Beyna T et al, 2017: Endoscopic treatment of pancreatic duct stones under direct vision. Revolution or resignation? A systematic review.
Beyna T, Gerges C, Neuhaus H.
Evangelisches Krankenhaus Düsseldorf, Department of Gastroenterology, Düsseldorf, Germany.
INTRODUCTION: 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. Extracorporal shock wave lithotripsy (ESWL) has emerged as the cornerstone of non-surgical treatment due to disappointing results of available endoscopic treatment options during the last decades. With new developments in the field of direct peroral pancreatoscopy (POP) and intracorporal lithotripsy, direct intraluminal treatment of main pancreatic duct (MPD) stones returns into spotlight. METHODS AND AIMS: To review the current data on direct pancreatoscopic treatment of MPD stones with focus on efficiency and safety of available technologies, endoscopes and lithotripsy devices. A systematic Medline search for relevant studies was performed. RESULTS: Ten relevant publications meeting the inclusion criteria have been identified (2 prospective series, 6 retrospective trials, 2 case reports, n=87 patients). Successful ductal clearance for POP guided treatment was reported between 43% and 100% compared to ESWL with 59% to 80%. Adverse event (AE) rate for POP guided therapy is reported with 0%-13.5%. One study showed a noticeable higher adverse event rate with 43%. In this trial POP was performed 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 lacking of prospective randomized controlled trials.
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Dig Endosc. 2017 Jun 28. doi: 10.1111/den.12909. [Epub ahead of print] Review
ESWL, usually followed by endoscopy, is regarded as a corner stone of pancreatic duct stone treatment. Success and limitations of ESWL are quoted by the authors: “Multiple studies have shown a MPD clearance after ESWL of 59% - 80% and a long term pain relief of 60 - 90%. Studies suggest that even ESWL alone is equal to ESWL followed by ERCP. But ESWL has some limitations. It is not everywhere available, an effective pain management with epidural catheter is recommended, general or intravenous anesthesia is needed and especially with more than one stone in different parts of MPD, multiple sessions are required to facilitate effective fragmentation and MPD clearance. In addition calculi with density of >820.5 Hounsfield units seem to respond less effective to ESWL.”
The literature search for direct peroral pancreatoscopy (POP), an upcoming technique, which is at present generally regarded as a third line treatment option showed only a few, low quality studies with only small patient numbers. The good results are obviously heavily biased by case selection.