Endoscopic treatment of pancreatic duct stones under direct vision. Revolution or resignation? A systematic review

Abstract

Introduction

The main treatment aim in chronic pancreatitis (CP) is symptom control and especially pain relief. Management of stone-predominant CP is challenging and requires a multidisciplinary approach. Extracorporal shock wave lithotripsy (ESWL) has emerged as the cornerstone of non-surgical treatment due to disappointing results of available endoscopic treatment options during the last decades. With new developments in the field of direct peroral pancreatoscopy (POP) and intracorporal lithotripsy, direct intraluminal treatment of main pancreatic duct (MPD) stones returns into spotlight.

Methods and Aims

To review the current data on direct pancreatoscopic treatment of MPD stones with focus on efficiency and safety of available technologies, endoscopes and lithotripsy devices. A systematic Medline search for relevant studies was performed.

Results

Ten relevant publications meeting the inclusion criteria have been identified (2 prospective series, 6 retrospective trials, 2 case reports, n=87 patients). Successful ductal clearance for POP guided treatment was reported between 43% and 100% compared to ESWL with 59% to 80%. Adverse event (AE) rate for POP guided therapy is reported with 0%-13.5%. One study showed a noticeable higher adverse event rate with 43%. In this trial POP was performed after ESWL. There is no reported mortality following POP treatment.

Conclusion

Available results are promising in terms of ductal clearance and pain relief compared to standard endoscopic techniques and ESWL as the current gold standard for lithotripsy. Interpretation of this data is limited by the small number of cases for POP and the lacking of prospective randomized controlled trials.

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