of Gastroenterology and Gastrointestinal Surgery , Copenhagen University Hospital Hvidovre , Hvidovre , Denmark
| | - Srdan Novovic
- c Department of Gastroenterology and Gastrointestinal Surgery , Copenhagen University Hospital Hvidovre , Hvidovre , Denmark
| | - Lise Lotte Gluud
- c Department of Gastroenterology and Gastrointestinal Surgery , Copenhagen University Hospital Hvidovre , Hvidovre , Denmark
| | - Erik Feldager
- c Department of Gastroenterology and Gastrointestinal Surgery , Copenhagen University Hospital Hvidovre , Hvidovre , Denmark
| | - Palle Nordblad Schmidt
- c Department of Gastroenterology and Gastrointestinal Surgery , Copenhagen University Hospital Hvidovre , Hvidovre , Denmark
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21
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Qian YY, Chen H, Tang XY, Jiang X, Qian W, Zou WB, Xin L, Li B, Qi YF, Hu LH, Zou DW, Jin ZD, Wang D, Du YQ, Wang LW, Liu F, Li ZS, Liao Z. Rectally administered indomethacin to prevent post-ESWL-pancreatitis (RIPEP): study protocol for a randomized controlled trial. Trials 2017; 18:513. [PMID: 29096689 PMCID: PMC5667485 DOI: 10.1186/s13063-017-2250-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2017] [Accepted: 10/10/2017] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Pancreatic extracorporeal shock wave lithotripsy (P-ESWL) is the first-line therapy for large pancreatic duct stones. Although it is a highly effective and safe procedure for the fragmentation of pancreatic stones, it is still not complication-free. Just like endoscopic retrograde cholangiopancreatography (ERCP), pancreatitis is the most common complication. To date, nonsteroidal anti-inflammatory drugs (NSAIDs) have proven to be the only effective prophylactic medication for post-ERCP pancreatitis and the European, American and Japanese Society for Gastrointestinal Endoscopy guidelines have recommended prophylactic rectally administered indomethacin for all patients undergoing ERCP. Given the little research about effective prevention for post P-ESWL pancreatitis, we aim to determine whether rectally administered indomethacin can reduce post-ESWL-pancreatitis. METHODS/DESIGN The RIPEP study is a prospective, randomized, double-blinded, placebo-controlled trial. One thousand three hundred and seventy patients with chronic pancreatitis and pancreatic stones (>5 mm in diameter) treated with P-ESWL at Changhai Hospital will be randomly allocated to rectally administered indomethacin or placebo therapy before the procedure. The primary endpoint is the incidence of post-ESWL pancreatitis. Secondary endpoints include the severity of pancreatitis, occurrence rate of asymptomatic hyperamylasemia and other complications. DISCUSSION The RIPEP trial is designed to show that rectally administered indomethacin reduces the development and severity of post-ESWL pancreatitis and benefits patients treated with P-ESWL. TRIAL REGISTRATION ClinicalTrials.gov, ID: NCT02797067 . Registered on 17 November 2016.
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Affiliation(s)
- Yang-Yang Qian
- Department of Gastroenterology, Digestive Endoscopy Center, Changhai Hospital, the Second Military Medical University, 168 Changhai Road, Shanghai, 200433 China
| | - Hui Chen
- Department of Gastroenterology, Digestive Endoscopy Center, Changhai Hospital, the Second Military Medical University, 168 Changhai Road, Shanghai, 200433 China
- Digestive Endoscopy Center, Changhai Hospital, the Second Military Medical University, Shanghai, China
| | - Xin-Ying Tang
- Department of Gastroenterology, Digestive Endoscopy Center, Changhai Hospital, the Second Military Medical University, 168 Changhai Road, Shanghai, 200433 China
| | - Xi Jiang
- Department of Gastroenterology, Digestive Endoscopy Center, Changhai Hospital, the Second Military Medical University, 168 Changhai Road, Shanghai, 200433 China
| | - Wei Qian
- Department of Gastroenterology, Digestive Endoscopy Center, Changhai Hospital, the Second Military Medical University, 168 Changhai Road, Shanghai, 200433 China
| | - Wen-Bin Zou
- Department of Gastroenterology, Digestive Endoscopy Center, Changhai Hospital, the Second Military Medical University, 168 Changhai Road, Shanghai, 200433 China
| | - Lei Xin
- Department of Gastroenterology, Digestive Endoscopy Center, Changhai Hospital, the Second Military Medical University, 168 Changhai Road, Shanghai, 200433 China
| | - Bo Li
- Department of Anesthesiology, Changhai Hospital, the Second Military Medical University, Shanghai, China
| | - Yan-Fen Qi
- Department of Gastroenterology, Digestive Endoscopy Center, Changhai Hospital, the Second Military Medical University, 168 Changhai Road, Shanghai, 200433 China
| | - Liang-Hao Hu
- Department of Gastroenterology, Digestive Endoscopy Center, Changhai Hospital, the Second Military Medical University, 168 Changhai Road, Shanghai, 200433 China
- Digestive Endoscopy Center, Changhai Hospital, the Second Military Medical University, Shanghai, China
| | - Duo-Wu Zou
- Department of Gastroenterology, Digestive Endoscopy Center, Changhai Hospital, the Second Military Medical University, 168 Changhai Road, Shanghai, 200433 China
- Digestive Endoscopy Center, Changhai Hospital, the Second Military Medical University, Shanghai, China
| | - Zhen-Dong Jin
- Department of Gastroenterology, Digestive Endoscopy Center, Changhai Hospital, the Second Military Medical University, 168 Changhai Road, Shanghai, 200433 China
- Digestive Endoscopy Center, Changhai Hospital, the Second Military Medical University, Shanghai, China
| | - Dong Wang
- Department of Gastroenterology, Digestive Endoscopy Center, Changhai Hospital, the Second Military Medical University, 168 Changhai Road, Shanghai, 200433 China
- Digestive Endoscopy Center, Changhai Hospital, the Second Military Medical University, Shanghai, China
| | - Yi-Qi Du
- Department of Gastroenterology, Digestive Endoscopy Center, Changhai Hospital, the Second Military Medical University, 168 Changhai Road, Shanghai, 200433 China
- Digestive Endoscopy Center, Changhai Hospital, the Second Military Medical University, Shanghai, China
| | - Luo-Wei Wang
- Department of Gastroenterology, Digestive Endoscopy Center, Changhai Hospital, the Second Military Medical University, 168 Changhai Road, Shanghai, 200433 China
- Digestive Endoscopy Center, Changhai Hospital, the Second Military Medical University, Shanghai, China
| | - Feng Liu
- Department of Gastroenterology, Digestive Endoscopy Center, Changhai Hospital, the Second Military Medical University, 168 Changhai Road, Shanghai, 200433 China
- Digestive Endoscopy Center, Changhai Hospital, the Second Military Medical University, Shanghai, China
| | - Zhao-Shen Li
- Department of Gastroenterology, Digestive Endoscopy Center, Changhai Hospital, the Second Military Medical University, 168 Changhai Road, Shanghai, 200433 China
- Digestive Endoscopy Center, Changhai Hospital, the Second Military Medical University, Shanghai, China
- Shanghai Institute of Pancreatic Diseases, Shanghai, China
- National Clinical Research Center of Digestive Diseases, Shanghai, China
| | - Zhuan Liao
- Department of Gastroenterology, Digestive Endoscopy Center, Changhai Hospital, the Second Military Medical University, 168 Changhai Road, Shanghai, 200433 China
- Digestive Endoscopy Center, Changhai Hospital, the Second Military Medical University, Shanghai, China
- Shanghai Institute of Pancreatic Diseases, Shanghai, China
- National Clinical Research Center of Digestive Diseases, Shanghai, China
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