Clinical Endoscopy

Focused Review Series: Endoscopic Intervention in Pancreatitis

Endoscopic Treatment of Pancreatic Calculi: Yong Hoon Kim, Sung Ill Jang, Kwangwon Rhee, Dong Ki Lee; Clin Endosc 2014;47(3):227-235. Published online May 31, 2014; DOI: https://doi.org/10.5946/ce.2014.47.3.227

Chronic pancreatitis is a progressive inflammatory disease that destroys pancreatic parenchyma and alters ductal stricture, leading to ductal destruction and abdominal pain. Pancreatic duct stones (PDSs) are a common complication of chronic pancreatitis that requires treatment to relieve abdominal pain and improve pancreas function. Endoscopic therapy, extracorporeal shock wave lithotripsy (ESWL), and surgery are treatment modalities of PDSs, although lingering controversies have hindered a consensus recommendation. Many comparative studies have reported that surgery is the superior treatment because of reduced duration and frequency of hospitalization, cost, pain relief, and reintervention, while endoscopic therapy is effective and less invasive but cannot be used in all patients. Surgery is the treatment of choice when endoscopic therapy has failed, malignancy is suspected, or duodenal stricture is present. However, in patients with the appropriate indications or at high-risk for surgery, endoscopic therapy in combination with ESWL can be considered a first-line treatment. We expect that the development of advanced endoscopic techniques and equipment will expand the role of endoscopic treatment in PDS removal.

Citations

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L. L. Generdukayev, Yu. S. Teterin, D. A. Blagovestnov, E. S. Yeletskaya, K. A. Nugumanova, P. A. Yartsev
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Combination Therapy Using Multi-biliary Endoprostheses and Oral Ursodeoxycholic Acid for Difficult, Large and Multiple Bile Duct Stones: Tae Hoon Lee, M.D., Sang-Heum Park, M.D., Yun Suk Shim, M.D., Sae Hwan Lee, M.D., Chang Kyun Lee, M.D., Il-Kwun Chung, M.D., Hong Soo Kim, M.D. and Sun-Joo Kim, M.D.; Korean J Gastrointest Endosc 2009;39(3):143-148. Published online September 30, 2009

Abstract PDF: Background
/Aims: Large common bile duct (CBD) stones accompanied by risk factors can be difficult to extract using conventional techniques. This study investigates the efficacy of combination therapy using multiple double pigtail stents and ursodeoxycholic acid (UDCA).
Methods
A total of 895 patients underwent the attempted removal of CBD stones. Multiple double pigtail stents (7 Fr or 10 Fr) were inserted into the CBD over a guidewire. The stents remained in place until endoscopic removal during a second attempt. All patients received oral UDCA (600 mg/day) during the follow-up.
Results
In 21 patients (2.34%), complete clearance was not achieved by the conventional method. Large, multiple stones, the presence of periampullary diverticulum, stricture of the distal CBD, and severe cardiopulmonary disease were observed as limiting factors for the successful removal of CBD stones. Complete endoscopic clearance was achieved in 12 patients (57.1%), and there was a statistically significant reduction in stone size (mean 4.60±2.45 mm, p=0.002). The mean duration of stenting and administration of medicine was 73.9 days. There was no immediate complication related to the procedure.
Conclusions
Our results suggest that combination therapy using pigtail stents and UDCA may be an easy and effective method for removal of difficult CBD stones. (Korean J Gastrointest Endosc 2009;39:143-148)

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담낭이 있는 총담관 담석 환자의 내시경 치료에 대한 연구 ( Endoscopic Treatment of Bile Duct Calculi in Patients with Gallbladder in Situ ): Korean J Gastrointest Endosc 2000;20(1):21-25. Published online November 30, 1999

Abstract PDF: Background
/Aims: Endoscopic sphincterotomy (EST) is a safe and effective method of managing CBD calculi. But whether EST of CBD calculi in patients with gallbladder in situ should be followed by routine post-EST cholecystectomy, is still a subject of controversy. The aims of this study was to identify the recurrence rate and predictive factors of biliary symptoms after EST of CBD calculi in patients with gallbladder in situ. Methods: 90 patients of CBD calculi with intact gallbladder treated with endoscopic sphincterotomy from 1992 to 1998 were reviewed. Follow up on the patients consisted of phone calls or personal interviews and the length of the follow up ranged from 6 to 77 months. Results: Cholecystectomy was required in 12 patients (13.3%) due to recurrent biliary symptoms and the remaining 78 patients (86.6%) were symptom free. Of the recurrence, 67.7% occurred within 12 months after EST and only one occurred after 5 years of follow-up. The risk of recurrence was higher in those patients with periampullary diverticulum in ERCP. Conclusions: The low recurrence rate of 13.3% after EST of CBD stones in patients with gallbladder in situ hardly justifies routine post-EST cholecystectomy and rather suggests selective post-EST cholecystectomy especially in high operative risk patients. (Korean J Gastrointest Endosc 2000;20:21~25)

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간외담관의 다발성 유두상 선암 1예 : ERCP 소견을 중심으로 ( A Case of Multiple Papillary Adenocarcinoma of the Extrahepatic Bile Duct : Findings of ERCP ): Korean J Gastrointest Endosc 1993;13(3):577-579. Published online November 30, 1992

Abstract PDF: Among the primary carcinoma of the extrahepatic bile duct, papillary carcinoma is the least common form and usually located in the distal common bile duct. The cholangiographic findings of the papillary carcinoma is similar to translucency produced by stone. We report a case of multiple papillary adenocarcinoma of the extrahepatic bile duct of which the cholangiographic findings mimicking stones.

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