Chronic Calcific Pancreatitis: Combination ERCP and Extracorporeal Shock Wave Lithotripsy for Pancreatic Duct Stones

Christopher Lawrence, MD; M. Faisal Siddiqi; Jonathan N. Hamilton, MD; Thomas E. Keane, MBBCh; Joseph Romagnuolo, MD; Robert H. Hawes, MD; Peter B. Cotton, MD

Disclosures

South Med J. 2010;103(6):505-508. 

In This Article

Abstract and Introduction

Abstract

Background: Chronic pancreatitis is commonly associated with debilitating abdominal pain, in part due to pancreatic duct obstruction. Pancreatic stones are often impossible to extract from the duct with endoscopic retrograde cholangiopancreatography alone. Extracorporeal shock wave lithotripsy (ESWL) is commonly used for fragmentation of obstructing nephrolithiasis and has demonstrated effectiveness in management of pancreatic stones. Our aim was to examine the outcomes of the first 30 patients with symptomatic pancreatic stones treated with a combination of ESWL and endoscopic therapies.
Methods: Patients with symptomatic chronic calcific pancreatitis referred for ESWL (2005–2009) were included. Technical success of ESWL was defined as a) stone fragmentation sufficient to allow extraction of main duct stones at ERCP or b) absence of the targeted main pancreatic duct stones on follow-up radiography. Clinical success of ESWL was defined by Patient Global Impression of Improvement (PGII) score of at least slightly improved.
Results: Thirty patients underwent ESWL. One patient was excluded due to adenocarcinoma. Technical success was achieved in 17/29 (58.6%) patients. 25 (86.2%) patients were available for follow-up (median 35 months, range 3–52 months). Fifteen of twenty-five (60%) patients experienced clinical improvement (10 patients very much improved), but there was no significant reduction in the proportion taking narcotics (50% before vs. 44.4% after ESWL). Pancreatic surgery has been avoided to date in 16 (64%) of the 25 patients.
Conclusions: A multidisciplinary approach, combining ERCP and ESWL, to painful obstructing pancreatic duct stones provided symptomatic improvement and allowed pancreatic surgery to be avoided in the majority of patients.

Introduction

Chronic pancreatitis is commonly associated with debilitating abdominal pain that may be episodic or continuous. The pathogenesis of pain in chronic pancreatitis is likely multifactorial with contributions from ischemia, neural factors, circulating oxygen-free radicals, and pancreatic duct obstruction with resultant ductal hypertension.[1] Endoscopic and some surgical treatments focus on relief of the purported increased ductal pressure.[2–4] Endoscopic retrograde cholangiopancreatography (ERCP) allows pancreatic sphincterotomy, stricture dilation, stenting, and stone extraction. However, pancreatic duct stone removal is often difficult due to size or hardness of the stones.

Extracorporeal shock wave lithotripsy (ESWL) is a standard treatment for fragmentation of obstructing nephrolithiasis. It has been used widely overseas for treating pancreatic stones but has had limited application in the US.[2–6] The use of ESWL for chronic calcific pancreatitis was introduced at the Medical University of South Carolina (MUSC) in 2005 through a collaborative effort involving the Division of Gastroenterology and the Department of Urology. We report our experience on the first 30 patients with symptomatic pancreatic stones treated with a combination of ESWL and endoscopic therapies.

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