Hepatic subcapsular hematoma after extracorporeal shock wave lithotripsy (ESWL) for pancreatic stones

We present a patient with complication of huge hepatic subcapsular hematoma after extracorporeal shock wave lithotripsy (ESWL) for pancreatic lithotripsy. The hematoma measured 78–110 mm. Angiography showed a subcapsular hematoma, rather than a hematoma in the liver. In the arterial phase, the distal end of the small vessel showed spotty opacification similar to microaneurysma, suggesting that it was an injury caused by separation of the liver and its capsule, caused by the shock waves. The portal vein and hepatic vein were normal. After 8 weeks of conservative therapy, the hematoma was gradually absorbed and the patient was discharged. Eight months after the accident, the hematoma had decreased to 40 mm in size. After 20 months, it was completely absorbed. The reported rate of renal subcapsular hematoma after ESWL for renal or ureter stones is 0.1%–0.7%. To date, however, only five cases of hepatic subcapsular hematoma after right renal stone disintegration have been reported. This is the first report of hepatic subcapsular hematoma after ESWL for pancreatic stones. Received: September 11, 1998 / Accepted: April 16, 1999     

Extracorporeal shock wave lithotripsy for the treatment of pancreatic duct stones

The purpose of endoscopic therapy in chronic pancreatitis is to decompress the main pancreatic duct and to remove the obstacles that impede the ductal flow of pancreatic juice. The availability of extracorporeal shock wave lithotripsy (ESWL) has improved the results of endoscopic drainage of the main pancreatic duct and has also expanded the indications of endoscopic therapy for chronic pancreatitis. This article briefly reviews ESWL for pancreatic duct stones in patients with chronic pancreatitis, including our experience with ESWL. ESWL is an effective and safe procedure for endoscopically unremovable main pancreatic duct stones, and, in selected patients, ESWL alone may be effective.     

The endoscopic approach to pancreatic duct stones

Pancreatic duct stones may complicate the course of chronic pancreatitis and be responsible for recurrent episodes of pancreatitis and/or exacerbations of abdominal pain. Endoscopic management of pancreatic duct stones with or without extracorporeal shock-wave lithotripsy (ESWL) is a relatively safe and effective method to treat main pancreatic duct stones in symptomatic patients. Selection of candidates most likely to respond to endoscopic therapy needs further evaluation. Studies comparing medical, surgical, and endoscopic treatment of pancreatic duct stones are still awaited.     

Endoscopic transpapillary pancreatic stenting for internal pancreatic fistula with the disruption of the pancreatic ductal system

BackgroundInternal pancreatic fistula (IPF) is a well-recognized complication of pancreatic diseases. Although there have been many reports concerning IPF, the therapy for IPF still remains controversial. We herein report our experiences with endoscopic transpapillary pancreatic stent therapy for IPF and evaluate its validity.MethodSix patients with IPF who presented at our department and received endoscopic transpapillary pancreatic stent therapy were investigated, focusing on the clinical and imaging features as well as treatment strategies, the response to therapy and the outcome.ResultsAll patients were complicated with stenosis or obstruction of the main pancreatic duct, and in these cases the pancreatic ductal disruption developed distal to the areas of pancreatic stricture. The sites of pancreatic ductal disruption were the pancreatic body in five patients and the pancreatic tail in one patient. All patients received endoscopic stent placement over the stenosis site of the pancreatic duct. Three patients improved completely and one patient improved temporarily. Finally, three patients underwent surgical treatment for IPF. All patients have maintained a good course without a recurrence of IPF.ConclusionEndoscopic transpapillary pancreatic stent therapy may be an appropriate first-line treatment to be considered before surgical treatment. The point of stenting for IPF is to place a stent over the stenosis site of the pancreatic duct to reduce the pancreatic ductal pressure and the pseudocyst's pressure.     

内镜下诊治伴发胰管结石慢性胰腺炎的价值

目的探讨ERCP在胰管结石诊断和治疗中的临床价值及其安全性评估。方法分析2008年2月～2008年10月期间共20例接受ERCP诊断和治疗的伴发胰腺结石慢性胰腺炎患者的临床资料。结果20例病例中,16例（80％）胰管结石位于胰头处,3例（15％）位于胰头及胰体处,1例（5％）累及全程胰管。14例（70％）患者一次性取石完全,5例患者术后接受体外震波碎石（ESWL）,1例患者未能完成取石,建议其外科手术治疗．18例表现为腹痛的病例,在接受内镜下治疗结石后,腹痛症状均消失,在接受治疗后2～10d内出院,平均（5．3±2．43）d。术后2例（10％）出现一过性的血淀粉酶升高。结论对于伴有胰管结石的慢性胰腺炎病例而青,内镜下取石是安全有效的方法,同时应川支架及鼻胰管引流,不仅对胰管结石的治疗有效,而且充分的胰液引流对于缓解腹痛症状、减少术后的胰腺炎、高淀粉酶m症的发乍有着重要的作用。     

Endoscopic pancreatic duct drainage and stenting for acute pancreatitis and pancreatic cyst and abscess

Background/Purpose

Endoscopic drainage of pancreatic pseudocysts using transpapillary and transmural approaches has been reported. In this study, endoscopic nasopancreatic drainage (ENPD) and pancreatic stenting were performed in patients with pseudocyst and abscess associated with acute pancreatitis, and the usefulness and problems of the procedures were investigated.

Methods

After endoscopic retrograde pancreatography was done, ENPD and/or pancreatic stenting were performed in 13 patients with pancreatitis and pseudocyst or abscess that communicated with the main pancreatic duct.

Results

ENPD was performed in seven patients, and was effective in all five patients with cysts: the cysts disappeared or shrank. However, the condition in the two patients with abscess was unchanged, and percutaneous drainage was performed. Stenting was carried out in six patients, and the cyst disappeared or pancreatitis was improved in all six. The stent was removed from two patients, but no recurrence has been noted so far.

Conclusions

ENPD and stenting are effective therapeutic choices for acute and chronic pancreatitis and pseudocysts, and they are superior to percutaneous drainage to avoid pancreatic fistula, but they may not be effective for pancreatic abscess. Selection of therapeutic methods corresponding to individual cases is important.     

Extracorporeal shock wave lithotripsy of pancreatic duct stones and patient factors related to stone disintegration

Background: Background: Stones in the main pancreatic duct (MPD) are difficult to remove by endoscopic devices alone in some patients who have chronic pancreatitis. We treated these patients with extracorporeal shock wave lithotripsy (ESWL) and analyzed the patient factors related to disintegration. Methods: Twenty-four patients were treated with ESWL alone or with combined endoscopic-ESWL to disintegrate or remove MPD stones. Results: Ten patients were treated by ESWL alone and 14 by combined endoscopic-ESWL. A total of 19 patients (79%) were effectively treated by either method. The mean MPD diameter decreased significantly after ESWL. In most of the patients who had chronic abdominal symptoms, these symptoms were relieved at discharge. Severe side effects of complications did not occur during ESWL therapy. Acute abdominal symptoms and a significant increase in the white blood cell count, total bilirubin, and aspartate aminotransferase were observed only immediately after ESWL. Although there were no significant differences, we observed that the patients with a higher stone disintegration success rate showed the following factors: (1) female, (2) non-alcoholic pancreatitis, (3) younger age, (4) shorter duration of symptoms, (5) smaller stones, and (6) a lower Hounsfield unit value of stones. Although about half of the patients had recurring abdominal symptoms and stones during a follow-up period of 12 months, the stones which caused relapse in short-term intervals were disintegrated easily by ESWL. Conclusions: We may consider the application of ESWL therapies for patients who show the factors associated with easily disintegratable stone conditions. These therapies are highly effective and relatively safe procedures for pancreatic duct stones in such patients. Received: February 2, 2001 / Accepted: October 5, 2001     

Efficacy of pancreatic stenting prior to extracorporeal shock wave lithotripsy for pancreatic stones

BackgroundExtracorporeal shock wave lithotripsy is the first-line therapy for large pancreatic duct stones; however, it requires a long duration of therapy.AimsTo clarify the effect of pancreatic stenting prior to extracorporeal shock wave lithotripsy on shortening the duration of therapy and reducing complications.MethodsWe retrospectively compared 45 patients who underwent pancreatic stenting prior to extracorporeal shock wave lithotripsy (stenting group) and 35 patients who did not undergo stenting prior to extracorporeal shock wave lithotripsy (non-stenting group) with regard to the cumulative number of shock waves required for stone fragmentation (stone size <3 mm) and the rate of complications.ResultsThe stenting group was associated with a significantly lower cumulative number of shock waves in univariate analysis (log-rank, p = 0.046) and multivariate Cox proportional hazard analysis (hazard ratio, 1.88; 95% confidence interval, 1.13–3.14; p = 0.015) than the non-stenting group. The frequency of pancreatitis tends to be lower in the stenting group than the non-stenting group (2.2% [1/45] vs 11.4% [4/35]; p = 0.162).ConclusionsPancreatic stenting prior to extracorporeal shock wave lithotripsy reduced the cumulative number of shock waves required for pancreatic stone fragmentation, and could be useful to shorten the duration of therapy.     

Clinicopathologic study on pancreatic cancer associated with pancreatic stones

Summary Four cases of pancreatic cancer associated with pancreatic stones were investigated clinicopathologically. In Case 1, pancreatic cancer was diagnosed 2 yr 9 mo after the diagnosis of pancreatolithiasis. Numerous large stones were present throughout the pancreas, and stones in the resected specimen were embedded in the tumor. Chronic inflammation, including inflammatory infiltration and fibrosis, were found around the pancreatic duct where the stones were present, both within and adjacent to the tumor, suggesting that chronic pancreatitis had been present for a protracted period. In Cases 2–4, a few small free stones were found in the dilated pancreatic ducts and a cyst upstream from the tumor, but there were no stones noted within the tumor. Microscopically, mild atrophy of the pancreatic parenchyma and fibrosis were seen. In each of these three cases, it was considered that the pancreatic cancer was the primary event, with the pancreatic stones arising as a secondary process. The pancreatic cancers associated with pancreatic stones were classified into two groups, one with pancreatic stones preceding the pancreatic cancer and the other three cases in which the reverse occurred.     

Surgical bypass vs. endoscopic stenting for pancreatic ductal adenocarcinoma

Background:

The majority of patients with pancreatic cancer are non-resectable and jaundiced at presentation. Methods of palliation in such patients with locally advanced disease comprise endoscopic placement of a biliary endoprosthesis or surgical bypass.

Methods:

This retrospective study compared morbidity, mortality, hospital stay, readmission rate and survival in consecutive patients with incurable locally advanced pancreatic ductal adenocarcinoma.

Results:

We identified a total of 56 patients, of whom 33 underwent endoscopic stenting and 23 underwent a surgical bypass consisting of a hepaticojejunostomy-en-Y and a gastrojejunostomy. There were no significant differences in complication or mortality rates between patients undergoing palliative stenting and those undergoing palliative surgery. However, after excluding admissions for chemotherapy-related problems, the number of readmissions expressed as a percentage of the group population size was greater in stented patients compared with biliary bypass patients (39.4% vs. 13.0%, respectively; P < 0.05). Overall survival amongst patients undergoing palliative bypass was significantly greater than in stented patients (382 days vs. 135 days, respectively; P < 0.05).

Conclusions:

On analysis of these data and the published literature, we conclude that surgical bypass represents an effective method of palliation for patients with locally advanced pancreatic cancer. Patients need to be carefully selected with regard to both operative risk and perceived overall survival.     

Mechanical lithotripsy and/or stenting in management of difficult common bile duct stones

BACKGROUND:Mechanical lithotripsy and/or stent insertion is the alternative therapeutic approach in difficult endoscopic retrograde cholangiopancreatography (ERCP)case.This study was designed to investigate the appropriate treatment for extraction of bile duct stones in difficult cases of ERCP. METHODS:Between 2000 and 2008,744 ERCP procedures were performed in 592 patients with choledocholithiasis in our endoscopy unit.The demographic features,and clinical and laboratory findings were collected from a pros...     

Endoscopic ultrasound elastography for small solid pancreatic lesions with or without main pancreatic duct dilatation

Background/Objectives: Endoscopic ultrasound elastography (EUS-EG) is useful for diagnosis of small solid pancreatic lesions (SPLs), particularly in excluding pancreatic cancer (PC), but its dependence on main pancreatic duct dilatation (MPDD) has not been examined. We aimed to investigate EUS-EG for diagnosis of small SPLs with and without MPDD.MethodsPatients with pathologically diagnosed SPLs of ≤20 mm were included and retrospectively analyzed. Using the blue:green ratio, an EUS-EG image was classified as blue-dominant, equivalent, or green-dominant. Using multiple EUS-EG images per patient, a lesion with a greater number of blue-dominant than green-dominant images was classified as stiff, and the others as soft. EUS-EG images in random order were judged by three raters. Considering stiff SPLs as PC, diagnostic performance of EUS-EG was examined for SPLs with and without MPDD.ResultsOf 126 cases analyzed, 65 (52%) were diagnosed as PC, and 63 (50%) had MPDD. A total of 1077 EUS-EG images were examined (kappa coefficient = 0.783). Lesions were classified as stiff in 91 cases and soft in 35 (kappa coefficient = 0.932). The ratio of stiff to soft lesions was significantly higher in PC than in non-PC (62:3 vs. 29:32, P < 0.001). The sensitivity, specificity, and negative predictive value of a stiff lesion with vs. without MPDD for diagnosis of PC were 94%, 23%, and 50% vs. 100%, 60%, and 100%, respectively.ConclusionsUsing the EUS-EG stiffness classification for small SPLs, PC can be excluded with high confidence and concordance for a soft lesion without MPDD.     

Early ERCP and biliary sphincterotomy with or without small-caliber pancreatic stent insertion in patients with acute biliary pancreatitis: better overall outcome with adequate pancreatic drainage

Abstract

Objective. To analyze the efficacy of pancreatic duct (PD) stenting following endoscopic sphincterotomy (EST) compared with EST alone in reducing complication rate and improving overall outcome in acute biliary pancreatitis (ABP). Methods. Between 1 January 2009 and 1 July 2010, 141 nonalcoholic patients with clinical, laboratory and imaging evidence of ABP were enrolled. Emergency endoscopic retrograde cholangiopancreatography (ERCP) was performed within 72 h from the onset of pain. Seventy patients underwent successful ERCP, EST, and stone extraction (control group); 71 patients (PD stent group) had EST, stone extraction and small-caliber (5 Fr, 3-5 cm) pancreatic stent insertion. All patients were hospitalized for medical therapy and jejunal feeding and were followed up. Results. The mean age, Glasgow score, symptom to ERCP time, mean amylase and CRP levels at initial presentation were not significantly different in the PD stent group compared to the control group: 60.6 vs. 64.3, 3.21 vs. 3.27, 34.4 vs. 40.2, 2446.9 vs. 2114.3, 121.1 vs. 152.4, respectively. Complications (admission to intensive care unit, pancreatic necrosis with septicemia, large (>6 cm) pseudocyst formation, need for surgical necrosectomy) were less frequent in the PD stent group resulting in a significantly lower overall complication rate (9.86% vs. 31.43%, p < 0.002). Mortality rates (0% vs. 4.28%) were comparable, reasonably low and without any significant differences. Conclusions. Temporary small-caliber PD stent placement may offer sufficient drainage to reverse the process of ABP. Combined with EST the process results in a significantly less complication rate and better clinical outcome compared with EST alone during the early course of ABP.     

RETRACTED ARTICLE: Preoperative endoscopic pancreatic stenting: a novel prophylactic measure against pancreatic fistula after distal pancreatectomy

Background/Purpose

The prevention of pancreatic fistula is still a major problem in distal pancreatectomy (DP). We have recently adopted preoperative endoscopic pancreatic stenting with the aim of preventing the leakage of pancreatic juice from the resection plane of the remnant pancreas after DP. We reviewed ten patients who underwent this intervention.

Methods

One to 6 days before surgery, the patients underwent an endoscopic transpapillary pancreatic stent (7 Fr., 3 cm) placement. The perioperative short-term outcomes were assessed.

Results

Preoperative endoscopic pancreatic stenting was successfully performed in all ten patients. Two (20%) patients, both with intraductal papillary mucinous tumor, developed mild acute pancreatitis after the stent placement. None of the ten patients developed pancreatic fistula. The pancreatic stent was removed 8–28 days (mean, 11 days) postoperatively.

Conclusions

Preoperative endoscopic pancreatic stenting may be an effective prophylactic measure against pancreatic fistula development following DP.

     

Biliary stenting with or without sphincterotomy for malignant biliary obstruction: A meta-analysis

AIM: To investigate the benefits of endoscopic sphincterotomy (EST) before stent placement by meta-analysis of randomized controlled trials (RCTs).METHODS: PubMed, EMBASE, Cochrane Library, and Science Citation Index databases up to March 2014 were searched. The primary outcome was incidence of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) and successful stent insertion rate. The secondary outcomes were the incidence of post-ERCP bleeding, stent migration and occlusion. The free software Review Manager was used to perform the meta-analysis.RESULTS: Three studies (n = 338 patients, 170 in the EST group and 168 in the non-EST group) were included. All three studies described a comparison of baseline patient characteristics and showed that there were no statistically significant differences between the two groups. Three RCTs, including 338 patients, were included in this meta-analysis. Most of the analyzed outcomes were similar between the groups. Although EST reduced the incidence of PEP, it also led to a higher incidence of post-ERCP bleeding (OR = 0.34, 95%CI: 0.12-0.93, P = 0.04; OR = 9.70, 95%CI: 1.21-77.75, P = 0.03, respectively).CONCLUSION: EST before stent placement may be useful in reducing the incidence of PEP. However, EST-related complications, such as bleeding and perforation, may offset this effect.     

Long term follow up of patients with chronic pancreatitis and pancreatic stones treated with extracorporeal shock wave lithotripsy

BACKGROUND: There have been conflicting reports as to whether pancreatic ductal drainage achieved by endoscopy and lithotripsy improves the clinical outcome of patients with chronic pancreatitis. AIMS: To determine the clinical outcome in patients with chronic pancreatitis who received extracorporeal shock wave lithotripsy (ESWL), and were followed up for two to eight years. METHODS: Eighty patients with severe chronic pancreatitis and endoscopically unretrievable obstructive stones underwent ESWL with a piezoelectric lithotripter between 1989 and 1996. Clinical status, relief of symptoms, further endoscopic or surgical interventions, and mortality were defined. RESULTS: Forty three (54%) patients were treated successfully with ESWL. The only feature associated with treatment success was the presence of a single stone rather than multiple stones. Successfully treated patients tended to experience less pain, although this did not reach statistical significance. A slight increase in weight was noted in our patients; however, there was no notable improvement in anomalous stools and diabetes mellitus. Five patients died due to extrapancreatic reasons. No pancreatic carcinomas developed. CONCLUSIONS: ESWL associated with endoscopic drainage is a safe technique that is particularly successful in patients with a single stone. However, pancreatic drainage by endoscopy and ESWL has almost no effect on pain in chronic pancreatitis. Furthermore, endoscopic management and ESWL does not prevent or postpone the development of glandular insufficiency.