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

BACKGROUND: Extracorporeal shock wave lithotripsy (ESWL) is a common treatment for pancreatic stones in chronic pancreatitis. In contrast, peroral pancreatoscopy-guided lithotripsy (POPS-L) remains underexplored, with limited comparative studies to ESWL. This study compared the treatment outcomes of disposable POPS-L tools and ESWL for pancreatic stones. METHODS: A retrospective analysis was conducted on 66 patients who had undergone pancreatic stone treatment at three institutions between 2006 and 2022. The treatment outcomes of POPS-L and ESWL were compared. RESULTS: This study included 19 and 47 patients who had undergone POPS-L and ESWL, respectively. In a comparison between POPS-L and ESWL, the stone clearance rates were 78.9% vs. 70.2% (p = 0.55), while the procedure-related complication rates were 21% vs. 6.3% (p = 0.09). The median total session counts were 1 vs. 5 (p < 0.01). The cumulative stone recurrence rates were comparable in both groups. Multivariate analysis revealed no significant factors influencing the stone clearance rates, and the choice between POPS-L and ESWL did not affect the stone clearance rates. CONCLUSIONS: POPS-L and ESWL exhibited comparable treatment outcomes in terms of stone clearance, complications, and recurrence rates. Furthermore, POPS-L is advantageous due to the need for fewer sessions to achieve pancreatic stone clearance.

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.

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.

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.

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

BACKGROUNDS/OBJECTIVES: Patients with chronic pancreatitis may develop pancreatic duct stones that can obstruct outflow leading to ductal hypertension and pain. Both endoscopic retrograde pancreatography (ERP) with per-oral pancreatoscopy (POP) and intraductal lithotripsy and extracorporeal shock wave lithotripsy (ESWL) are feasible options to attempt ductal stone clearance. This study aims to compare POP-guided lithotripsy with ESWL in the management of refractory symptomatic main pancreatic duct stones. METHODS: This is an open-label, multi-center, parallel, randomized clinical trial. Patients with chronic pancreatitis and main pancreatic duct stones ≥5 mm who fail standard ERP methods for stone removal will be eligible for this study. In total, 150 subjects will be randomized 1:1 to either ESWL or POP. A maximum of 4 sessions of either ESWL or POP will be allowed in each arm, with crossover permitted thereafter. The primary outcome is complete stone clearance and secondary outcomes include quality of life, pain scores, number of interventions, and daily opiate requirements. CONCLUSIONS: This study aims to answer the question of which lithotripsy method is superior in removing refractory pancreatic duct stones while addressing the effects of lithotripsy on quality of life and pain in patients with chronic calcific pancreatitis (ClinicalTrials.gov NCT04115826).

EUS-guided pancreatic duct drainage with rendezvous technique for post-Whipple pancreatic duct stone.

Video 1EUS-guided pancreatic drainage using the rendezvous technique in a patient with pancreaticojejunal anastomosis stenosis and pancreatic duct stone.

[Conservative or surgical treatment of chronic pancreatitis?] / Konservative oder chirurgische Therapie der chronischen Pankreatitis?

The cardinal symptom of chronic pancreatitis is severe belt-like upper abdominal pain, which requires immediate and adequate treatment. Furthermore, advanced stage chronic pancreatitis is often associated with complications, such as pancreatic pseudocysts, pancreatic duct stones and stenosis as well as biliary stenosis. The various endoscopic and surgical treatment options for chronic pancreatitis patients have been controversially discussed for decades. The new German S3 guidelines on pancreatitis now clearly define the best treatment options depending on the indications for treatment. For the treatment of pain in chronic pancreatitis it has been known for a long time that a surgical intervention is superior to endoscopic intervention concerning long-term pain relief. The recently published ESCAPE study has further underlined this by showing that early surgical intervention was superior to a step-up approach with initial endoscopic treatment. For the treatment of pancreatic pain, an initial endoscopic treatment attempt is therefore justified for short-term pain relief but in the midterm and long term, surgical intervention is the treatment of choice. In contrast, pancreatic pseudocysts, solitary proximally situated pancreatic duct stones and benign biliary strictures (except in calcifying pancreatitis) can nowadays generally be managed endoscopically. For distal pancreatic duct stones and symptomatic pancreatic duct stenosis surgical treatment is again the method of choice. This review article discusses these indication-related procedures in detail and explains them in relation to the recently published S3 guidelines on pancreatitis of the German Society for Gastroenterology, Digestive and Metabolic Diseases (DGVS).

Head and tail pancreatic duct stones mimicking duplex staghorn renal calculi: A rare case.

INTRODUCTION: Pancreatolithiasis is an uncommon disease and the diagnosis of pancreatic duct stones is challenging. The radiological findings of pancreatic duct stones may mimic other diseases, such as renal stones. CASE PRESENTATION: A 42-year-old male came with chief complaint of recurrent bilateral flank pain accompanied by fever which worsen 7 days before admission. The patient was diagnosed as gastritis and received analgesics in several hospitals. Ultrasonography and IVP examinations showed stones in both kidneys. CT-scan was not performed due to limitation in the hospital. Patient was diagnosed bilateral staghorn nephrolithiasis. The patient underwent bilateral bivalve nephrotomy for staghorn renal stone performed by urologist, but intraoperatively, no stones were found. The patient was then consulted intraoperatively to the digestive surgeon and get immediate median laparotomy. Intraoperatively, stones were palpated in the head and tail of the pancreas. The stones were evacuated. The symptoms were relieved, neither recurrence, nor pain, nor postoperative leakage was found. Patient was discharged uneventfully 4 days after the procedure and had no complaints in further follow-ups. DISCUSSION: The symptoms of pancreatolithiasis may overlap with nephrolithiasis and gastritis. The presented case was unique because from the history taking, clinical symptoms, USG, and IVP findings supported the diagnosis of nephrolithiasis, but intraoperative findings reveal pancreatic duct stones. CONCLUSION: For patient diagnosed with renal calculi based on sonography and IVP findings, differential diagnosis of pancreatic stone should be considered especially if no underlying cause is detected. In such circumstances relying on IVP and sonographic findings alone can be misleading.

Acute Pancreatitis in Pancreas Divisum Secondary to an Impacted Stone in the Minor Papilla.

Pancreas divisum is reported to occur in up to 14% of the population. The majority of patients with this congenital anomaly remain asymptomatic. Pancreas divisum can be associated with recurrent pancreatitis due to inadequate drainage of pancreatic secretions through the dorsal pancreatic duct and the minor papilla. We present a patient with a six-month history of recurrent acute pancreatitis due to an impacted pancreatic duct stone in the minor papilla and an unrecognized pancreas divisum. This situation has only been reported in two other cases in the literature.

Laparoscopic pancreatic duct incision and stone removal and T-type tube drainage for pancreatic duct stone: A case report and review of literature.

To study a more micro-invasive procedure for patients having pancreatic duct stones (PDS). Till now, there has been no report of laparoscopic pancreatic duct incision and stone removal and T-type tube drainage for PDS in the English literature. An 82-year-old man suffered from subxiphoid pain associated with a dilated pancreatic duct (7 mm) containing one stone, but without a mass in the head of the pancreas. Laparoscopic pancreatic duct incision, stone removal, and T-type tube drainage were successfully performed without intraoperative or postoperative complications. An uneventful operation was performed with laparoscopically completed procedures in 160 min. The intraoperative loss of blood was around 50 mL. After patient a discharge on day 11, complete relief from the subxiphoid pain was reported at a follow-up visit 15 mo later. Laparoscopic pancreatic duct incision with stone removal and T-type tube drainage is applicable in carefully selected patients and can be effectively and safely used for the treatment of the abdominal pain of chronic pancreatitis.

Surgical and micro-invasive treatment of pancreatic duct stones: an analysis of 42 patients / 中华肝胆外科杂志

Pancreatic duct stone is a sequel of chronic pancreatitis and may be found in the main ducts,side branches or parenchyma.These stones obstruct the pancreatic ducts and produce ductal hypertension,which leads to pain,the cardinal feature of CP.Surgical operation has been the preferred treatment of pancreatic duct stones in many domestic and external pancreatic medical centers.Lithotomy by longitudinal pancreatic duct incision and Roux-en-Y anastomosis of pancreatic duct to jejunum is the main and effective surgical procedure,while micro-surgery was also rational for the treatment of pancreatic duct stones.However,further studies with a larger sample size and longer follow-up duration are needed to improve the surgical technique and verify our initial results.

Pancreatic duct stones: A report on 16 cases.

BACKGROUND: Pancreatolithiasis occurs in less than 1% of the general population and is mainly recognized in patients with chronic pancreatitis. Selection of the appropriate treatment method depends on the location, size and number of stones. OBJECTIVES: The aim of the study was to analyze data concerning patients with pancreatic duct stones who were hospitalized at Wroclaw Medical University's Department of Gastroenterology and Hepatology from 2010 to 2014. MATERIAL AND METHODS: The study presents data on 16 patients with pancreatic duct stones, who constituted 7% of all 228 patients with chronic pancreatitis hospitalized at the Department in the study period. The clinical data were compared with findings reported in the literature. RESULTS: Epigastric pain was the most common symptom reported by patients with pancreatolithiasis. The sensitivity of imaging tests in the diagnosis of pancreatic duct stones was as follows: abdominal ultrasonography - 31%, endoscopic retrograde cholangiopancreatography (ERCP) - 67%, computed tomography - 71%, endoscopic ultrasonography - 73%. In 6 patients ERCP and sphincterotomy were performed along with stenting of the main pancreatic duct. Three other subjects were qualified for surgical treatment. In 7 selected patients conservative treatment and further observation were applied. CONCLUSIONS: Endoscopic ultrasonography is characterized by high sensitivity in the diagnosis of pancreatic duct stones. ERCP is the first-line treatment in the case of a small number of stones with sizes below 5 mm located in the head or body of the pancreas. In the case of stones with sizes ≥ 5 mm, extracorporeal shock wave lithotripsy should be performed before endoscopic drainage during ERCP. Stenosis of the main pancreatic duct is the key risk factor for the recurrence of pancreatolithiasis.

Total pancreatic head resection with duodenum and bile duct preserving: a report of 31 patients / 中华肝胆外科杂志

Objective To investigates the role of duodenum and bile duct preserving pancreatic head resection (DBPPHR) in treatment of benign or low-grade malignant diseases located in the head of pancreas.Methods The clinical data of 31 patients who underwent DBPPHR between April 2012 to May 2016 in Zhejiang Provincial People's Hospital and Zhangzhou Municipal Hospital of Fujian Province were analyzed retrospectively.Results Of the 31 patients,4 patients underwent laparoscopic DBPPHR.One patient in the open group was converted to pancreaticoduodenectomy.For the open group,the mean operation time was (165.3 ±63.6) min;the mean estimated blood loss was (258.1 ± 156.9) ml;and the mean postoperative stay was (11.7 ± 6.3) days.The postoperative complications included 1 reoperation due to postoperative bleeding,1 bile leakage and 13 patients developed grade A pancreatic fistula (48.2％).For the laparoscopic group,the mean operation time was 350.0 (280.0 ～ 450.0) min;the mean estimated blood loss was 425.0 (250.0 ～600.0) ml;and the mean postoperative stay was 14 days.Three patients developed postoperative pancreatic fistula (grade A).The pathological diagnosis were:12 patients with pancreatolithiasis,8 patients with serous cystadenoma,4 patients with branched intraductal papillary mucinous neoplasm,5 patients with neuroendocrine tumor and 2 patients with mucinous cystadenoma.The follow-up period was 1 ～ 48 month,and there was no patient with diabetes or diarrhea.Conclusions DBPPHR was safe and efficacious.It is less invasive to treat benign or low-grade malignant diseases located in the head of pancreas.

Innovations in Intraductal Endoscopy: Cholangioscopy and Pancreatoscopy.

Cholangioscopy was first performed in the 1970s. We now use the term cholangiopancreatoscopy (CP) to reflect the wider application of these miniature reusable dual-operator "mother-daughter" endoscope systems and now fully disposable and digital single-operator optical catheters for evaluating the biliary or pancreatic duct. Cholangioscopy is an established modality for the management of large biliary stones and for the diagnosis and exclusion of biliary tumors. Pancreatoscopy is increasingly being performed to treat difficult pancreatic duct stones and may be used to distinguish malignant from benign ductal pathology. This review covers available CP technologies, indications, technique, efficacy, and complications.

Surgical treatment of patients with pancreatic ductal stones: a report of 60 cases / 中华肝胆外科杂志

Objective To analyze the perioperative complications and prognosis of surgical treatment of pancreatic ductal stones.Methods 60 patients diagnosed to have pancreatic ductal stones and were admitted into our hospital from January 2009 and December 2014 were enrolled into this retrospective study.There were 47 males and 13 females.The average age was (44.1 ± 12.0).Results All patients underwent surgical operation and there was no perioperative death.Perioperative complications occurred in 7 patients (11.7％), including pancreatic fistula in 4 patients, delayed gastric emptying in 1 patient, abdominal infection in 1 patient, anastomotic bleeding in 1 patient.Eight patients developed elevated amylase levels.The fasting time was 3.4 ± 1.2 days and the hospital stay was 10.0 ±4.0 days.The follow-up rate was 88.3％ (53/60), at a mean follow-up of 27 months.In 51 patients who presented with abdominal pain, 43 patients (84.3％) had complete pain relief and 7 patients (13.7％) had partial pain relief.In 14 patients with preoperative diabetes mellitus, 1 patient had improvement and 2 patients recovered from diabetes.Two additional patients were diagnosed to have diabetes two years after the operation.Of the 2 patients who were shown to have pancreatic cancer on histopathological study, 1 patient was lost to follow-up while another patient died at 27 months after the operation.The patients diagnosed to have epithelial dysplasia were followed-up and none developed pancreatic cancer.Conclusions The relationship between chronic pancreatitis and pancreatic ductal stones was very close.Chronic pancreatitis also caused exocrine and endocrine dysfunction.Surgical operation plays an important role in symptomatic relief and in delaying pancreatic dysfunction.

Experience for diagnosis and surgical treatment of 21 patients with pancreatic duct stone / 中国医师进修杂志

ObjectiveTo explore diagnosis and surgical treatment of pancreatic duct stone.MethodsClinical data of 21 patients with pancreatic duct stone was analyzed retrospectively. All patients were diagnosed definitely by B-ultrasonography,CT and MRI, the positive rates were 90.5％( 19/21 ),66.7％(14/21) and 55.6％ (5/9) respectively, 15 cases did transpancreatic duct lithotomy and pancreatico-intestinal anastomosis, 1 case excised the tail of pancreas simultaneously, 1 case did pancreaticoduodenectomy, 4 cases treated by endoscopy. ResultsAll operations succeeded, 1 case occurred with pancreatic leakage after a small amount of discharge tube, 1 case appeared acute pancreatitis after endoscopic treatment,who was discharged after conservative treatment. Following up 19 cases from 4 to 72 months, the symptom was released, no stone relapsed,6 cases with mild catarrhal dysentry. ConclusionB-ultrasonography, CT can basically make definite diagnosis for pancreatic duct stone, and B-ultrasonography has higher rate of diagnosis, transpancreatic duct lithotomy and pancreatico-intestinal anastomosis are the main surgical treatments, endoscopy is the method to treat pancreatic duct stone.

Clinical characteristics and surgical treatment of pancreatic duct stone / 中华内分泌外科杂志

Objective To explore clinical characteristics and surgical treatment of pancreatic duct stone.Methods Clinical data of 25 cases pancreatic duct stone undergoing operation from 1990 to 2008 were retrospectively analyzed. Results All of the 25 cases suffered upper abdominal pain, among whom 8 cases were concomitant with type 2 diabetes mellitus, 5 with steatorrhea, 2 with obstructive jaundice, 1 with pancreatic head cancer and 6 with acute pancreatitis recurrence history. All cases were confirmed by imaging diagnosis, such as ultrasonography, abdominal X-ray film, CT, endoscopic retrograde cholangiopancreatography and magnetic resonance cholangiopancreatography. 20 cases underwent pancreolithotomy with Roux-en-Y side-to-side pancreaticojejunostomy. 4 cases underwent body-tail pancreatectomy with pancreatojejunostomy and 1 case underwent pancreatoduodenectomy. No complication was found. 25 cases were followed for 2 months to 4 years after operation. Among all 25 cases with upper abdominal pain, 20 cases got rid of the symptoms and 5 cases were relieved postoperatively.Among 8 cases with diabetes mellitus, 4 cases resumed normal blood glucose postoperatively. Among 5 cases with steatorrhea, steatorrhea disappeared in 2 cases and 1 case were alleviated postoperatively. Conclusions Imaging examinations are the main diagnostic methods for pancreatic duct stone. Pancreolithotomy and Roux-en-Y side-toside pancreaticojejunostomy are effective operative techniques.

What is the role of endotherapy in chronic pancreatitis?

Chronic pancreatitis (CP) can have debilitating clinical course due to chronic abdominal pain, malnutrition and related complications. Medical, endoscopic and surgical treatment of CP should aim at control of symptoms, prevention of progression of the disease and correction of complications. Endoscopic management plays a specific role in carefully selected patients as primary interventional therapy when medical measures fail or in high-risk surgical candidates. Endotherapy for CP is utilized also as a bridge to surgery or to assess potential response to pancreatic surgery. In this review we address the role of endotherapy for the relief of obstruction of the pancreatic duct (PD) and bile duct, closure of PD leaks and drainage of pseudocysts in the setting of CP. In addition, endotherapy for relief of pancreatic pain by endoscopic ultrasound-guided celiac plexus block for CP is discussed.

Migrating pancreatic duct stone: a case report / 한국간담췌외과학회지

Most reports describe acute gallstone pancreatitis as a result of common bile duct and pancreatic duct obstruction at the Ampulla of Vater. The pathophysiology leading to the development of pancreatitis includes the common channel theory of obstruction leading to bile reflux, ductal hypertension secondary to pancreatic duct obstruction, and sphincter incompetence with duodenal content reflux.Rarely stones which from common bile duct have been demonstrated by ERCP to lie within the pancreatic duct. We experienced the patient who complained epigastric and RUQ pain. She was 51-year-old and had both intrahepatic duct, common bile duct stones and pancreatic duct stone. Initial amylase and lipase was 112 IU/L, 1925 U/L. We performed Lt. lateral segmentectomy, Roux-en-Y choledochojejunostomy, distal pancreatectomy. So We report this case.

A Case of a Pancreaticobiliary Fistula Accompanied by Pancreatic Duct Stones / 대한소화기내시경학회지

A Pancreaticobiliary fistula is a rare complication of acute necrotizing pancreatitis or pancreatic abscess. One case is herein reported of pancreaticobiliary fistula that was found following removal of pancreatic duct stones by extracorporeal shock-wave lithotripsy and endoscopic sphincterotomy. The patient was a 53-year old woman who was admitted with epigastric pain and fever. Endoscopic retrograde pancreatography revealed multiple stones in the main pancreatic duct. Pus from the pancreatic duct was drained through the major papilla during cannulation. On balloon cholangiogram obtained after removal of the stones, a direct fistulous connection between the main pancreatic duct and distal common bile duct was noted. It is speculated that pancreatic abscess or mechanical compression of pancreatic duct stones may contribute to the destruction of the intrapancreatic bile duct, which leads to the formation of a pancreaticobiliary fistula.

The management of pancreatolithiasis:a report of 37 cases / 中国普通外科杂志

Objective To study the surgical treatment of pancreatolithiasis.Methods The clinical data of thirty-seven patients with pancreatolithiasis admitted to our hospital from 1994 to 2007 were reviewed.Results According to the results of imaging examination (BUS,CT,ERCP) and finding during surgery, pancreatolithiasis was classified into three types: TypeⅠ,the stones were mainly located in the head of pancreas, and Whipple procedure was the treatment of choice. TypeⅡ, the stones were mainly located in the body and tail of pancreas, and resection of the tail of pancreas alone or combined with splenectomy was the management of choice. TypeⅢ, the stones were diffusely scattered in the main duct from the head to tail of pancreas, and pancreatoduodenectomy,together with pancreatolithotomy and pancreatojejunostomy with wide anastomotic stoma was the choice of management. There was no mortality in this series. Within 2 weeks after treatment, symptoms ameliorated to different degrees in all the patients. Thirty one patients were followed up for 6 to 72 months, the results were satisfactory.Conclusions The individualized strategy, based on the type of stone location, is of great importance in the management of pancreatolithiasis. The key of surgical treatment of pancreatolithiasis is as follows: removal of pancreatoliths, excision of diseased pancreas, and adequate pancreatic drainage.