Endoscopic treatment of pancreatic duct stones under direct vision: Revolution or resignation? Systematic review

Abstract

Background and Aim: The main treatment aim in chronic pancreatitis (CP) is symptom control and especially pain relief. Management of stone-predominant CP is challenging and requires a multidisciplinary approach. Extracorporeal shock wave lithotripsy (ESWL) has emerged as the cornerstone of nonsurgical treatment as a result of disappointing results of available endoscopic treatment options during the last decades. With new developments in the field of direct peroral pancreatoscopy (POP) and intracorporeal lithotripsy, direct intraluminal treatment of main pancreatic duct (MPD) stones returns to the spotlight.Methods: Herein, we reviewed the current data on direct pancreatoscopic treatment of MPD stones with a focus on efficiency and safety of available technologies, endoscopes and lithotripsy devices. A systematic Medline search for relevant studies was done.Results: Ten relevant publications meeting the inclusion criteria were identified (two prospective series, six retrospective trials, two case reports, n = 87 patients). Successful ductal clearance for POP-guided treatment was reported as between 43% and 100% compared to ESWL with 59% to 80%. Adverse event rate for POP-guided therapy was reported as 0-13.5%. One study showed a noticeable higher adverse event rate of 43%. In this trial, POP was carried out after ESWL. There is no reported mortality following POP treatment. Conclusion:Available results are promising in terms of ductal clearance and pain relief compared to standard endoscopic techniques and ESWL as the current gold standard for lithotripsy. Interpretation of this data is limited by the small number of cases for POP and the lack of prospective randomized controlled trials.

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“…Due to the small cohort, no definite answer can be provided as to whether laser lithotripsy or EHL is more effective. However, it is in line with reported PEP rates in average high-risk ERCP patients of 20.2 % to 40 % [14 -15] and in SOVP patients with PEP up to 28 % [2,4,6]. Risk factors include patient-, physician-or procedure-related and are additive [14].…”

Success of extracorporeal shock wave lithotripsy and ERCP in symptomatic pancreatic duct stones: a systematic review and meta-analysis

“…Intraductal lithotripsy techniques, including laser lithotripsy (LL) and electrohydraulic lithotripsy (EHL), can be attempted either after failure of ESWL or before in an experimental setting. Literature on these lithotripsy techniques in PD stones is scarce, with only one systematic review published showing complete ductal clearance in 43-100 % and adverse events in 0 % to 13.5 % [45]. Large, prospective studies are needed to prove efficiency and safety of these techniques and to compare outcomes with ESWL.…”

Endoscopic and Conservative Management of Chronic Pancreatitis and Its Complications

“…Howell et al [82] first described MPD stone removal under direct visualization using an electrohydraulic lithotripsy (EHL) probe in 1999. A systematic review from 2017 including 88 patients from 10 publications, among them 2 prospective studies, showed high treatment success rates with acceptable complication rates [83]: 5 studies used EHL, 4 studies used laser, 1 study used a basket for stone extraction, 1 study compared laser with EHL, and 1 study used a combination of ESWL first, followed by EHL during POP. The study in which ESWL had been performed before POP described an exceptionally low treatment success (43%) and the highest complication rate (28%) [84].…”