Saleem N. et al., 2023: Timing of ERCP after extracorporeal shock wave lithotripsy for large main pancreatic duct stones.
Saleem N, Patel F, Watkins JL, McHenry L, Easler JJ, Fogel EL, Gromski MA, Lehman GA, Sherman S, Tong Y, Bick BL.
Division of Gastroenterology and Hepatology, Indiana University School of Medicine, 550 University Blvd, Suite UH1602, Indianapolis, IN, 46202-5250, USA.
Division of Gastroenterology and Hepatology, Indiana University School of Medicine, 550 University Blvd, Suite UH1602, Indianapolis, IN, 46202-5250, USA.
Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, IN, USA.
Abstract
Background and aims: Extracorporeal shock wave lithotripsy (ESWL) is performed to fragment large main pancreatic duct (MPD) stones in symptomatic patients. Subsequent endoscopic retrograde cholangiopancreatography (ERCP) is often performed to clear the stone fragments. Edema of surrounding tissue after ESWL theoretically affects the ability to perform ERCP. However, the optimal timing of ERCP after ESWL is not clearly defined. The aim of this study is to determine the efficacy and safety of same-day ERCP after ESWL and to determine if the timing of ERCP after ESWL affects outcomes.
Methods: This is a retrospective study of consecutive patients from January, 2013 to September, 2019 who received ESWL for MPD stones at our center. Included patients received subsequent same-day ERCP under the same general anesthesia session or later session ERCP (1-30 days after ESWL). Demographics, anatomical findings, history, and outcomes were collected. Success was defined as complete or near complete (> 80%) stone fragmentation with clearance.
Results: 218 patients were treated with ESWL and subsequent ERCP. 133 (61.0%) received ERCP on the same day immediately after ESWL, while 85 (39.0%) returned for ERCP at a later day (median 3.0 days after ESWL). Baseline characteristics demonstrated patients who received same-day ERCP had a higher rate of pain at baseline (94.7% vs 87.1%, p = 0.045). Main outcomes demonstrated an overall successful MPD stone clearance rate of 90.4%, with similar rates between same-day ERCP and later session ERCP (91.7% vs 88.2%, p = 0.394). Additionally, successful cannulation at ERCP, adverse events, and post-procedure admission rates were similar.
Conclusions: Delaying ERCP to allow peripancreatic tissue recovery after ESWL does not affect outcomes. Same-day ERCP after ESWL is safe and effective.
Surg Endosc. 2023 Dec;37(12):9098-9104. doi: 10.1007/s00464-023-10467-2. Epub 2023 Oct 5.PMID: 37798530
Comments 1
“During the course of this study period, the decision to perform same-day ERCP was generally based on patient preference and scheduling availability.”
This sounds as if there was no bias in patient selection that could have had an influence on the results. They admit that selection could be a bias: “The second limitation of our study pertains to its retrospective design with potential for selection bias, since we could not determine the rationale for choosing same day or delayed ERCP after ESWL in the patients we evaluated.”
For a urologist two facts are difficult to understand: 1. the number of shots applied and 2. the adverse event rates
1. “shock waves were given until the stone was adequately fragmented per physician discretion as seen on fluoroscopy or until a maximum of 11,000 shock waves were achieved.”
2. adverse events were low and not statistically not different in both groups: Group 1: 6 (4,5%), group 2 : 4 ( 4,7%).
The pancreas obviously reacts different on ESWL than kidneys.
Peter Alken