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BACKGROUND Chronic pancreatitis occasionally requires surgical treatment that can be performed with various techniques. Often, this type of surgery presents with postoperative complications. We report a case of a successful retrograde pancreatojejunostomy for chronic pancreatitis and infected pancreatic cysts. CASE SUMMARY A 62-year-old male with a 10-year history of chronic pancreatitis presented with epigastric pain for one week and a 20 kg weight loss over one year. Computed tomography showed stones in the pancreas (mainly the head), expansion of the main pancreatic duct, and thinning of the pancreatic parenchyma. Magnetic resonance imaging showed infected pancreatic cysts connected to the stomach with a fistula from the splenic hilum to the caudal portion of the liver’s lateral segment. An endoscopic retrograde pancreatography was performed; the guide wires could not pass through the stones in the pancreas and therefore, drainage of the main pancreatic duct was not achieved. Next, a distal pancreatomy and splenectomy were performed; however, the pancreatic juice in the remaining parenchyma was blocked by the stones. Hence, we performed a retrograde pancreatojejunostomy and Roux-en-Y anastomosis. The patient had no postoperative complications and was discharged from the hospital on postoperative day 14. CONCLUSION A distal pancreatomy, retrograde pancreatojejunostomy, and Roux-en-Y anastomosis could be an effective surgical procedure for intractable chronic pancreatitis.

Background Despite pancreatic extracorporeal shock wave lithotripsy (P-ESWL) is a minimally invasive treatment for pancreatic stones, complications exist. Case presentation A 37-year-old male was diagnosed with chronic pancreatitis and admitted to our hospital for recurrent acute pancreatitis. After the first P-ESWL session, the patient complained of a new type of pain different from the previous pain pattern. Computerized tomography and colonoscopy were arranged and colonic hematoma was found. Since the patient had stable vital signs, no special treatment was given focusing on the colonic hematoma. Five days later, P-ESWL treatment was repeatedly performed for four consecutive days. Two days after the last P-ESWL session, the patient underwent endoscopic retrograde cholangiopancreatography. At the three-month follow up visit, the colonic hematoma disappeared and pancreatic stones decreased significantly. Conclusions To the best of our knowledge, colonic hematoma after P-ESWL for pancreatic stones has never been reported. Here, we present the only case of colonic hematoma after P-ESWL, which was coincidentally found in more than 6000 P-ESWL sessions in our hospital. As the symptoms of colonic hematoma are mild, we believe the incidence of colonic hematoma has been underestimated. Many people with colonic hematoma after P-ESWL may be undiagnosed or misdiagnosed. Treatment for colonic hematoma depends on whether there is severe clinical state. Exploration of more precise location method for pancreatic stones may reduce the probability of P-ESWL complication.

Video Video 1 Pancreatic stones treated via an EUS-guided pancreaticogastrostomy with a fully covered self-expandable metal stent. A 42-year-old man who had undergone a distal pancreatectomy 2 years earlier for chronic pancreatitis due to alcohol use, with pancreatic stones, presented because of severe abdominal pain. Blood tests revealed elevated inflammatory markers and pancreatic enzymes. CT depicted pancreatic stones up to 1 cm in size in the entire pancreatic parenchyma and main pancreatic duct. Obstructive pancreatitis caused by pancreatic stones was diagnosed. Transpapillary removal of the stones was attempted, but the main pancreatic duct could not be approached because of the pancreatic stones near the duodenal papilla. We attempted to approach the main pancreatic duct via the transgastric route with endoscopic ultrasound guidance. CT showed pancreatic stones in the main pancreatic duct.

Although surgical or endoscopic treatment is effective for pain control in symptomatic calcified chronic pancreatitis, it is still unknown whether early intervention in mild symptomatic pancreatic stones would reduce the frequency of acute exacerbation and improve long-term outcomes. The aim of this randomized-controlled trial was to explore the efficacy of early endotherapy for mild symptomatic pancreatic stones in comparison with the wait-and-see policy.Patients with mild symptoms because of pancreatic stones were assigned randomly to the endotherapy or the wait-and-see group. The wait-and-see group received endotherapy only when they developed refractory exacerbation or intractable pain. The primary outcome was the cumulative incidence of intolerable pain attacks and acute exacerbation. The secondary outcomes were the development of pancreatic insufficiency and the progression of pancreatic atrophy.A total of 20 patients were enrolled between March 2008 and March 2011. The study was terminated prematurely because of the poor patient enrollment. Early endotherapy tended to reduce the cumulative incidence of pain attacks and exacerbation, (P=0.17) with the composite incidence of pain attacks and exacerbation of 30% in the endotherapy group and 60% in the wait-and-see group. There were no significant differences in terms of diabetic status and the presence of steatorrhea. The thickness of the pancreas decreased significantly in the wait-and-see group (9.2-6.8 mm, P=0.041), but not in the endotherapy group (8.7-9.0 mm, P=0.60).In a small group of patients, early endotherapy in mild symptomatic chronic pancreatitis was associated with a trend toward a minor number of acute attacks and atrophy progression of the pancreas.

Direct endoscopic visualization of the biliary and pancreatic ducts by single-operator cholangioscopy (SOC) and pancreatoscopy (SOP) is an expanding technique with an increasing number of indications. This review provides technical tips and tricks and a literature update on the usefulness of SOC and SOP in clinical practice. SOC has shown a 91.3% and 87.3% diagnostic procedural success in indeterminate strictures and difficult stones respectively, with a 9.4%–16.4% complication rate. Although the interpretation of the images suspected for malignancy can be challenging, new classifications based in mucosal and vascular patterns as well as better devices are in development. A higher sensitivity has been associated to targeted biopsies, compared to brushing and blinded biopsies. Indeed, SOC has recently demonstrated a decrease in the number of procedures and costs when compared with endoscopic retrograde cholangiopancreatography. This technique has also been reported for many other diagnostic and therapeutic indications, such as cholangiocarcinoma staging and foreign body extraction. Similarly, diagnostic and therapeutic SOP in indeterminate strictures or pancreatic stones, and intraductal papillary mucinous neoplasms, has been successfully reported. Research to date supports the use of cholangioscopy as a complementary examination in patients with indeterminate strictures, difficult stones and specific situations. In a near future, there will probably be new established indications, a better understanding of the imaging findings and a place of SOC/SOP as first line in selected scenarios.

Background/Aims: Our study aimed to evaluate the effect of oral litholysis in patients with chronic calcific pancreatitis (CCP) unresponsive to or ineligible for extracorporeal shock wave lithotripsy (ESWL) and endoscopic therapy. Methods: Trimethadione, an antiepileptic agent, was administered orally at a dose of 0.6–0.9 g/day to 15 patients with this condition. Treatment outcome was evaluated by assessment of dissolution of the pancreatic stones on plain X-ray films and computed tomography scans of the upper abdomen. Plasma glucose, hemoglobin A1c, and body mass index (BMI) were also monitored throughout the therapy. Results: Litholysis was observed in 13 out of 15 patients (86.7%) and was definite in 10 and partial in 3. Six patients had pancreatitis attacks during the therapy; 5 of whom showed definite litholysis and had only 1 mild attack. Of the 11 patients with normal or impaired glucose tolerance at baseline, none developed diabetes mellitus and all showed litholysis. BMI significantly increased in patients whose pancreatic stones dissolved. There was no vital organ impairment by trimethadione. Conclusion: Oral litholysis using trimethadione may represent a noninvasive and effective complementary treatment in patients with CCP unresponsive to or ineligible for ESWL and endoscopic therapy.

Endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) play a critical role in the diagnosis and management of benign and malignant pancreatobiliary diseases. In the last several years, role of ERCP has evolved from just a diagnostic procedure to mostly a therapeutic procedure. It plays a key role in the diagnosis of indeterminate biliary strictures and evaluation of bile leaks. Therapeutic ERCP utilizes various techniques for the extraction of biliary and pancreatic stones, management of bile leaks, and the treatment of malignant and benign strictures. EUS plays a central role in tissue acquisition for diagnostic purposes. Therapeutic applications of EUS have significantly increased in the recent years and include management of pancreatic fluid collections, pancreatic necrosis, drainage of the biliary obstruction, gall bladder drainage, and EUS-assisted ERCP. These procedures have good efficacy and acceptable side effect profile when performed by expert endoscopists at tertiary care medical centers.

BACKGROUND AND AIM Although endotherapy for pancreatic stones is less invasive compared with surgical interventions, its recurrence rate is high and residual pancreatic stones can be a cause of recurrence. We previously reported usefulness of a novel basket catheter with nitinol fine reticular structure for pancreatic stone retraction. In this retrospective study, we aimed to evaluate the long-term outcomes of endotherapy for pancreatic stones with and without the use of this dedicated basket catheter. METHODS We retrospectively compared patients with symptomatic pancreatic stones who underwent the initial endotherapy between 2008 and 2019. The primary outcome was the symptomatic recurrence after complete stone clearance. Secondary outcomes were the rate of complete stone clearance, complications, risk factors for recurrences, and the treatment cost. RESULTS A total of 101 patients who underwent endotherapy for pancreatic stones were analyzed: 41 patients by using the dedicated basket catheter and 60 patients by only the conventional devices. The complete stone clearance was achieved in 87.8% in the dedicated basket group and 88.3% in the conventional device group. Symptomatic recurrence was observed in 16.7% of the dedicated basket group and 47.2% of the conventional device group (P

Pancreatic calculi are typically a sequela of chronic pancreatitis. Here, we present a patient who was found to have an obstructing one-centimeter pancreatic calculus secondary to recurrent gallstone pancreatitis. Recent retrospective studies have focused on the optimal treatment of large pancreatic calculi that were defined as greater than five millimeters. But most studies fail to comment on much larger stone as in this case report. Further guidelines and investigation need to be done aiming toward the optimal treatment of relatively large pancreatic stones.

Pancreatic duct stones are sequela of chronic pancreatitis. They can cause pancreatic duct obstruction which is the most important cause of pain in chronic pancreatitis. Stone resolution has shown to improve pain. The goal of this review is to highlight recent endoscopic and surgical advancements in treatment of pancreatic duct stones. Stone fragmentation by extracorporeal shock wave lithotripsy has become first line and the mainstay of treatment for majority of patients with pancreatic duct stones. Introduction of digital video pancreatoscopy in the last few years with the capability of guided lithotripsy has provided a robust therapeutic option where extracorporeal shock wave lithotripsy is unsuccessful or unavailable. Historically, surgery has been considered a more reliable and durable option when feasible. However, it had not been compared with more effective endoscopic therapy. Lithotripsy (extracorporeal and pancreatoscopy guided) is evolving as a strong treatment modality for pancreatic stones.

Pancreatic extracorporeal shock wave lithotripsy (P-ESWL) has been recommended for the management of large pancreatic stones. It is considered to be a noninvasive and low morbidity procedure. However, despite its minimal invasiveness, it does have complications.

Aim. To determine surgical tactics and principles of preferential surgical intervention for chronic calculous pancreatitis based on assessment of results of various approaches and methods of surgical correction. Material and Methods. Since January 1989 till March 2016 475 patients were treated. There were 234 draining, 15 resection-draining operations and 14 resections. In 174 patients (36.6%) 2 or more operations were executed due to ineffective primary intervention. Results. Two patients died after draining operations. After draining operations the incidence of early and long-term postoperative complications was 10.3% and 23.9% respectively, after resection-draining operations – 6.7% and 13.3%; after resections – 21.4% and 78.6%. Obstructive jaundice was not observed after resection-draining operations. One patient had pancreatic diabetes and recurrent abdominal pain. Topographic and anatomical features of calculous pancreatic changes were established. Ductal hypertension is accompanied by its enlargement in 75.9% of patients. Pancreatic stones are predominantly localized in glandular head along anterior surface. Virsungolithiasis was noted in 20–25% of patients. Conclusion. Parenchyma-sparing interventions are more effective compared with resections. In our opinion, the most advisable surgery for chronic calculous pancreatitis are resection-draining operations including longitudinal pancreaticocystojejunostomy by Frey’s procedure type supplemented by contact ultrasound lithotripsy. It is suggested clinical classification of chronic calculous pancreatitis that should be kept in mind to determine surgical tactics.

AIM To evaluate the endoscopic treatment efficacy and prognostic factors of long-term response to treatment for painful chronic pancreatitis. METHODS This retrospective analysis identified 168 patients with painful chronic pancreatitis hospitalized during January 2010-January 2015 in a Romanian tertiary referral center. Data on demographics, medical history, alcohol consumption, smoking habit, clinical parameters, type and number of endoscopic procedures and hospital admissions number were collected from the medical charts and analyzed. The absence or substantial reduction of pain (mild pain) at the end of the follow-up associated with the technical success of endotherapy was considered as clinical success. RESULTS Among the 168 patients with painful chronic pancreatitis admitted to our department during the study period, 39 (23.21%) had optimal response to the medical therapy. One hundred and twenty-nine patients required endoscopic treatment. The median follow-up period was 15 mo (range, 0-60 mo). Overall, technical success of endotherapy was achieved in 105 patients (81.39%). More than two-thirds of patients (82.78%) had substantial improvement of pain after the endoscopic treatment, including frequency and severity of the pain attacks. Patients younger than 40 years had significantly more successful endoscopic procedures (P = 0.041). Clinical success was higher in non-smoking patients (P = 0.003). The hospital admission rate was higher in patients with recognized alcohol consumption (P = 0.03) and in smokers (P = 0.027). The number and location of pancreatic stones and locations of strictures did not significantly influence the technical success (P > 0.05) or the clinical success (P > 0.05). CONCLUSION Younger age than 40 years can be considered an important factor positively influencing endoscopic treatment outcome in patients with painful chronic pancreatitis.

Background and aims Pancreatic extracorporeal shock wave lithotripsy (P-ESWL) is recommended as the first-line treatment for pancreatic stones. However, how well P-ESWL performs in pediatric patients remains unclear. We aimed to evaluate the safety and efficacy of P-ESWL for pediatric patients with chronic pancreatitis. Methods This prospective observational study was conducted in patients with painful chronic pancreatitis who underwent P-ESWL. Patients aged under 18 years were included in the pediatric group; patients aged over 18 years who underwent P-ESWL in the same period were assigned to the control group. For investigation of long-term follow-up, the pediatric group were matched with patients from the control group in a 1:1 ratio. The primary outcomes were P-ESWL complications and pain relief. The secondary outcomes included: stone clearance, physical and mental health, quality of life score, and growth and developmental state. Results From March 2011 to March 2015, P-ESWL was performed in 1135 patients (72 in the pediatric group, 1063 in the control group). No significant differences were observed in the occurrence of P-ESWL complications between the two groups (11.1 % vs. 12.8 %; P = 0.68). Among the 67 pediatric patients (93.1 %) who underwent follow-up for 3.0 years (range 1.3 – 5.2), complete pain relief was achieved in 52 patients (52 /67; 77.6 %); this value was not significantly different from that of the matched controls (55 /69; 79.7 %; P = 0.94). Conclusions P-ESWL is safe and effective for pediatric patients with chronic pancreatitis. It can promote significant pain relief and stone clearance, and can benefit growth and development.

A 43-year-old female with hereditary chronic pancreatitis presented with increasing pancreatic pain and multiple pancreatic stones, despite extracorporeal shockwave lithotripsy and pancreatic stenting 12 months previously. Direct lithotripsy was performed via endoscopic retrograde cholangio-pancreatography and the stones were further evaluated.

Resumen La pancreatitis crónica es un trastorno irreversible y progresivo del páncreas caracterizado por inflamación, fibrosis y cicatrización. Las funciones exocrinas y endocrinas se pierden, lo que a menudo conduce al dolor crónico. La etiología es multifactorial, aunque el alcoholismo es el factor de riesgo más importante en los adultos. Si se sospecha pancreatitis crónica, la tomografía computarizada con contraste es la mejor modalidad de diagnóstico por imágenes. Aunque los narcóticos y los antidepresivos proporcionan el mayor alivio del dolor, más de la mitad de los pacientes eventualmente requiere una intervención por endoscopia o cirugía. La colangiopancreatografía retrógrada endoscópica es una alternativa eficaz para una variedad de terapias en el tratamiento de enfermedades benignas y malignas del páncreas. En los últimos 50 años, la endoterapia ha evolucionado hasta convertirse en la terapia de primera línea en la mayoría de las enfermedades inflamatorias agudas y crónicas del páncreas. A medida que avanza este campo, es importante que los gastroenterólogos mantengan un conocimiento adecuado de la indicación del procedimiento, mantengan el volumen de procedimiento suficiente para manejar la endoterapia pancreática compleja y comprendan enfoques alternativos a las enfermedades pancreáticas, incluidos el tratamiento médico, la terapia guiada por ecografía endoscópica, el manejo de las estenosis sintomáticas y cálculos, las intervenciones sobre el plexo celíaco y el drenaje de los pseudoquistes pancreáticos. Abstract Chronic pancreatitis is an irreversible and progressive disorder of the pancreas characterized by inflammation, fibrosis and scarring. Exocrine and endocrine functions are lost often leading to chronic pain. Its etiology is multifactorial, although alcoholism is the most important risk factor in adults. If chronic pancreatitis is suspected, computed tomography with contrast is the best imaging modality. Although narcotics and antidepressants provide the greatest pain relief, more than half of all patients eventually require intervention by endoscopy or surgery. Endoscopic retrograde cholangiopancreatography (ERCP) is an effective alternative for a variety of therapies for treating benign and malignant diseases of the pancreas. In the last 50 years, endoscopic treatment has evolved to become the first-line therapy for most acute and chronic inflammatory diseases of the pancreas. As this field progresses, it has become important for gastroenterologists to keep their knowledge of indications for this procedure up-to-date and to perform a sufficient volume of procedures to allow them to manage complex pancreatic endoscopic therapy. Keeping up-to-date should include an understanding of alternative approaches to pancreatic diseases including medical treatment, therapy guided by endoscopic ultrasound, management of symptomatic stenoses and stones, interventions on the celiac plexus, and drainage of pancreatic pseudocysts.

Purpose To assess the usefulness of factors unique to NCCT for the prediction of ESWL outcomes in patients with pancreatic duct stones. Materials and methods We retrospectively evaluated 148 patients with multiple PDS who had undergone ESWL therapy. All patients received an examination for NCCT both before and after ESWL. The following parameters were measured and recorded: patient characteristics including sex and age; NCCT parameters including mean stone length, mean stone volumes before and after ESWL, mean value of CT attenuation, standard deviation of CT attenuation, variation coefficient of CT attenuation, skin-to-stone distance, and pancreatic duct diameter; ESWL outcome indexes including stone clearance rate calculated using the formula \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\frac{V0 - V1}{V0} \times 100\%$$\end{document}V0-V1V0×100%, and the number of ESWL sessions. All patients were divided into groups based on their SCR: A group (SCR ≥ 90%), B group (SCR between 50% and 90%), and C group (SCR

Background and study aim: Pancreatic stones occasionally develop in autoimmune pancreatitis (AIP), often worsen endocrine and exocrine functions, and occasionally cause pain attacks. However, the risks of pancreatic stones in AIP have been poorly studied. The aim of this study was to analyze the risk factors associated with pancreatic stone formation in cases of AIP. Patients and methods: In total, 50 patients with AIP (39 males, 11 females; mean age 64.0 years), followed up for at least a year, were analyzed for their demographic and clinical findings and pancreatic stone occurrence. Results: In total, 50 patients were followed up for an average of 59.7 (12 – 120) months, with steroid treatment in 44 patients (88 %); pancreatic stones occurred in 14 (28 %) patients after the diagnosis of AIP and endoscopic treatment was needed in one patient with pain attack. The pancreatic stones appeared only in patients with long follow-up period (P

Introduction The paucity of specific standardized criteria leads to uncertainties in clinical practice regarding the management of chronic pancreatitis (CP).Objectives This paper reports some of the systematic guidelines for the diagnosis and treatment of CP recently elaborated by an Italian multicenter study group. We review recommendations on clinical and nutritional aspects of the disease, assessment of pancreatic function, treatment of exocrine pancreatic failure and secondary diabetes, treatment of pain, and prevention of painful relapses. The review also looks at the role of endoscopy in the management of pancreatic pain, pancreatic stones, duct narrowing and dilation, and complications; the appropriate use of various imaging techniques, including endoscopic ultrasound; and the indications for and techniques used in surgical management of CP.

BACKGROUND/AIMS We aimed to evaluate whether the advanced techniques have influenced the minor papilla approach. METHODS We studied the success rate of guide wire insertion by using ordinary techniques and advanced techniques (rendezvous method and precut method) in 30 patients via the minor papilla. We compared the selection of the access routes between before (52 patients) and after (28 patients) the introduction of the Soehendra stent retriever. RESULTS In 19 out of 30 patients (63%), guide wire insertion via the minor papilla could be achieved by using ordinary techniques. In total, the guide wire could be inserted in 27 patients (90%) by using the advanced techniques. Before introduction of the Soehendra stent retriever, the major papilla approach was chosen in 38 cases (73%), and the minor papilla approach in 14 cases (27%). After introduction of the Soehendra stent retriever, the major papilla approach was used in 26 cases (93%) and the minor papilla in 2 cases (7%). The frequency of selecting the minor papilla approach has significantly decreased (p

ESWL+内視鏡は膵石治療の第一選択として定着し，高い除痛率を中心に良好な成績が報告されている．この18年間に当院で経験した膵石症は237例で，有症状225例に治療を行なった．その内の214例に内科的治療（ESWL and/or内視鏡治療）を行ない，排石率は72%,除痛率は97%,結石再発率10%，内外分泌能改善はそれぞれ32%,33%であった．体部狭窄膵管の尾側に結石を有した有症状例9例は外科手術を行なった．仮性嚢胞·膿瘍合併は49例で，経皮的ドレナージ·ESWL·内視鏡で治療した．また仮性動脈瘤合併は5例であった．膵管狭窄を解除し結石再発を防止する方策として，1996年より内視鏡的膵管バルーン拡張術（EPDBD；Endoscopic Pancreatic Duct Balloon Dilation）を118例で行ない良好な結果を得た．またこの5年間に副乳頭経由の排石治療を31例で行ない，Wirsung管狭窄例等で良好な結果を得た．経過観察中の死亡例は16例で，膵癌2，肺癌2，咽頭癌1，食道癌1，大腸癌1，急性アルコール中毒1，多病死8で，排石治療後も膵癌のみならず消化管·呼吸器·耳鼻科領域の発癌を念頭におく必要がある．

We aimed to determine the cumulative rate of diabetes mellitus (DM) and the risk factors for DM in patients with chronic pancreatitis (CP) in Japan. We conducted a follow-up survey of CP in 2002 in patients registered as having CP in 1994, and confirmed 656 patients to be checked in regard to the survey items concerning diabetes. We analyzed the cumulative rate of DM and the risk factors for DM over an 8-year follow up period. In 1994, 35.1% of 656 CP patients had DM, and the incidence of diabetes had increased to 50.4% in 2002. Of 418 patients without diabetes in 1994, 28.9% (121/418) were newly diagnosed with DM in 2002. Alcoholic CP was the most common type of CP in patients with newly developed diabetes, accounting for 67.8%. The incidence of DM was highest in those with alcoholic CP (34.3%) followed by idiopathic CP (23.0%). The risk of diabetes increased 1.32-fold after the onset of pancreatic calcification. Of 121 patients with newly diagnosed DM in 2002, 37 (30.6%) had pancreatic stones in 1994 and 49 (40.5%) had a stone in 2002. The highest incidence of newly diagnosed DM was observed in patients with continuous alcoholic intake (40.9%). Patients treated with camostat mesilate developed DM less frequently than those without camostat mesilate. The present study showed that the incidence of DM in patients with CP increased with time. Of 418 CP patients without DM in 1994, 28.9% developed DM over a period of 8 years. Continuous alcoholic intake aggravated CP and increased the risk of DM in those with CP.

Extracorporeal shockwave lithotripsy (ESWL) and endoscopic lithotripsy are useful for the fragmentation and extraction of pancreatic stones. However, pancreatic stones often recur, for which an adequate strategy is needed. Treatment for stricture of the main pancreatic duct (MPD) with a pancreatic stent after clearance of pancreatic stones may reduce the recurrence of pancreatic symptoms and stones.Forty patients with chronic pancreatitis with MPD stones were treated with ESWL in combination with endoscopic stone extraction. After clearance of the stones, a pancreatic stent was inserted when a stricture of MPD was observed on pancreatography. The stent was exchanged every 3 months and removed after a total of 1 year. We examined episodes of recurrent pain and pancreatitis in patients with and without stenting, as well as the MPD diameter, during follow-up.MPD stricture was seen in 27 patients, and a stent was successfully inserted in 24 of them. Pancreatic symptoms recurred in five patients (21%) in the stenting group and in three patients (23%) in the control group during a mean follow-up period of 1.5 and 1.2 years, respectively. The diameter of the MPD, before, just after, and 1 year after treatment, was 7.6, 5.4, and 5.8 mm, respectively. It was significantly decreased after 1 year of follow-up, as well as just after stent removal, compared with before treatment (P0.05).Additional stenting for MPD after extraction of pancreatic stones may reduce the risk of recurrence of pancreatic symptoms.

Background: Stricture of the main pancreatic duct associated with chronic pancreatitis is a cause of pain due to ductal high pressure and the formation of pancreatic stones, but there is no established non-surgical therapeutic procedure. We attemped a new method for treating this condition, called short-term metal stenting. Methods: In three patients who had experienced recurrent stones and pancreatitis attacks several times after extracorporeal shock wave lithotripsy, a self-expandable metal stent was placed into the pancreatic duct for 2–7 days. Results: Dilatation was successful in all cases. Over observation periods of 18–25 months (mean, 22 months) following stent withdrawal, no recurrence of stones or attacks of pancreatitis was observed. Conclusion: Short-term metal stenting is an effective procedure for dilating stricture of the main pancreatic duct. It is also promising as a method for preventing recurrence of stones or episodes of pancreatitis.

AIM: To provide consensus statements on the use of per-oral cholangiopancreatoscopy (POCPS). METHODS: A workgroup of experts in endoscopic retrograde cholangiopancreatography (ERCP), endosonography, and POCPS generated consensus statements summarizing the utility of POCPS in pancreaticobiliary disease. Recommendation grades used validated evidence ratings of publications from an extensive literature review. RESULTS: Six consensus statements were generated: (1) POCPS is now an important additional tool during ERCP; (2) in patients with indeterminate biliary strictures, POCS and POCS-guided targeted biopsy are useful for establishing a definitive diagnosis; (3) POCS and POCS-guided lithotripsy are recommended for treatment of difficult common bile duct stones when standard techniques fail; (4) in patients with main duct intraductal papillary mucinous neoplasms (IPMN) POPS may be used to assess extent of tumor to assist surgical resection; (5) in difficult pancreatic ductal stones, POPS-guided lithotripsy may be useful in fragmentation and extraction of stones; and (6) additional indications for POCPS include selective guidewire placement, unexplained hemobilia, assessing intraductal biliary ablation therapy, and extracting migrated stents. CONCLUSION: POCPS is important in association with ERCP, particularly for diagnosis of indeterminate biliary strictures and for intra-ductal lithotripsy when other techniques failed, and may be useful for pre-operative assessment of extent of main duct IPMN, for extraction of difficult pancreatic stones, and for unusual indications involving selective guidewire placement, assessing unexplained hemobilia or intraductal biliary ablation therapy, and extracting migrated stents.

A partial or total absence of stones in pancreaticolithiasis therapy can be reached by using ESWL. We report on a patient who happened to get an incarceration of a fragment in the distal pancreatic duct after having been treated by ESWL without a previous sphincterotomy to the ductus Wirsungianus. This emphasizes the recommendation to carry out a papillotomy of the pancreatic main duct before applying ESWL to pancreatic stones.

Pancreatic calculi are a cardinal manifestation of chronic pancreatitis. The precipitation of calcium carbonate and stone growth lead to duct obstruction, fibrosis, and impaired secretory function. Endotherapy using the traditional endoscopic tools, such as sphincterotomy and balloon or basket extraction, have limitations when applied to a tortuous or strictured pancreatic duct. For this reason, adjunctive use of extracorporeal shockwave lithotripsy is a keystone to successful endoscopic extraction. Clearance of stones from a dilated duct often relieves pain related to outflow obstruction, and success is usually associated with a decreased pancreatic duct diameter. Because of the complexity of pancreatic stone management, patients are best treated at referral centers with the necessary expertise and resources.

Painful, chronic pancreatitis is of complex etiology, but increasing clinical experience suggests that removal of pancreatic duct stones in many cases significantly improves patients’ symptoms. The development and refinement of therapeutic endoscopic retrograde choledochopancreatography have permitted improved access to the pancreatic duct, which makes the development of new techniques of stone fragmentation and fragment removal a much more successful nonsurgical intervention. A major step forward has been the understanding of the safety and efficacy of pancreatic sphincterotomy, which is necessary for the removal of these difficult stones. The recognition that extracorporeal shock wave lithotripsy can be delivered safely with good efficacy has revolutionized the nonsurgical management of pancreatic duct stones. Nevertheless, advanced and sophisticated therapeutic endoscopy is necessary to achieve clearance of the duct, which can generally be accomplished in the majority of selected patients. State-of-the-art treatments are described, and some new approaches using pancreatoscopy and electrohydrolic lithotripsy are discussed. Newly recognized long term complications are reviewed. Finally, it must be recognized that chronic pancreatitis is an ongoing disease that does not have a simple treatment or cure, and frequently represents a process of remissions and relapses requiring interventions and problem solving.

OBJECTIVES The aim of our study was to examine the suitability of a rhodamine 6G laser with an integrated stone-tissue detection system (STDS) for fragmenting pancreatic stones. METHODS A total of 64 pancreatic duct stones were measured for weight, diameter, main chemical components and in some cases for their computerized tomography density. Recognition of all stones was checked with the standard STDS or a prototype version. Number of fragmentation pulses, total fragmentation energies and correlation with the individual stone parameters were determined. The quality of the tissue-detection mode was evaluated in postmortem pancreata. RESULTS The standard STDS detected only 45% of the pancreatic stones correctly. When using the prototype, the detection rate improved significantly up to 75% (P < 0.01). All laser pulses were cut off if tissue contact occurred. All the stones were completely disintegrated by the laser pulses. A slight correlation was found only between the required fragmentation energy and the stone weight (linear regression: R2 = 0.77); other factors had no significant impact. CONCLUSION The rhodamine 6G laser is suitable for the fragmentation of pancreatic stones in vitro. The integrated STDS is less effective for pancreatic stones than reported for biliary stones.

Pancreaticoenteric anastomotic stricture can occur as a late complication of pancreatic head resection and is difficult to manage. The surgically altered anatomies of patients that have undergone pancreatic head resection make it difficult to perform pancreatic duct drainage using conventional endoscopes, and it is especially difficult to endoscopically identify stenotic pancreaticojejunal anastomoses. A 40-year-old woman was referred to our department for the treatment of symptomatic multiple pancreatic stones and anastomotic stricture after end-to-side pancreaticojejunostomy. Endoscopic ultrasound-guided pancreaticogastrostomy was performed in an attempt to avoid re-surgery. At 18 days after the initial procedure, a guidewire was successfully placed in the jejunum through the anastomotic stricture. The anastomotic stricture was dilated using a dilation balloon, and all of the stones were pushed into the jejunum using a retrieval balloon. No complications were experienced during the procedure. At 22 months after the stone removal, the main pancreatic duct displayed a decreased diameter, and no stone recurrence was detected.

Background Endoscopic removal of pancreatic stones in patients with chronic pancreatitis is still challenging. With a conventional basket catheter, introduction to the target area or catching pancreatic stones is sometimes difficult. Objective To evaluate a novel double-lumen basket catheter composed of nitinol wires with fine reticular structures in the distal end and loose mesh in the proximal part. Design A prospective feasibility study. Setting Tertiary-care center. Patients This study involved 10 patients with main pancreatic duct stones of 5 mm or less in the shorter diameter of the largest stone. Intervention In the first 5 cases, a nitinol basket catheter was used as salvage after stone extraction with a conventional basket catheter and retrieval balloon (salvage group). In the following 5 cases, stones were initially removed by using a nitinol basket catheter, and the presence of residual stones was evaluated by pancreatogram along with balloon sweep (initial group). Main Outcome Measurements Success rate of removal of the target stones and procedure-related adverse events. Results A nitinol basket catheter was easily introduced to the target stone in all patients. In the salvage group, additional stones were retrieved with a nitinol basket catheter in 3 of 5 patients. In the initial group, stone extraction by a nitinol basket catheter was successful, and no residual stones were extracted by additional balloon cleaning in any patients. Basket impaction or after-ERCP pancreatitis was not observed. Limitations A small sample size without a control group. Conclusion This novel nitinol basket catheter is useful for the extraction of small pancreatic stones. A randomized, controlled trial is warranted to confirm its efficacy.

This study aimed to investigate risk factors for pancreatic stones and atrophy in autoimmune pancreatitis (AIP).Seventy-one patients with AIP observed for more than 1 year were enrolled. The frequency of pancreatic stone development and atrophy on computed tomography as well as their risk factors were examined.Pancreatic stones and atrophy were observed in 13 and 43 patients, respectively. Alcohol consumption of greater than 50 g/d was the only significant risk factor for pancreatic atrophy in univariate analysis. Alcohol intake of greater than 50 g/d was observed in 6 of 13 patients with stones and 10 of 58 patients without stones (46% vs 17%, P = 0.059). Alcohol intake of greater than 50 g/d was observed in 14 of 43 patients with atrophy and 2 of 28 patients without atrophy (33% vs 7.1%, P = 0.018). In multivariate analysis, alcohol consumption was a significant risk factor both for pancreatic stone formation (odds ratio [OR], 7.47; P = 0.040) and atrophy (OR 6.24; P = 0.034). Higher age at onset was another significant risk factor for pancreatic atrophy (OR 1.07 per year; P = 0.029).Alcohol consumption of greater than 50 g/d increases the risk of pancreatic stone development and atrophy in patients with AIP.

This chapter provides an overview of the physiology of pancreatic exocrine function and the pathophysiology of pancreatic stone formation. The natural history and the clinical sequelae are reviewed. Potential pharmacologic intervention is addressed and a detailed description and analysis of the endoscopic management is outlined.