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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.

) and com-puted tomography. We performed extracorporeal shock wavelithotripsy (ESWL) starting from the pancreatic head to tailwith a third-generation lithotripter (Compact Delta II;Dornier MedTech, Wessling, Germany) to treat the stones. Amaximum of 5000 shock waves were delivered per therapeu-tic session. Repeated sessions of ESWL were performed on 5successive days. The pancreatic stones spontaneously clearedduring the ESWL therapy (Figure

“Porter: Faith sir, we were carousing till the second cock; and drink, sir, is a great provoker of three things.MacDuff: What three things does drink especially provoke?“Chronic calcifying pancreat...

This study prospectively assessed whether the presence of a bull's-eye pattern of pancreatic-duct stones on multidetector computed tomography (MDCT) correlated with gene-mutation-associated pancreatitis (GMAP) and whether other signs suggestive of GMAP can be detected with MDCT.Forty-seven patients with chronic calcific pancreatitis underwent genetic testing for CFTR, SPINK1 and PRSS1 mutations and an MDCT scan of the abdomen. Qualitative analysis assessed the presence or absence of pancreatic-duct stones with bull's-eye appearance. Quantitative analysis included the number and maximum diameter of stones and the diameter of the main pancreatic duct.Fifteen of 47 patients (32%) were positive for gene mutations (GMAP patients). The bull's-eye pattern was found in 10/15 patients (67%) with GMAP and in 4/32 (12%) patients with chronic pancreatitis not associated with GMAP (NGMAP; p0.0001). The mean diameter of duct stones was 15 mm in patients with GMAP and 10 mm in patients with NGMAP (p0.04).The presence of duct stones with a bull's-eye pattern correlates with GMAP. Duct stones with diameter ≥15 mm are another sign suggestive of GMAP.

This paper gives practical guidelines for diagnosis and treatment of chronic pancreatitis. Statements have been elaborated by working teams of experts, by searching for and analysing the literature, and submitted to a consensus process by using a Delphi modified procedure. The statements report recommendations on clinical and nutritional approach, assessment of pancreatic function, treatment of exocrine pancreatic failure and of secondary diabetes, treatment of pain and prevention of painful relapses. Moreover, the role of endoscopy in approaching pancreatic pain, pancreatic stones, duct narrowing and dilation, and complications was considered. Recommendations for most appropriate use of various imaging techniques and of ultrasound endoscopy are reported. Finally, a group of recommendations are addressed to the surgical treatment, with definition of right indications, timing, most appropriate procedures and techniques in different clinical conditions and targets, and clinical and functional outcomes following surgery. © 2010 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved. Keywords: Pancreatitis, chronic; Complications; Surgery; Radiography; Therapy; Ultrasonography; Cholangiopancreatography

Endoscopic pancreatic sphincteroromy and removal of pancreatic stones has been helpful in selected cases of patients with chronic pancreatitis. This article reports the case of an 18-year-old native Indian woman with cystic fibrosis who was experiencing pain related to pancreatitis, complicated by pancreatic duct stricture and lithiasis. Subsequent dilation of the pancreatic stricture and lithotripsy of the pancreatic ductal stones successfully eliminated the abdominal pain

Pancreatic stones from 25 patients were compared by morphological and/or radiological examination. Twenty patients, mostly alcoholics, had calcified stones. Five (four nonalcoholic women) had radiolucent stones. Aspect and consistency of calcified stones varied from compact and resistant to coralliform and brittle but were identical in the same patient. In the coralliform type, organic fibrils with a diameter up to 10 microm and a length up to a few centimeters were observed, strongly attached to mineral crystals. The lithostathine (formerly called pancreatic stone protein, PSP) content was estimated in each stone significantly lower in the populations with larger stone mass, compared to populations with small amounts of stones. Transparent stones were built up of an amorphous material solubilized at acidic pH and corresponding to degraded forms of lithostathine-S (S for secretory). In one patient, we followed over seven years the evolution of a radiolucent calculus. We observed that the radiolucent core occurred first, and was secondarily wrapped in a calcified shell. We conclude that morphological differences observed in this study among pancreatic stones suggest that different mechanisms have been involved in their formation. Among them, lithostathine transformation into insoluble polypeptides may provide different types of protein aggregates, some of them being able to promote CaCO(3) apposition and others having no affinity for calcium.

Endoscopic sphincterotomy with stone extraction has been successful in the majority of patients with biliary stones; however, large biliary stones and pancreatic stones in the smaller pancreatic duct may require a new approach. Pulsed dye laser has proven effective in treating pancreatic duct calculi during ERCP. With an outpatient procedure to eliminate pancreatic duct calculi, patients can be treated safely and effectively without major surgery. The procedure is less invasive for the patient, thereby reducing morbidity and expense.

Endotherapy for pancreatic stone is an emerging specialty. The judicious application of extracorporeal shock-wave lithotripsy (ESWL) and endoscopic retrograde cholangiopancreatography (ERCP) in selected groups of patients has increased the success rates of endotherapy, with excellent long-term results. In this review the authors share their vast experience of treating patients with pancreatic stones. The article will focus on the basic principles of pancreatic endotherapy, the instrumentation required, details of the ESWL technique and its applications, as well as the limitations, success rate, and complications of endotherapy in selected patients.

(12.2% vs. 3.1%; p

Background & Aims: The aim of this study was to evaluate the short- and long-term results of extracorporeal shockwave lithotripsy (ESWL) and endoscopic therapy for pancreatic stones. Methods: A total of 117 patients with pancreatic stones underwent ESWL and endoscopic treatment in our institute. Seventy patients who were followed-up for over 3 years after treatment were evaluated retrospectively. Results: Immediate pain relief was achieved in 97% and complete removal of stones was achieved in 56%. During the long-term follow-up evaluation, 49 of 70 patients continued to be asymptomatic. Pain recurred more frequently in patients with incomplete removal than in those with complete removal (P < .05). Twenty-one patients who became symptomatic during the follow-up period underwent additional therapy, and pain relief was attained without surgery in all of them. Both endocrine and exocrine function deteriorated after the long-term follow-up period (P < .05). Conclusions: ESWL and endoscopic treatment of pancreatic stones proved to be effective for long-term pain relief, especially in patients in whom stones were removed completely at initial therapy.

Background: Obstruction of the main pancreatic duct with upstream hypertension and dilation is a cause of pain in patients with chronic pancreatitis. Pancreatic ductal drainage can be achieved endoscopically by intraductal stone removal after endoscopic pancreatic sphincterotomy and/or by insertion of a pancreatic stent. Extracorporeal shock wave lithotripsy may be needed whenever stones cannot be removed by endoscopic procedures. We present our results in 35 patients treated with a combined endoscopic-extracorporeal shock wave lithotripsy approach with at least 6 months of follow-up. Methods: Thirty-five patients with severe chronic pancreatitis were treated by extracorporeal shock wave lithotripsy for endoscopically unretrievable obstructive stones. Extracorporeal shock wave lithotripsy was performed with an electromagnetic lithotriptor in 29 patients and an electrohydraulic lithotriptor in 6. Results: The procedures were well tolerated by the majority of patients. Fragmentation of stones was obtained in all cases while complete clearance and decompression of pancreatic duct were obtained in 26 of 35 (74.3%) and in 30 of 35 (85.7%) cases, respectively. There was no mortality related to the procedure. Morbidity was observed in 8 of 35 patients (22.8%). Conclusions: Extracorporeal shock wave lithotripsy is a safe and effective treatment for endoscopically unretrievable pancreatic stones in the main pancreatic duct. Extracorporeal shock wave lithotripsy should be considered complementary and not an alternative to endoscopic drainage. Combined with endoscopy, extracorporeal shock wave lithotripsy may increase the success rate of nonsurgical treatment of patients with chronic pancreatitis.(Gastrointest Endosc 1997;46:231-6.)

Some patients with autoimmune pancreatitis (AIP) form pancreatic stones suggestive of transformation into chronic pancreatitis (CP). The present study examined the underlying risk factors and mechanism of AIP progression to confirmed CP. We compared the clinical and laboratory parameters of subjects who progressed to confirmed CP with those of the subjucts who did not in a cohort of 73 type 1 AIP patients. A total of 16 (22%) AIP patients progressed to CP. Univariate analysis revealed that relapse was significantly more frequent in the progression group, and multivariate analysis indicated that pancreatic head swelling (OR 12.7, P = 0.023) and nonnarrowing of the main pancreatic duct in the pancreatic body (OR 12.6, P = 0.001) were significant independent risk factors for progression to CP. Kaplan-Meier testing showed that the progression rate to CP was approximately 10% at 3 years and 30% at 10 years in total AIP patients and 30% at 3 years and 60% at 10 years in subjects with both risk factors. AIP with pancreatic head swelling and a history of relapse may cause pancreatic juice stagnation and nonnarrowing of the main pancreatic duct in the pancreatic body, which can progress to advanced stage chronic pancreatitis., Article, International Journal of Rheumatology. 2013:272595 (2013)

Obstruction of the pancreatic duct together with an increased outflow pressure for the pancreatic juice proximal to an obstacle is believed to be one pathogenic factor of persistent pain in patients with chronic calcifying pancreatitis. Obstruction may be caused by stenoses and/or calcified stones in the pancreatic duct. It has been shown that surgical or endoscopic drainage procedures may lead to allevation of pain [2–4, 6, 7]. However, endoscopic extraction of pancreatic calculi may be prevented by their size in relation to the duct anatomy. Therefore, a combined approach of extracorporeal shock wave lithotripsy (ESWL) together with endoscopic drainage procedures was described some years ago [1, 5, 8, 9].

膵石症に対する内視鏡治療において，併存する主膵管狭窄を治療することにより，膵炎や疼痛などの再発を予防し得るかは明らかでない．そこで，当施設で治療を行った膵石症61例について，症状の再発に寄与する因子を検討するとともに，膵管狭窄が症状の再発に及ぼす影響，膵管狭窄に対するステント治療による症状再発の予防効果について検討した．膵管狭窄は41例に合併し，24例に対してステントを留置した．平均観察期間3.3年で症状の再発を28例（46%）に認め，病悩期間が長いほど，症状再発のリスクは高くなった．膵管狭窄による症状再発のリスクは2.3倍（p=0.12），ステント留置による症状再発のリスクは0.35倍（p=0.057）であり，ステント治療の有用性が示唆された．一方で，留置中に13例（54%）に少なくとも1回の膵炎を合併しており，安全な留置法や留置期間などについては十分な検討が必要である．

膵石に対する体外衝撃波結石破砕療法（ESWL）と内視鏡治療は，その低侵襲性ゆえに近年，臨床応用が盛んに行われている．当科における治療成績でも，両者を併用することにより破砕効果97%，完全排石56%，疼痛改善効果97%であり，特に治療後の疼痛改善効果に優れていることが示されている．一方，膵外分泌機能に関しては，膵石治療後短期的には改善する症例が多かったが，長期経過では，膵外分泌機能，膵内分泌機能ともに低下する症例が多かった．特にアルコール性慢性膵炎での飲酒継続群では低下する傾向が顕著であった．

Two male patients with complications associated with chronic pancreatitis are described. In each patient, preoperative examinations revealed a large stone obstructing the main duct in the head of the pancreas. Lateral pancreaticojejunostomy was performed to relieve pain and prevent further attacks of pancreatitis. During each operation, the stone was fragmented under direct visual control with the use of a flexible choledochoscope and a contact electrohydraulic lithotriptor. The stone was removed and ductal flow through the head of the pancreas was reestablished. Our experience shows that endoscopie electrohydraulic lithotripsy facilitates operative removal of pancreatic stones deeply located in the head of the pancreas.

Until recently, pancreas divisum represented a major technical barrier to a complete evaluation of pancreatic ductal anatomy. Technical refinements have now made it possible to achieve minor papilla cannulation and dorsal ductography in more than 90% of attempts. In 120 consecutive dorsal ductograms, structural pathology was demonstrated in 36 subjects (30%): chronic pancreatitis in 23, pancreatic stones in 10, pseudocyst(s) in 4, ductal "cut-off" in 7, pancreatic cancer in 3, and partial agenesis in 1 (some patients had more than one finding). For patients in whom alcohol abuse was excluded, ductal pathology was present in 25%. Abnormal ventral ductograms were present in only 8% of cases, demonstrating that dorsal ductography has an appreciable additional diagnostic yield. When the clinical situation indicates the need for pancreatography, minor papilla cannulation should be performed if major papilla cannulation fails or reveals only the ventral pancreatogram of pancreas divisum.

Human pancreatic stones consist predominantly of calcium carbonate. In this note I report on a study of the carbon and oxygen isotope composition of pancreatic calculi from three different geographic areas (India, Italy, Federal Republic of Germany). The objectives were a) to relate isotopic variations to geographic enrivonment, b) to evaluate the extent to which biochemical isotopic fractionations are significant in stone formation, and c) to compare the carbon isotopic composition of pancreatic stones with that of kidney stones.

Answers on p 505 . A 26 year old woman presented with history of recurrent colicky abdominal pain since childhood. There was a history suggestive of steatorrhoea, polyuria, and polydipsia of eight years’ duration. On general examination she had pulse rate of …

Aim: pancreatic stones are frequently reported to be a factor of failure of endoscopic treatment of chronic pancreatitis. Our series tried to evaluate the efficacy of extracorporeal piezoelectric shock wave lithotripsy (ESWL) to disintegrate pancreatic stones in the main pancreatic duct. Methods- Patients: 51 patients (40 men, 11 women) with a mean age of 51 years, presenting with chronic pancreatitis, have been treated between May 1995 to January 1990. The mean number of sessions of lithotripsy was 4.96 per patient with the piezoelectric lithotriptor EDAP LT02. The mean cumul (power (%) x time (sec) x frequency (shock/sec.) /160) per patient was 70,5 +/- 40,5. The total or uncomplete success was defined by the feasibility ofpancreatic stenting. Results: The fragmentation of stones in the main pancreaticduct was achieved in 83,3 % of cases. The total success was achievedin 25 patients (49%), an uncomplete succcess in 11 patients (21%) and atotal failure in 15 patients (29%). Pancreatic stenting failed in 3/33patients after the ESWL and 10/33 patients before the ESWL. Pain disappearedin 72% of the cases after ESWL. There was a significant relationbetween the fragmentation of stones and the disappearance of pain. A significantrelationship was shown between the cumul value and the fragmentationrate. Conclusion: ESWL with the piezoelectric lithotriptor provides satisfactory results on the disappearance of the pain and on the fragmentation. ESWL seems helpful in the endoscopic treatment of chronic pancreatitis.

Aim Extracorporeal Shock Wave Lithotripsy(ESWL) is an effective treatment for gallstones and renal stones. However, few data are available on the usefulness of ESWL for pancreatolithiasis. We evaluated the usefulness of ESWL in the treatment of pancreatic stones. Patients and methods 21 patients of pancreatolithiasis were analyzed. For these patients, we first perform endoscopic sphincterotomy(EST) and attempt endoscopic removal of the stones. If complete clearance of the stones was not achieved by endoscopic methods, ESWL was added. We evaluated the rate of therapeutic success and complications after ESWL. Results Stone removal was successful by only EST in 9 patients(42%). In the remaining 12 patients, ESWL were employed. Among these 12 patients, complete stone removal was achieved in all but one patients(93%). Symptomatic improvement was obtained in all patients. Mortality was zero percent and mild acute pancreatitis as a procedure related complication occurred in only one patient. Conclusions ESWL is a safe and effective treatment for the patients of pancreatic stones. Combined with endoscopic therapy, ESWL may increase the success rate of removal of the pancreatic stones.