Extracorporeal shock wave lithotripsy for pancreatic stones
- Myriam Delhaye, MD
Myriam Delhaye, MD
- Universite Libre de Bruxelles, Belgium
Treatment of human calculi by extracorporeal shock wave lithotripsy (ESWL) was first used in patients for the treatment of kidney stones in 1980 . Subsequently, this technique has been applied to gallstones  and pancreatic stones . (See "Nonsurgical treatment of gallstones".)
The treatment of pancreatic stones using ESWL will be reviewed here. The treatment of chronic pancreatitis, electrohydraulic lithotripsy, and laser lithotripsy are discussed separately. (See "Treatment of chronic pancreatitis" and "Electrohydraulic lithotripsy in the treatment of bile and pancreatic duct stones" and "Laser lithotripsy for the treatment of bile duct stones".)
CLINICAL SIGNIFICANCE OF PANCREATIC STONES
Pancreatic duct stones are found in approximately 22 to 60 percent of patients with chronic pancreatitis (CP) . The stones can lead to obstruction of the outflow of pancreatic secretions, causing increased intraductal pressure . Because the pancreas is relatively noncompliant, the rise in intraductal pressure can induce tissue hypertension and ischemia, which may be a major factor causing pain in patients with CP . This hypothesis is supported by the observation that symptoms may improve following pancreatic duct drainage [7,8].
The extraction of pancreatic duct stones has usually been attempted during endoscopic retrograde cholangiopancreatography (ERCP). However, successful stone extraction during ERCP depends upon the size and location of the stones and may not be possible if strictures are present or pancreatic stones have become embedded in the ductal system. As a result, a method of stone disruption prior to endoscopic extraction could be helpful. ESWL leads to the fragmentation of pancreatic stones, which has improved the results of endoscopic therapy and may have additional indications in the treatment of patients with CP .
Lithotripsy works by concentrating focused shock waves (SWs) on stones, which causes their disruption. SWs can be generated by three methods:
- Chaussy C, Brendel W, Schmiedt E. Extracorporeally induced destruction of kidney stones by shock waves. Lancet 1980; 2:1265.
- Sauerbruch T, Delius M, Paumgartner G, et al. Fragmentation of gallstones by extracorporeal shock waves. N Engl J Med 1986; 314:818.
- Sauerbruch T, Holl J, Sackmann M, et al. Disintegration of a pancreatic duct stone with extracorporeal shock waves in a patient with chronic pancreatitis. Endoscopy 1987; 19:207.
- Drake DH, Fry WJ. Ductal drainage for chronic pancreatitis. Surgery 1989; 105:131.
- Bradley EL 3rd. Pancreatic duct pressure in chronic pancreatitis. Am J Surg 1982; 144:313.
- Reber HA, Karanjia ND, Alvarez C, et al. Pancreatic blood flow in cats with chronic pancreatitis. Gastroenterology 1992; 103:652.
- Schneider MU, Lux G. Floating pancreatic duct concrements in chronic pancreatitis. Pain relief by endoscopic removal. Endoscopy 1985; 17:8.
- Sherman S, Lehman GA, Hawes RH, et al. Pancreatic ductal stones: frequency of successful endoscopic removal and improvement in symptoms. Gastrointest Endosc 1991; 37:511.
- Delhaye M, Vandermeeren A, Baize M, Cremer M. Extracorporeal shock-wave lithotripsy of pancreatic calculi. Gastroenterology 1992; 102:610.
- Sauerbruch T. Extracorporeal shock wave lithotripsy. Digestion 1997; 58 Suppl 1:98.
- Freeman ML. Mechanical lithotripsy of pancreatic duct stones. Gastrointest Endosc 1996; 44:333.
- Neuhaus H, Hoffmann W, Classen M. Laser lithotripsy of pancreatic and biliary stones via 3.4 mm and 3.7 mm miniscopes: first clinical results. Endoscopy 1992; 24:208.
- Guda NM, Partington S, Freeman ML. Extracorporeal shock wave lithotripsy in the management of chronic calcific pancreatitis: a meta-analysis. JOP 2005; 6:6.
- Matos C, Metens T, Devière J, et al. Pancreatic duct: morphologic and functional evaluation with dynamic MR pancreatography after secretin stimulation. Radiology 1997; 203:435.
- Schneider HT, May A, Benninger J, et al. Piezoelectric shock wave lithotripsy of pancreatic duct stones. Am J Gastroenterol 1994; 89:2042.
- Johanns W, Jakobeit C, Greiner L, Janssen J. Ultrasound-guided extracorporeal shock wave lithotripsy of pancreatic ductal stones: six years' experience. Can J Gastroenterol 1996; 10:471.
- Brand B, Kahl M, Sidhu S, et al. Prospective evaluation of morphology, function, and quality of life after extracorporeal shockwave lithotripsy and endoscopic treatment of chronic calcific pancreatitis. Am J Gastroenterol 2000; 95:3428.
- Ong WC, Tandan M, Reddy V, et al. Multiple main pancreatic duct stones in tropical pancreatitis: safe clearance with extracorporeal shockwave lithotripsy. J Gastroenterol Hepatol 2006; 21:1514.
- van der Hul R, Plaisier P, Jeekel J, et al. Extracorporeal shock-wave lithotripsy of pancreatic duct stones: immediate and long-term results. Endoscopy 1994; 26:573.
- Martin RF, Hanson BL, Bosco JJ, et al. Combined modality treatment of symptomatic pancreatic ductal lithiasis. Arch Surg 1995; 130:375.
- Ohara H, Hoshino M, Hayakawa T, et al. Single application extracorporeal shock wave lithotripsy is the first choice for patients with pancreatic duct stones. Am J Gastroenterol 1996; 91:1388.
- Schreiber F, Gurakuqi GC, Pristautz H, et al. Sonographically-guided extracorporeal shockwave lithotripsy for pancreatic stones in patients with chronic pancreatitis. J Gastroenterol Hepatol 1996; 11:247.
- Costamagna G, Gabbrielli A, Mutignani M, et al. Extracorporeal shock wave lithotripsy of pancreatic stones in chronic pancreatitis: immediate and medium-term results. Gastrointest Endosc 1997; 46:231.
- Sauerbruch T, Holl J, Sackmann M, Paumgartner G. Extracorporeal lithotripsy of pancreatic stones in patients with chronic pancreatitis and pain: a prospective follow up study. Gut 1992; 33:969.
- Grimm H, Meyer WH, Nam VC, Soehendra N. New modalities for treating chronic pancreatitis. Endoscopy 1989; 21:70.
- Adamek HE, Jakobs R, Buttmann A, et al. Long term follow up of patients with chronic pancreatitis and pancreatic stones treated with extracorporeal shock wave lithotripsy. Gut 1999; 45:402.
- Inui K, Tazuma S, Yamaguchi T, et al. Treatment of pancreatic stones with extracorporeal shock wave lithotripsy: results of a multicenter survey. Pancreas 2005; 30:26.
- Tadenuma H, Ishihara T, Yamaguchi T, et al. Long-term results of extracorporeal shockwave lithotripsy and endoscopic therapy for pancreatic stones. Clin Gastroenterol Hepatol 2005; 3:1128.
- Smits ME, Rauws EA, Tytgat GN, Huibregtse K. Endoscopic treatment of pancreatic stones in patients with chronic pancreatitis. Gastrointest Endosc 1996; 43:556.
- Dumonceau JM, Devière J, Le Moine O, et al. Endoscopic pancreatic drainage in chronic pancreatitis associated with ductal stones: long-term results. Gastrointest Endosc 1996; 43:547.
- Kozarek RA, Brandabur JJ, Ball TJ, et al. Clinical outcomes in patients who undergo extracorporeal shock wave lithotripsy for chronic calcific pancreatitis. Gastrointest Endosc 2002; 56:496.
- Farnbacher MJ, Schoen C, Rabenstein T, et al. Pancreatic duct stones in chronic pancreatitis: criteria for treatment intensity and success. Gastrointest Endosc 2002; 56:501.
- Tandan M, Reddy DN, Santosh D, et al. Extracorporeal shock wave lithotripsy and endotherapy for pancreatic calculi-a large single center experience. Indian J Gastroenterol 2010; 29:143.
- Suzuki Y, Sugiyama M, Inui K, et al. Management for pancreatolithiasis: a Japanese multicenter study. Pancreas 2013; 42:584.
- Ohyama H, Mikata R, Ishihara T, et al. Efficacy of stone density on noncontrast computed tomography in predicting the outcome of extracorporeal shock wave lithotripsy for patients with pancreatic stones. Pancreas 2015; 44:422.
- Ammann RW, Akovbiantz A, Largiader F, Schueler G. Course and outcome of chronic pancreatitis. Longitudinal study of a mixed medical-surgical series of 245 patients. Gastroenterology 1984; 86:820.
- Seven G, Schreiner MA, Ross AS, et al. Long-term outcomes associated with pancreatic extracorporeal shock wave lithotripsy for chronic calcific pancreatitis. Gastrointest Endosc 2012; 75:997.
- Tandan M, Reddy DN, Talukdar R, et al. Long-term clinical outcomes of extracorporeal shockwave lithotripsy in painful chronic calcific pancreatitis. Gastrointest Endosc 2013; 78:726.
- Moole H, Jaeger A, Bechtold ML, et al. Success of Extracorporeal Shock Wave Lithotripsy in Chronic Calcific Pancreatitis Management: A Meta-Analysis and Systematic Review. Pancreas 2016; 45:651.
- Dumonceau JM, Costamagna G, Tringali A, et al. Treatment for painful calcified chronic pancreatitis: extracorporeal shock wave lithotripsy versus endoscopic treatment: a randomised controlled trial. Gut 2007; 56:545.
- Delhaye M, Arvanitakis M, Verset G, et al. Long-term clinical outcome after endoscopic pancreatic ductal drainage for patients with painful chronic pancreatitis. Clin Gastroenterol Hepatol 2004; 2:1096.
- Li BR, Liao Z, Du TT, et al. Risk factors for complications of pancreatic extracorporeal shock wave lithotripsy. Endoscopy 2014; 46:1092.
- Gulbis B, Delhaye M, Vandermeeren A, et al. Biological markers of cell damage during shock wave lithotripsy: Evidence for a shock wave related granulocyte damage. J Stone Dis 1992; 4:34.
- CLINICAL SIGNIFICANCE OF PANCREATIC STONES
- PATIENT SELECTION
- Stone localization
- Antibiotic prophylaxis
- Application of shock waves
- Need for ERCP
- Technical results
- Clinical results
- - Pain relief
- - Pancreatic endocrine and exocrine function
- - Stone recurrence
- ESWL monotherapy compared to ESWL combined with endoscopic drainage
- Need for surgery
- SUMMARY AND RECOMMENDATIONS