Jaben IL. et al., 2020: Comparison of Urologist- vs Gastroenterologist-Directed Extracorporeal Shock Wave Lithotripsy for Pancreaticolithiasis
Jaben IL, Cote GA, Forster E, Moran RA, Broussard KA, Scott N, Cotton PB, Keane T, Elmunzer BJ.
Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina; Department of Internal Medicine, Medical University of South Carolina, Charleston, South Carolina.
Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina.
Department of Internal Medicine, Medical University of South Carolina, Charleston, South Carolina.
NextMed Management Services, Tucson, Arizona.
Department of Urology, Medical University of South Carolina, Charleston, South Carolina.
Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina.
Abstract
Background & aims: Extracorporeal shock wave lithotripsy (ESWL) for pancreaticolithiasis is most commonly performed by urologists. We investigated the effects of transitioning from urologist- to gastroenterologist-directed ESWL on case complexity, process measures, and duct clearance.
Methods: We performed a retrospective study of patients who underwent ESWL for pancreaticolithiasis from 2014 through 2019 at a single center. We collected demographic, clinical, radiographic, and procedural data in duplicate and compared case complexity and process measures between the periods that the procedure was performed by urologists (January 2014 through February 2017; 18 patients, 0/47 patients/month) vs gastroenterologists (March 2017 through December 2019; 61 patients; 1.79 patients/month). We also compared data on pancreatic duct stone characteristics and technical success (duct clearance, determined by imaging analysis).
Results: There were no differences in patient demographics, comorbidities, pancreatic stone morphology, or time from referral to ESWL during the period the procedure was performed by urologists vs gastroenterologists. Patients received a higher mean number of ESWL shocks per session during the gastroenterology period (4341) than during the urology period (3117) (P < .001). A higher proportion of patients underwent same-session endoscopic retrograde cholangiopancreatography during the gastroenterology time period (66%) than the urology time period (6%) (P < .001). A higher proportion of patients had partial or complete duct clearance during the gastroenterology period (71%) than during the urology period (44%) (P = .04). During the urology period, a higher proportion of patients were hospitalized following ESWL, although there was no difference in captured adverse events between the periods.
Conclusions: Transition from urologist- to gastroenterologist-directed ESWL did not affect case complexity or wait times for ESWL. However, the transition did result in increased procedure volume, more shocks per ESWL session, and improved duct clearance.
Clin Gastroenterol Hepatol. 2020 Jul 23:S1542-3565(20)31004-1. doi: 10.1016/j.cgh.2020.07.042. Online ahead of print. PMID: 32712398
Comments 1
When it was shown that SWL was an excellent energy source for disintegration of pancreas stones, a collaboration between urologists and gastroenterologists was established in many places. The reason was that urologists had the lithotripters and experience of stone disintegration while gastroenterologists had the necessary experience of pancreas stones. The present article describes how the complete care of this group of patients was improved when the SWL procedure was transferred from the shared organization in which two specialists were responsible for the treatment to a unified clinical solution.
The obviously better stone clearance was explained by several changes. Not only were gastroenterologists responsible for the SWL procedure, but it was commonly possible to carry out ERCP directly after the SWL procedure. It is not mentioned in the article what kind of lithotripter that was used.
The assumption that a larger number of shockwaves was part of the success is doubtful because most pancreas stones are composed of calcium carbonate and such stone are usually brittle.
One of the greatest advantages of modern SWL is that the treatment can be carried out with only analgesics and sedatives, but this approach was obviously not utilized.
It is possible that urologists had less focus on the stone disintegration, but it is also mentioned in the article that a technician carried out the lithotripsy.
The bottom-line of this discussion is that to get the best out of SWL it is necessary to be sufficiently interested in the problem and the procedure and to apply all available tricks and auxiliary procedures that enables the least invasive treatment. There are, however, no details on how SWL was carried out.
Hans-Göran Tiselius