Endoscopic treatment of pancreatic duct stones using a 10F pancreatoscope and electrohydraulic lithotripsy.

BACKGROUND: Endoscopic therapy with adjunctive extracorporeal shock wave lithotripsy fails to provide clearance of pancreatic duct stones in up to 25% of symptomatic patients. Direct contact lithotripsy may provide an additional option for removal of refractory stones. We report our initial experience using a prototype 10F "baby" endoscope to administer electrohydraulic lithotripsy. METHODS: Five patients failing extracorporeal shock wave lithotripsy and one patient with recurrent pancreatic duct stones after surgery were selected to undergo endoscopic electrohydraulic lithotripsy. After pancreatic sphincterotomy and balloon dilation (8 or 10 mm), the 10F endoscope was introduced and electrohydraulic lithotripsy was used to fragment stones under direct visualization. RESULTS: Six patients underwent 9 intraductal electrohydraulic lithotripsy procedures. Complete or partial pancreatic duct clearance was accomplished in all but one. No complications from the lithotripsy procedure were noted. The 5 patients with partial or complete duct clearance experienced complete relief of abdominal pain of at least 6 months' duration following their final procedure. CONCLUSION: Electrohydraulic lithotripsy within the pancreatic duct provides an adjunctive endoscopic option for treatment of patients with symptomatic pancreatic duct stones. Our initial experience suggests that electrohydraulic lithotripsy therapy can successfully fragment stones refractory to conventional endoscopic stone extraction methods or extracorporeal shock wave lithotripsy. Further experience is necessary to establish the risks of electrohydraulic lithotripsy within the pancreatic duct.

Combined modality treatment of symptomatic pancreatic ductal lithiasis.

OBJECTIVE: To assess the efficacy and safety of the removal of pancreatic duct stones by a combined modality approach in patients with pancreatic ductal lithiasis and recurrent abdominal pain. DESIGN: Retrospective review with a mean follow-up of 19 months (range, 1 to 56 months). SETTING: A tertiary care, private community hospital with a university affiliation. PATIENTS: The records of patients who presented to the hospital or who were referred with recurrent abdominal pain and who were demonstrated to have pancreatic ductal lithiasis between 1989 and 1994 were reviewed. Patients were assessed by their clinical response to pancreatic duct stone extraction by a variety of therapeutic interventions. RESULTS: Fifteen patients were included in the study. One patient was excluded from analysis because of a concurrent choledochocele. Two patients required operative decompression and stone extraction for endoscopically inaccessible stones. Six patients were treated with endoscopic management alone, and six were treated with a combination of extracorporeal shock wave lithotripsy and endoscopic stone retrieval. Twelve patients had complete clearance of the pancreatic duct. One patient had a stone that was not removed, but adequate pancreatic ductal decompression was achieved. The remaining patient had incomplete clearance of pancreatic stone fragments following extracorporeal shock wave lithotripsy but had adequate ductal drainage. No patient has required further therapy or hospitalization for abdominal pain. No complications occurred as a result of any intervention in this study. CONCLUSIONS: A multidisciplinary combined modality approach is a safe and effective method for extracting pancreatic duct stones in symptomatic patients. Stone extraction and reestablishment of adequate ductal drainage appear to relieve symptoms in some patients.

Staging of renal cell carcinoma: cost-effectiveness of routine preoperative bone scans.

The use of bone scans in the evaluation of renal cell carcinoma has become routine in many centers. In a retrospective analysis of 42 patients undergoing radical nephrectomy for renal cell carcinoma, we analyzed the cost-effectiveness of routine preoperative bone scans. Although these scans accurately predict metastatic disease to bone, they are not cost-effective as a routine preoperative tool because they do not alter outcome. In selected patients with bone pain and no other positive staging studies, preoperative bone scans may be of value in the decision to perform extirpative surgery.

Surgical management of persistent, symptomatic nonvenereal sclerosing lymphangitis of the penis.

Nonvenereal sclerosing lymphangitis of the penis is a rare condition involving the distal lymphatics of the penis. Its association with trauma has been shown. Although there is a minimal inflammatory response the etiology is unknown. Clinically, the patient notices a nontender, serpiginous nodular mass just proximal to the coronal sulcus. Most cases are self-limited and conservative management is indicated. Surgical excision is warranted for persistently symptomatic lesions.

Incidence of later ureteral obstruction after antireflux surgery in infants and children.

Forty infants and children who underwent antireflux surgery for primary reflux had long-term follow-up with intravenous pyelograms (IVP). The IVPs were evaluated for the incidence of late ureteral obstruction. Although 4 cases (5.5 per cent) of early ureteral obstruction were noted, no instances of late ureteral obstruction were found. After antireflux surgery, patients should have a follow-up IVP within the first six months to rule out the possibility of early ureteral obstruction. The need for performing periodic IVPs for many years postoperatively, when obstruction is absent in the immediate postoperative period, is questioned.