Extracorporeal shockwave lithotripsy in combination with endoscopy as a treatment modality for painful chronic obstructive pancreatitis – a case report

Overview

Chronic pancreatitis (CP) is a serious condition with a great impact on the quality of life, and it can lead to some serious long-term consequences such as pancreatic cancer or secondary diabetes mellitus. Associated pancreatic exocrine insufficiency leads to malnutrition with weight loss; however, the main symptom of the disease is abdominal pain, often very severe. The primary treatment option for painful CP is pharmacotherapy (pancreatic enzyme replacement therapy, analgesics). If this is not effective, CP can be treated via endoscopy, extracorporeal shockwave lithotripsy (ESWL), their combination, or surgery. We present a case of painful chronic obstructive pancreatitis in a patient successfully treated with ESWL in combination with endoscopy.

Keywords:

endoscopy – chronic pancreatitis – extracorporeal shockwave lithotripsy – pancreatic duct stones

INTRODUCTION

Chronic pancreatitis (CP) is a serious disease, typically presenting with chronic abdominal pain and malnutrition. It can be treated pharmacologically with pancreatic enzyme replacement therapy and analgesics with varying levels of success. Pain unresponsive to medical therapy usually mandates interventions including endoscopy, extracorporeal shockwave lithotripsy (ESWL), and surgery, although these have been utilized with considerable variations among centers and countries [1]. Endoscopic treatment for painful CP is indicated in the presence of stones within the main pancreatic duct (MPD), symptomatic or refractory MPD strictures, or in the case of local complications, e.g., common bile duct stenosis or duodenal stenosis. For pancreatic duct (PD) stones, the European Society of Gastrointestinal Endoscopy (ESGE) recommends endoscopic therapy ±ESWL as the first line treatment [2]. Surgical therapy for painful CP consists of drainage (Partington-Rochell), resection (pancreatectomy, total pancreatectomy, or Beger), or combined procedures (Frey or Izbicki) [3,4].

CASE REPORT

A 66-year-old male with a 3-year history of alcohol- induced CP was referred to our department due to an MPD stricture with a stone visualized on magnetic resonance imaging. The chief complaints were protracted abdominal pain and weight loss with minimal response to maximal medical therapy, corresponding to painful obstructive CP. We performed endoscopic ultrasonography (EUS) revealing an 8mm stone within a stenosed MPD (Fig. 1), followed by endoscopic retrograde cholangiopancreatography (ERCP) confirming features of severe CP, grade IV according to the Cambridge classification. We then placed a 7Fr 10cm pancreatic stent over the site of the stricture to pass the stone; however, it did not lead to symptoms resolution. We thus proceeded with ESWL, which was performed in three separate sessions on 3 consecutive days. Each session was carried out using the EDAP TMS Sonolith® i-sys lithotripter that is based on an electroconductive energy source, by applying 3,000 shock waves (9,000 in total) with the pulse repetition frequency of 2 Hz and 93% of device energy level on average. The shock wave energy was adapted during the sessions based on the patient’s pain response and overall tolerance of the procedure. The patient was premedicated with piritramide 15 mg, and a periprocedural infusion of diclofenac 75 mg was also administered, which proved to be adequate to ensure good tolerance of lithotripsy without a need of general anesthesia. The effect of ESWL was evident immediately on periprocedural fluoroscopy (Figs. 2, 3). Five days following the last session of ESWL, we performed another ERCP showing stone fragments that were extracted through the major papilla using endoscopic balloon (Fig. 4a, b). The formerly placed pancreatic stent was replaced with two parallel 7Fr 15cm and 7Fr 9cm plastic stents. A follow-up ERCP at 6 months confirmed the MPD stricture had remodeled with no signs of pancreatic stones, and both pancreatic stents were extracted. A follow-up EUS at 12 months showed normal findings of the MPD (Fig. 5), including its lumen width and absence of stones. At the time, the patient had been well, had no abdominal pain, and gained 6 kg of body weight.

DISCUSSION

Painful obstructive CP is a lingering disease necessitating complex management with uncertain outcomes. The ESGE recommends endoscopic therapy ±ESWL as the first-line treatment for painful CP with an MPD stone obstruction [2]. If these interventions fail to provide sufficient treatment results, the case should be discussed within a multidisciplinary team, and surgical options should be considered [2]. The objective of endoscopy ±ESWL is to resolve issues causing MPD obstructions, and they should be considered only in patients with ductal abnormalities (dilation, advanced stages of Cambridge classification of chronic pancreatitis). According to a nationwide survey from Japan, endoscopic therapy alone facilitated PD stones extraction in only a minority of patients (14% of 1,834 cases) [5]. On the other hand, ESWL allowed PD stones extraction in more than 80% of patients on subsequent endoscopy [6]. Notably, endoscopy with mechanical lithotripsy was associated with higher rates of adverse events (AE) in a retrospective study of 712 patients, such as fractured traction wire, trapped basket, or pancreatic ductal leak [7].

PD stone fragmentation was shown to be successfully achieved in up to 90% of patients following ESWL [8]. Multiple sessions may be required. We typically perform three sessions on 3 consecutive days, followed by endoscopic clearance of stone fragments a week after ESWL. The success rate of stone fragment clearance was higher in stones located within the pancreatic head or in solitary stones [9] with ERCP done ≥2 days after ESWL [10], or when a pancreatic stent was placed prior to ESWL [11], which is a practice we adhere to in all of our patients. The pancreatic stent helps in locating and targeting PD stones on fluoroscopy during ESWL, and it secures pancreatic drainage afterwards. We perform ERCP to facilitate clearance of stone fragments approximately a week after the last ESWL session. ESWL can be complicated by a bout of pancreatitis, which was the most frequently reported AE (4.2%) according to a recent meta-analysis [12]. Other AEs included gastrointestinal mucosal injury, hematuria, asymptomatic hyperamylasemia, acute stone incarceration in the papilla, bleeding, and perforation, of which 1.1% were reported as moderate or severe [13]. Contraindications to ESWL include pregnancy, coagulopathy, and shockwave paths through bone, lung tissue, or calcified vessels [14].

Per-oral pancreatoscopy has been introduced as a useful method also in the treatment of obstructive CP, as it can facilitate direct lithotripsy. A recent meta-analysis comprising 15 studies and including 370 patients with PD stones treated with either electrohydraulic or laser lithotripsy found both techniques to have similar efficacy; technical and clinical success rates were approximately 90% [15].

Regarding surgical aspects in this patient population, the first randomized controlled trial (RCT) comparing endoscopic and surgical therapy was carried out by Dite et al. in 2003 [16]. The long-term outcomes of the study favored surgery (absence of pain in 34% after surgery vs 15% after endoscopy); however, ESWL was not used in the study cohort. In 2007, Cahen et al. included ESWL as part of endoscopic therapy [17]. Nonetheless, surgery proved superior at the time as well (absence of pain in 40% after surgery vs 16% after endoscopy ±ESWL). A recent RCT by the Dutch group comparing early surgery vs initial endoscopic therapy ±ESWL reported better outcomes in the surgery arm (absence of pain in 35% after surgery vs 20% after endoscopy ±ESWL) [18]. A crucial factor in surgical therapy is timing of the procedure. Early surgery is favored over surgery performed at a more advanced stage of the disease in terms of optimal long-term pain relief [19]. Higher postoperative pain resistance rates were observed when preoperative duration of CP was greater than 3 years [20,21].

CONCLUSION

We presented the case of a patient with painful obstructive CP, which was successfully treated using a combination of endoscopic pancreatic stent placement and subsequent ESWL. This combination of therapeutic methods achieved extremely favorable results in this patient. The patient has now remained symptom free for two years since the procedure, which has allowed him to regain weight and has significantly improved his quality of life.

Conflict of interests

The authors declare that they have not conflict of interest in connection with the article and that the article was not published in any other journal except congress abstracts and clinical guidelines.

Rozhl Chir. 2022;101:545–548

Assoc. Prof. Lumir Kunovsky, M.D., Ph.D.
2nd Department of Internal Medicine – Gastroenterology and Geriatrics,
University Hospital Olomouc
Faculty of Medicine, Palacky University Olomouc
e-mail: lumir.kunovsky@fnol.cz
ORCID:0000-0003-2985-8759