Türer ÖB. et al., 2020: Extracorporeal shock wave lithotripsy in the management of a 14-year-old girl with chronic calcific pancreatitis
Türer ÖB, Soyer T, Parlak E, Özcan HN, Bilen CY, Tanyel FC. Turk J.
Departments of Pediatric Surgery, Hacettepe University Faculty of Medicine, Ankara, Turkey.
Departments of Gastroenterology, Hacettepe University Faculty of Medicine, Ankara, Turkey.
Departments of Radiology, Hacettepe University Faculty of Medicine, Ankara, Turkey.
Departments of Urology, Hacettepe University Faculty of Medicine, Ankara, Turkey.
Background: Chronic pancreatitis is very rare in childhood and causes chronic/relapsing abdominal pain, frequent hospitalizations, malnutrition, growth retardation, and stone formation in the main duct. Although pancreatic extracorporeal shock wave lithotripsy (P-ESWL) is commonly used in the treatment of pancreatic stones (PS) in adults, the use in children is still controversial. An adolescent girl with multiple PS is presented to discuss the use of ESWL as a treatment alternative in children with PS.
Case: A 14-year-old girl was admitted with abdominal pain and elevated pancreatic enzyme levels. Abdominal US showed irregularity and rough echogenicity in pancreas revealing pancreatitis. Multiple stones were seen in main pancreatic duct on Magnetic resonance cholangiopancreatography (MRCP). Endoscopic retrograde cholangiopancreatography (ERCP) was performed and dilated pancreatic duct, thickened pancreatic secretion were detected. Endoscopic sphincterotomy was performed. Endoscopic removal of stones could not be achieved since the largest stone was 17x8 mm. Pancreatic extracorporeal shock wave lithotripsy (P-ESWL) was performed using electromagnetic lithotripter under general anesthesia. Following ESWL, fragmentation of stones in the main duct was confirmed with ERCP. After 3 sessions of ESWL, no ESWL-related complication was observed. Pain relief was achieved. The patient is still under follow-up regarding endocrine and exocrine function of pancreas.
Conclusion: ESWL may be an effective and safe management option in pediatric PS which could not be removed by ERCP. The patients managed with ESWL should be followed-up for a long time regarding the endocrine and exocrine functions of the pancreas. As in management of adult pancreatitis, clinical guidelines are needed regarding the management of pediatric PS.
Pediatr. 2020;62(4):685-689. doi: 10.24953/turkjped.2020.04.023. PMID: 32779426. FREE ARTICLE
I was surprised to read, “The stones greater than 5 mm, multiple in number and distal location cannot be removed by ERCP.”
This reflects the recommendation of the most recent guideline on the treatment of pancreatic stones (1): “ESGE recommends ESWL for the clearance of radiopaque obstructive MPD stones larger than 5mm located in the head/body of the pancreas and endoscopic retrograde cholangiopancreatography (ERCP) for MPD stones that are radiolucent or smaller than 5mm. Strong recommendation, moderate quality evidence.”
Obviously, there is work to do by the makers of flexible scopes.
1. Dumonceau JM, et. Endoscopic treatment of chronic pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Updated August 2018. Endoscopy. 2019 Feb;51(2):179-193. doi: 10.1055/a-0822-0832.