Ikeura T. et al., 2025: Complete clearance of painless pancreatic stones with endotherapy prevents the progression of pancreatic parenchyma atrophy in patients with chronic pancreatitis: Multicenter cohort study.

Tsukasa Ikeura, Ayaka Takaori, Kazuhiro Kikuta, Ken Ito, Tetsuya Takikawa, Takaaki Eguchi, Tadahisa Inoue, Yasuki Hori, Kenji Nakamura, Mamoru Takenaka , Yoshio Sogame, Tadayuki Takagi, Nao Fujimori, Satoshi Yamamoto, Akira Nakamura, Toshitaka Sakai, Arata Sakai, Takashi Tamura, Tomotaka Saito, Koichi Fujita, Atsushi Kanno, Kunihiro Hosono, Keisuke Iwata, Atsushi Irisawa, Kazuhisa Okamoto, Masaki Kuwatani, Makoto Naganuma, Atsushi Masamune, Yoshifumi Takeyama; Japan Pancreatitis Study Group for CP
Dig Endosc. 2025 Feb 27. doi: 10.1111/den.14998

Abstract

Objectives: This retrospective multicenter study aimed to clarify the clinical impact of endotherapy for painless pancreatic duct (PD) stones compared with that in patients who received conservative treatment without endotherapy.

Methods: We enrolled 268 patients suffering from chronic pancreatitis with painless PD stones (145 with endotherapy and 123 without endotherapy) and evaluated the impact of endotherapy for painless PD stones on clinical and radiological outcomes.

Results: When conservative treatment without endotherapy was set as a reference, complete clearance of the targeted PD stones decreased the relative risk for atrophy of pancreatic parenchyma after inclusion (hazard ratio [HR] 0.42; 95% confidence interval [CI] 0.21-0.84). Incomplete clearance of the targeted PD stones was identified as a risk factor for new-onset or worsening of diabetes (HR 2.08; 95% CI 1.10-3.91) and inducement of pain attack (HR 4.03; 95% CI 1.45-11.19), although complete clearance was not correlated with these outcomes.

Conclusion: In chronic pancreatitis patients with painless PD stones, endotherapy with complete stone clearance allows the maintenance of pancreatic parenchymal volume. However, if complete clearance fails, endotherapy could lead to aggravation of glucose tolerance and pain attacks during follow-up.

Comment Peter Alken

They may get trouble! None of the 13 authors was co-author of the 2021 Evidence-based clinical practice guidelines for chronic pancreatitis by the Guidelines Committee for Creating and Evaluating the ‘‘Evidence-Based Clinical Practice Guidelines for Chronic Pancreatitis’’ of the Japanese Society of Gastroenterology (1) And the 2020 International consensus guidelines on interventional endoscopy in chronic pancreatitis (2) has a clear statement: “Endoscopic or surgical treatment should be offered to patients with chronic pancreatitis with persistent severe pain. Intervention in the form of either surgery or endotherapy is not recommended in asymptomatic patients with chronic pancreatitis who do not have abdominal pain to improve pancreatic exocrine and/or endocrine function or chronic pancreatitis.”
As a urologist I better don’t mix into this debate. However, I think that this a very detailed multicentre study that certainly will stimulate a debate. It reminds me of the urological debate on small asymptomatic kidney stones and – who knows? – maybe in the future we will read a paper on “Facilitated clearance of small, asymptomatic, pancreatic stones with burst wave lithotripsy and ultrasonic propulsion.” from the BWL group (3).
1 Shimizu K, et al. Evidence-based clinical practice guidelines for chronic pancreatitis 2021. J Gastroenterol. 2022 Oct;57(10):709-724. doi: 10.1007/s00535-022-01911-6.

2 Kitano M, et al. International consensus guidelines on interventional endoscopy in chronic pancreatitis. Recommendations from the working group for the international consensus guidelines for chronic pancreatitis in collaboration with the International Association of Pancreatology, the American Pancreatic Association, the Japan Pancreas Society, and European Pancreatic Club. Pancreatology. 2020 Sep;20(6):1045-1055. doi: 10.1016/j.pan.2020.05.022.

3 Harper JD, et al. Facilitated clearance of small, asymptomatic, renal stones with burst wave lithotripsy and ultrasonic propulsion. J Urol. 2025 Mar 17:101097JU0000000000004533. doi: 10.1097/JU.0000000000004533.

Peter Alken