Large or multiple pseudocysts can impede or complicate the nonsurgical treatment of pancreatolithiasis.

Objectives: We aimed to determine when a coexisting pseudocyst was likely to complicate the nonsurgical treatment of pancreatolithiasis. Methods: We treated 165 patients with pancreatolithiasis nonsurgically between 1992 and 2020, including 21 with pseudocysts. Twelve patients had a single pseudocyst less than 60 mm in diameter. Pseudocysts in the other nine patients had diameters of at least 60 mm or were multiple. The locations of pseudocysts along the length of the pancreas varied from the area with stone involvement to the pancreatic tail. We compared the outcomes in these groups. Results: We found no significant differences in pain relief, stone clearance, stone recurrence, or the likelihood of adverse events between pseudocyst groups or between patients with vs without pseudocysts. However, 4 of 9 patients with large or multiple pseudocysts required transition to surgical treatment (44%) compared with 13 of 144 patients with pancreatolithiasis and no pseudocyst (9.0%) (P=0.006). Conclusions: Patients with smaller pseudocysts typically underwent nonsurgical stone clearance successfully with few adverse events, similar to findings in patients with pancreatolithiasis and no pseudocysts. Pancreatolithiasis complicated by large or multiple pseudocysts did not cause more adverse events but was more likely to require transition to surgery compared with pancreatolithiasis without pseudocysts. In patients with large or multiple pseudocysts, early transition to surgery should be considered when nonsurgical treatment is ineffective.

Extracorporeal shock wave lithotripsy and endoscopic pancreatic stenting without pancreatic sphincterotomy for the treatment of pancreatolithiasis: a case series.

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.

Documento de consenso de la Sociedad Española de Endoscopia Digestiva sobre SpyGlass-DS / SEED Consensus Document on SpyGlass-DS

La colangiopancreatografía retrógrada endoscópica (CPRE) es la técnica de elección para el tratamiento de la patología biliopancreática. Sin embargo, las imágenes fluoroscópicas no siempre permiten un diagnóstico adecuado. Por otra parte, algunos cálculos de gran tamaño no se pueden extraer con los métodos habituales. En estas situaciones, la colangioscopia ha mostrado ser una herramienta fundamental para el diagnóstico de las estenosis biliares y el tratamiento de los cálculos de gran tamaño. Además, su papel en la patología pancreática está en creciente aumento. El desarrollo de un colangioscopio de un único operador y desechable ha permitido expandir la técnica entre buena parte de los hospitales que realizan CPRE. Por este motivo, la Sociedad Española de Endoscopia Digestiva ha desarrollado este documento de consenso sobre la utilización del colangioscopio Spyglass-DS. El documento ha sido elaborado por un grupo de endoscopistas expertos en colangioscopia, revisando la evidencia científica de las principales indicaciones actuales de la colangiopancreatoscopia.(AU)

Endoscopic retrograde cholangiopancreatography (ERCP) is the technique of choice for the treatment of biliopancreatic pathology. However, fluoroscopic imaging does not always allow an adequate diagnosis. On the other hand, some large stones cannot be removed by the usual methods. In these situations, cholangioscopy has proven to be an essential tool for the diagnosis of biliary strictures and the treatment of large stones. Its role in pancreatic pathology is also increasing. The development of a single-operator, disposable cholangioscope has made it possible to expand the technique to a large number of hospitals that perform ERCP. For this reason, the Spanish Society of Digestive Endoscopy has developed this consensus document on the use of the Spyglass-DS cholangioscope. The document has been prepared by a group of endoscopists with expertise in cholangioscopy, reviewing the scientific evidence on the main current indications for cholangiopancreatoscopy.(AU)

SEED Consensus Document on SpyGlass-DS. / Documento de consenso de la Sociedad Española de Endoscopia Digestiva sobre SpyGlass-DS.

Endoscopic retrograde cholangiopancreatography (ERCP) is the technique of choice for the treatment of biliopancreatic pathology. However, fluoroscopic imaging does not always allow an adequate diagnosis. On the other hand, some large stones cannot be removed by the usual methods. In these situations, cholangioscopy has proven to be an essential tool for the diagnosis of biliary strictures and the treatment of large stones. Its role in pancreatic pathology is also increasing. The development of a single-operator, disposable cholangioscope has made it possible to expand the technique to a large number of hospitals that perform ERCP. For this reason, the Spanish Society of Digestive Endoscopy has developed this consensus document on the use of the Spyglass-DS cholangioscope. The document has been prepared by a group of endoscopists with expertise in cholangioscopy, reviewing the scientific evidence on the main current indications for cholangiopancreatoscopy.

Application of peroral pancreatoscope in the diagnosis and treatment of pancreatic duct diseases (with video) / 中华消化内镜杂志

A retrospective study was conducted on data of 23 patients with pancreatic duct diseases who were underwent peroral pancreatoscopy (POPS) at the Pancreatic Center of the First Affiliated Hospital of Nanjing Medical University from August 2020 to October 2022. The intraoperative observation, postoperative complications, and the diagnosis and treatment of POPS for pancreatic duct diseases were analyzed. All patients underwent POPS and achieved technical success. Among them, 7 patients were diagnosed as having intraductal papillary mucinous neoplasm of pancreas and 3 pancreatic malignant tumor. Eight patients with pancreatolithiasis accepted laser or eletrohydraulic lithotripsy under POPS. Abdominal pain improved in 2 patients with chronic pancreatitis after treatment. Melena disappeared in 2 patients with pancreatic duct hemorrhage or pancreatic enterostomy inflammation after conservative treatment. The symptom of 1 patient with pancreatic enterostomy stenosis improved after balloon dilation. There was no complication in the 23 patients, and the operation time was 35-90 min. The results indicate POPS is safe, effective with distinctive advantages in the diagnosis and treatment for pancreatic duct diseases.

The Visceral-to-subcutaneous Adipose Tissue Area Ratio Is Associated with Retreatment in Chronic Pancreatitis Patients with Pancreatolithiasis after Extracorporeal Shock Wave Lithotripsy.

Objective Extracorporeal shock wave lithotripsy (ESWL) has been used to treat pancreatolithiasis in patients with chronic pancreatitis (CP), but the high recurrence rate remains challenging. We therefore evaluated the association between body composition parameters and the prediction of retreatment after ESWL. Methods This study retrospectively evaluated 42 patients with CP who had been treated with ESWL between 2008 and 2019 in a single center. Body composition parameters were measured on pretreatment computed tomography images. Patients who underwent repeat ESWL were classified as the retreatment group. Results There were 13 (31.0%) and 29 (69.0%) patients in the retreatment and non-retreatment groups, respectively. The visceral-to-subcutaneous adipose tissue area ratio (VSR) of the retreatment group was significantly lower than that of the non-retreatment group (p=0.016). When divided by the median VSR, 10 of the 20 patients with a VSR of <0.85 underwent retreatment, whereas 3 of the 22 patients with a VSR of ≥0.85 underwent retreatment (p=0.019). According to a multivariate analysis, the VSR (p=0.010) and age (p=0.037) were independent factors associated with retreatment after ESWL. Conclusion This study showed that the VSR can predict the retreatment of patients with CP after ESWL.

Per-oral pancreatoscopy-guided lithotripsy for the endoscopic management of pancreatolithiasis: A systematic review and meta-analysis.

OBJECTIVE: Pancreatic stones result from chronic pancreatitis and can occur in the main pancreatic duct, pancreatic branches or parenchyma. Although extracorporeal shock wave lithotripsy (ESWL) is considered the first-line treatment, per-oral pancreatoscopy (POP) has emerged as a useful method for treating pancreatic stones. The aim of this systematic review and meta-analysis was to determine the efficacy and safety of POP-guided lithotripsy, electrohydraulic lithotripsy (EHL) and laser lithotripsy (LL), in patients with pancreatolithiasis. METHODS: Literature review was conducted in PubMed, OVID, MEDLINE and Cochrane Library databases for studies published up to August 2020. RESULTS: Altogether 15 studies were analyzed, of which 11 were retrospective and four were prospective. The studies comprised 370 patients, of whom 66.4% were male. The patients underwent 218 EHL and 155 LL. The pooled technical and clinical success rate of the overall POP was 88.1% and 87.1%. For EHL-POP, the pooled technical success rate was 90.9% (95% CI 87.2%-95.2%) and the pooled clinical success rate was 89.8% (95% CI 87.2%-95.2%). While for LL-POP, the pooled technical and clinical success rate was 88.4% (95% CI 85.9%-95.1%) and 85.8% (95% CI 80.6%-91.6%). In total 43 adverse events occurred (12.1%; 95% CI 8.7%-15.5%). CONCLUSION: POP-guided lithotripsy has a high rate of technical and clinical success for managing pancreatolithiasis with a low complication rate. Both EHL-POP and LL-POP achieve similar efficacy in the endoscopic therapy of pancreatolithiasis. Further large randomized controlled trials are needed to compare EHL-POP and LL-POP with ESWL and evaluate whether POP may replace ESWL as the first-line management of pancreatolithiasis.

Obstructive pancreatolithiasis in a cat with triaditis and concurrent hypercalcaemia.

CASE SUMMARY: A 7-year-old neutered female domestic longhair cat was presented for further investigation of suspected hepatobiliary disease. Increases in serum 1,2-o-dilauryl-rac-glycero-3-glutaric acid-(6'-methylresorufin) ester lipase and hepatobiliary enzymes, with concurrent hypoalbuminaemia, were documented on blood biochemistry. Abdominal ultrasonography findings were consistent with acute pancreatitis with multiple pancreatoliths visualised within the pancreatic duct. Treatment for suspected triaditis was initiated with a hydrolysed protein diet, amoxicillin-clavulanate, hepatoprotectants and buprenorphine. Fifty-three days later, the patient presented with hypercalcaemia and obstructive pancreatolithiasis, and was euthanased. Post-mortem examination revealed severe chronic active pancreatitis with moderate chronic lymphocytic, plasmacytic cholangiohepatitis and mild chronic lymphocytic-plasmacytic duodenal enteritis (triaditis). Multiple calcium carbonate pancreatoliths present within the pancreatic ducts had resulted in pancreatic duct obstruction. RELEVANCE AND NOVEL INFORMATION: Pancreatolithiasis is a very rare condition in cats, with only five reports to date. In human medicine, pancreatolithiasis is often a sequala to chronic pancreatitis, seen in up to 50-90% of patients. However, in cats the aetiology of pancreatolithiasis, and indeed chronic pancreatitis, is poorly understood. This report describes a case of obstructive pancreatolithiasis in a cat with histopathological confirmation of triaditis and is the first report of hypercalcaemia in a cat with obstructive pancreatolithiasis. This further adds to the evidence base that pancreatolithiasis may have a similar pathogenesis to humans and can develop secondarily to chronic pancreatitis in cats.

Obstructing Pancreatic Ductal Calculus: A Case Report and Literature Review.

Pancreatic calculi are typically a sequela of chronic pancreatitis. Here, we present a patient who was found to have an obstructing one-centimeter pancreatic calculus secondary to recurrent gallstone pancreatitis. Recent retrospective studies have focused on the optimal treatment of large pancreatic calculi that were defined as greater than five millimeters. But most studies fail to comment on much larger stone as in this case report. Further guidelines and investigation need to be done aiming toward the optimal treatment of relatively large pancreatic stones.

Laparoscopy combined with holmium laser in the treatment of chronic pancreatitis complicated with pancreatic ductal stones / 中华肝胆外科杂志

Objective To study the safety and feasibility of laparoscopy combined with holmium laser in the treatment of chronic pancreatitis complicated with pancreatic ductal stones.Methods To compare the clinical data in patients who underwent laparoscopy combined with holmium laser (10 patients,group A) with those who underwent laparoscopy only (21 patients,group B) at Zhejiang Provincial People' s Hospital from January 2012 to August 2018.The operation time,intraoperative blood loss,intraoperative conversion rate,pancreatic ductal incision length,postoperative pancreatic fistula rate,length of postoperative hospital stay,residual stone rate and relief of postoperative abdominal pain rate of the two groups were documented and analyzed.Results Three of 31 patients were converted to open surgery.The remaining patients in the two groups were discharged home without any perioperative death.Group A and B were significant differences in the pancreatic ductal incision length (5.0±0.8 vs.6.5±1.0) cm,operation time (289.3±51.6 vs.349.5± 34.7) min,and postoperative hospital stay (8.0± 1.2 vs.10.2± 1.6) d between the two groups (P＜0.05).There were no significant differences in the intraoperative conversion to open rate,intraoperative blood loss,postoperative pancreatic fistula rate,residual stone rate and relief of postoperative abdominal pain rate between the two groups (P ＞ 0.05).Conclusions It was safe and feasible to treat chronic pancreatitis complicated with pancreatolithiasis by laparoscopy.Laparoscopy combined with holmium laser had the added advantages of easy access through the pancreaticojejunostomy,shorter operation time,and less intraoperative blood loss.

Bovine pancreatolithiasis: case report and review of the literature.

An 8-y-old lactating Holstein cow was presented to the herd veterinarian with a history of acute ataxia, and because of poor prognosis, the animal was euthanized and submitted for postmortem examination. A lumbar vertebra was incompletely fractured and had an adjacent subdural hematoma. The pancreas had a hard texture with exaggerated nodular appearance, and on cut surface, the pancreatic ducts appeared fibrotic and contained scores of round-to-faceted pancreatoliths of 0.5-2.0 mm diameter. These calculi extended from the major ducts to the pancreatic duct, sphincter, and into the duodenal lumen. Microscopically, the pancreas had severe acinar atrophy and dissecting glandular fibrosis. The major pancreatic ducts were ulcerated with fibrosis and inflammation. In humans, chronic pancreatitis has been linked to osteoporosis and increased risk of bone fractures. Manual evaluation of ribs at the time of autopsy did not reveal abnormalities in bone pliability or fragility in our cow.

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.

New developments in diagnosis and non-surgical treatment of chronic pancreatitis.

Chronic pancreatitis is progressive and irreversible, leading to digestive and absorptive disorders by destruction of the exocrine pancreas and to diabetes mellitus by destruction of the endocrine pancreas. When complications such as pancreatolithiasis and pseudocyst occur, elevated pancreatic ductal pressure exacerbates pain and induces other complications, worsening the patient's general condition. Combined treatment with extracorporeal shock-wave lithotripsy and endoscopic lithotripsy is a useful, minimally invasive, first-line treatment approach that can preserve pancreatic exocrine function. Pancreatic duct stenosis elevates intraductal pressure and favor both pancreatolithiasis and pseudocyst formation, making effective treatment vitally important. Endoscopic treatment of benign pancreatic duct stenosis stenting frequently decreases pain in chronic pancreatitis. Importantly, stenosis of the main pancreatic duct increases risk of stone recurrence after treatment of pancreatolithiasis. Recently, good results were reported in treating pancreatic duct stricture with a fully covered self-expandable metallic stent, which shows promise for preventing stone recurrence after lithotripsy in patients with pancreatic stricture. Chronic pancreatitis has many complications including pancreatic carcinoma, pancreatic atrophy, and loss of exocrine and endocrine function, as well as frequent recurrence of stones after treatment of pancreatolithiasis. As early treatment of chronic pancreatitis is essential, the new concept of early chronic pancreatitis, including characteristics findings in endoscopic ultrasonograms, is presented.

Pancreaticobiliary fistula associated with pancreatolithiasis.

We report here a case of pancreaticobiliary fistula associated with pancreatolithiasis. A 47-year-old female without a habit of alcohol drinking was admitted by her family physician after suffering from mild acute pancreatitis. Computed tomography revealed mild acute pancreatitis with pancreatolithiasis at the head of the pancreas. The pancreatolithiasis was exposed to the inner surface of the common bile duct and possibly compressed and narrowed the Wirsung and Santorini ducts, resulting in the pancreatitis attack. We used extracorporeal shock wave lithotripsy to treat the pancreatolithiasis. After complete elimination of stones by extracorporeal shock wave lithotripsy, endoscopic retrograde cholangiography showed an apparent pancreaticobiliary fistula between a branch of the Santorini duct and the lower portion of the common bile duct. There was no communication between the bile duct and the Wirsung duct or its branches; therefore, the diagnosis was not pancreaticobiliary maljunction. There have only been a few reports of pancreaticobiliary fistula without an association with pancreatic pseudocysts or intraductal papillary-mucinous pancreatic neoplasm, and there have only been few reports of pancreaticobiliary fistula with pancreatolithiasis.

Surgical management of chronic pancreatitis complicated with pancreatolithiasis / 中华消化外科杂志

Objective To explore the surgical management of chronic pancreatitis complicated with pancreatolithiasis (CPPL). Methods The clinical data of 66 patients with CPPL were retrospectively analyzed. Pancreatolithiasis was classified into 4 types according to the location of stones: stones located in the head of the pancreas (type Ⅰ, n=28), stones located in the body of the pancreas (type Ⅱ, n=30), stones located in the tail of the pancreas (type Ⅲ, n=1) and stones located from the head to tail of the main duct of pancreas (type Ⅳ, n=7). Ten patients (including 4 with type Ⅰpancreatolithiasis, 5 with type Ⅱ and 1 with type Ⅳ) received conservative treatment; 10 patients with type Ⅰ pancreatolithiasis underwent lithotomy under endoscope; pancreaticoduodenectomy and Beger procedure were carried out on 14 patients with type Ⅰ pancreatolithiasis, pancreatolithotomy+pancreaticojejunostomy on 25 patients with type Ⅱ pancreatolithiasis, resection of pancreatic tail and spleen on 1 patient with type Ⅲ pancreatolithiasis, and Puestow-Gillesby procedure, dividing of the neck of pancreas+removing stones from both ends of pancreatic duct+Roux-en-Y pancreatojejunostomy on 6 patients with type Ⅳ pancreatolithiasis. Results Sixty-two patients were followed up for 2 months to 15 years, and the number of patients with recurrence for type Ⅰ, Ⅱ, Ⅲ and Ⅳ pancreatolithiasis was 4, 2, 0 and 3, respectively. Conclusions Early surgical management according to the location of stones should be carried out after confirmed diagnosis of CPPL. Individualized management based on correct diagnosis and classification plays an important role in the prevention of pancreatolithiasis recurrence.

Pancreaticoduodenectomy and Pancreatic Resection in Chronic Pancreatitis

PURPOSE: Chronic pancreatitis is difficult to cure because relapse is common. In particular the removal of stone is very difficult in pancreatolithiasis (pancreatic stone), and is associated with pancreatic duct stenosis. We attempted to evaluate the risk and the outcome of pancreatic resection in chronic pancreatitis. METHODS: We retrospectively reviewed the clinical records of twelve patients with chronic pancreatitis who had undergone pancreatic resection at our hospital between January, 1991 and December, 2000. RESULTS: Pancreaticoduodenectomy was performed in nine cases and distal pancreatectomy in three cases. In the nine cases of pancreaticoduodenectomy, five cases were associated with pancreatolith and four cases were suspected malignancy. In one case of distal pancreatectomy, a pigtail drain was inserted due to postoperative pancreatic leakage. Additionally, one patient who underwent distal pancreatectomy was readmitted one year later due to recurred pancreatitis. The remaining ten patients were discharged without complications and followed up without pain. CONCLUSION: According to two complementary theories (visceral compartment syndorme and neural inflammatory theory), pancreatic resection is better than more conservative treatment, ensuring the elimination of pain. If performed by an expert surgeon, pancreatic resection is a safe and effective treatment for chronic pancreatitis.

Choledochoscopy Combined with Electrohydraulic Lithotripsy for the Treatment of Pancreatolithiasis / 中国微创外科杂志

Objective To evaluate the clinical value of choledochoscopy combined with electrohydraulic lithotripsy (EHL) for the treatment of pancreatolithiasis. Methods From October 2002 to July 2006, choledochoscopy combined with EHL was used in 11 patients with pancreatolithiasis during a dissection of the pancreatic duct combined with pancreato-jejunum Roux-en-Y anastomosis (EHL group). The data of these patients were compared with the data of 12 patients with pancreatolithiasis, who were treated by routine dissection of the pancreatic duct combined with pancreato-jejunum Roux-en-Y anastomosis from January 1995 to September 2002 (Routine group). Results The intraoperative blood loss and the postoperative rate of residual stones in the EHL group were significantly less than those in the routine group [(145.5?82.0) ml vs (406.7?384.9) ml, t=-2.201, P= 0.039; and 0% vs 41.7%, P= 0.037]. The postoperative rate of pain relief in the EHL group was higher than that in the routine group (90.9% vs 58.3%), however the difference was not significant (P=0.155). In the EHL group, 6 patients had diarrhea before the operation, 4 of them achieved relief after the surgery (4/6), which was not significantly more than that in the routine group (5/9, P=1.000). Before the operation, 7 patients in the EHL group and 9 in the routine group had diabetic mellitus; in each group, the disease was relieved in 2 patients after the operation (2/7 vs 2/9, P=0.665). Conclusions Choledochoscopy combined with EHL is effective for the treatment of pancreatolithiasis. The procedure can increase the rate of stone removal, decrease the intraoperative blood loss, and elevate the postoperative rate of pain relief.