Removal of large impacted pancreatic stone

Chang-Il Kwon, MD, and Stuart Sherman, MD, from the Division of Gastroenterology/Hepatology, Indiana University School of Medicine, in Indianapolis, Indiana, USA present this VideoGIE case, “Large impacted pancreatic stone removed with single-operator pancreatoscopy and electrohydraulic lithotripsy.”

In patients with obstructive chronic calcific pancreatitis, endoscopic decompression of the main pancreatic duct with stone removal is an effective first-line approach and alternative to surgery. Despite advances in technology, including extracorporeal shockwave lithotripsy (ESWL) and electrohydraulic lithotripsy (EHL), complete stone removal from the main pancreatic duct (MPD) is achieved in only 44%-75% of cases. The main reason is that obstructing pancreatic stones may be accompanied by a MPD stricture in 60%-70% of cases. Also, attempts at stone removal can be hindered by stone size.

Figure 1. Endoscopic retrograde pancreatographic view of impacted pancreatic duct stone (arrow) near the genu of the pancreas.

This video demonstrates successful fragmentation of an impacted pancreatic stone using Spyglass and EHL after dilation of the pancreatic duct adjacent to the stone using multiple catheters and a dilating balloon. A 59-year-old male with chronic calcific pancreatitis secondary to alcohol and smoking presented with chronic abdominal pain and acute recurrent pancreatitis. CT scan revealed features of chronic pancreatitis including a 15mm calculus in a dilated MPD. On a previous ERCP examination 2 months prior, diffuse changes in the pancreatic ductal system were noted consistent with severe chronic pancreatitis. It also showed an obstructing impacted MPD stone near the genu. Standard and dilating catheters and stone retrieval balloons could not be advanced around the stone due to stone size. A 5 Fr Soehendra stent retriever was advanced into the pancreatic duct upstream to the impacted stone. Then, a pancreatic duct stent was successfully placed.

This video mainly shows the follow-up ERCP with single operator-pancreatoscopy two months later. After successfully advancing a guidewire upstream to the impacted stone and dilating the MPD, the duct was explored using Spyglass. Under direct visualization in an aqueous environment, EHL was utilized to achieve greater than 50% fragmentation of the impacted stone allowing for successful removal of the fragments using a stone retrieval balloon.

Pancreatic endotherapy with SpyGlass and EHL after aggressive pancreatic duct dilatation can provide dramatic results and avoid a more invasive surgical procedure in selected patients with obstructive chronic calcific pancreatitis. Endoscopists should consider a number of options of therapy for patients with obstructing  MPD stones—SpyGlass with EHL is a good alternative to surgery in well selected candidates.

This work was done during Dr. Kwon’s research fellowship at Indiana University Hospital. He would like to thank Professor Sherman for mentoring him in the production of this VideoGIE.

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The information presented in Endoscopedia reflects the opinions of the authors and does not represent the position of the American Society for Gastrointestinal Endoscopy (ASGE). ASGE expressly disclaims any warranties or guarantees, expressed or implied, and is not liable for damages of any kind in connection with the material, information, or procedures set forth.

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