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 1, Ayaka Takaori 1, Kazuhiro Kikuta 2, Ken Ito 3, Tetsuya Takikawa 2, Takaaki Eguchi 4, Tadahisa Inoue 5, Yasuki Hori 6, Kenji Nakamura 7, Mamoru Takenaka 8, Yoshio Sogame 9, Tadayuki Takagi 10, Nao Fujimori 11, Satoshi Yamamoto 12, Akira Nakamura 13, Toshitaka Sakai 14, Arata Sakai 15, Takashi Tamura 16, Tomotaka Saito 17, Koichi Fujita 18, Atsushi Kanno 19, Kunihiro Hosono 20, Keisuke Iwata 21, Atsushi Irisawa 22, Kazuhisa Okamoto 23, Masaki Kuwatani 24, Makoto Naganuma 1, Atsushi Masamune 2, Yoshifumi Takeyama 25; Japan Pancreatitis Study Group for CP
1Division of Gastroenterology and Hepatology, Kansai Medical University Hospital, Osaka, Japan.
2Division of Gastroenterology, Tohoku University Graduate School of Medicine, Miyagi, Japan.
3Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Omori Medical Center, Tokyo, Japan.
4Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, Osaka, Japan.
5Department of Gastroenterology, Aichi Medical University, Aichi, Japan.
6Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Aichi, Japan.
7Department of Gastroenterology, Tokyo Dental College Ichikawa General Hospital, Chiba, Japan.
8Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka, Japan.
9Department of Molecular Gastroenterology and Hepatology, Kyoto Prefectural University of Medicine, Kyoto, Japan.
10Department of Gastroenterology, Fukushima Medical University School of Medicine, Fukushima, Japan.
11Department of Medicine and Bioregulatory Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan.
12Department of Gastroenterology, Fujita Health University Bantane Hospital, Nagoya, Japan.
13Second Department of Internal Medicine, Shinshu University School of Medicine, Matsumoto, Japan.
14Department of Gastroenterology, Sendai City Medical Center Sendai Open Hospital, Miyagi, Japan.
15Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Hyogo, Japan.
16Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan.
17Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
18Department of Gastroenterology and Hepatology, Yodogawa Christian Hospital, Osaka, Japan.
19Department of Medicine, Division of Gastroenterology, Jichi Medical University, Tochigi, Japan.
20Department of Gastroenterology and Hepatology, Yokohama City University Hospital, Kanagawa, Japan.
21Department of Gastroenterology, Gifu Municipal Hospital, Gifu, Japan.
22Department of Gastroenterology, Dokkyo Medical University School of Medicine, Tochigi, Japan.
23Department of Gastroenterology, Faculty of Medicine, Oita University, Oita, Japan.
24Department of Gastroenterology and Hepatology, Hokkaido University Graduate School of Medicine, Hokkaido, Japan.
25Department of Surgery, Kindai University Faculty of Medicine, Osaka, Japan.
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.
Dig Endosc. 2025 Feb 27. doi: 10.1111/den.14998. Online ahead of print. PMID: 40012465
Comments 1
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