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Revista Española de Enfermedades Digestivas

versión impresa ISSN 1130-0108

Rev. esp. enferm. dig. vol.105 no.9 Madrid oct. 2013

http://dx.doi.org/10.4321/S1130-01082013000900012 

LETTERS TO THE EDITOR

 

Successful extracorporeal shockwave lithotripsy in chronic calcified pancreatitis management

Litotripsia extracorpórea con ondas de choque eficaz en el tratamiento de la pancreatitis crónica calcificada

 


Key words: Stones. Pancreatobiliary. ESWL (extracorporeal shockwave lithotripsy). Endoscopic ultrasonography.


 

Dear Editor,

Pancreatic duct (PD) stones are a common feature of chronic calcified pancreatitis (CCP). Extracorporeal shockwave lithotripsy (ESWL) has been long used in recent years with good results in pain relief (1,2).

 

Case report

A 33-year-old woman with a 3-year history of idiopathic CCP and recurrent attacks of acute pancreatitis was referred to our institution for PD stones management. Prior attempts of endoscopic retrograde cholangiopancreatography (ERCP) approach had failed. Plain abdominal X ray showed calcified stones in the pancreatic area (Fig. 1A). Magnetic resonance cholangiopancreatography (MRCP) demonstrated a dilated pancreatic main duct with multiple stones along it (Fig. 1B). Endoscopic ultrasound (EUS) revealed a dilated PD (5.5 mm) in the body and tail of the pancreas, with several hyper-echogenic structures inside the duct, the largest measuring 9.3 mm (Fig. 1C). Initial approach utilized ESWL therapy with an electromagnetic lithotripter (Dornier Medtech®). ESWL was performed twice in a 2-month period (session 1: 2.7 Hz, 1078 frequency waves, intensity of 6, 40.38 Julies; session 2: 2.7 Hz, 1,458 frequency waves, intensity of 7, 68.66 Julies). The patient did well after each session, with no complications. EUS eight weeks after second ESWL session showed the absence of pancreatic stones in the PD and significant reduction of its size (Fig. 1D). Since then, the patient has shown no new recurrent episodes of pancreatitis (two year follow-up).

 

 

 

Discussion

ESWL with or without interventional endoscopy has been long used for treatment of PD stones associated with CCP (1,3), with good results in pain relief and improvement in quality of life (2). ESWL alone seems to be equally effective than its combination with interventional endoscopy (4,5). EUS is a minimally invasive, low risk method for diagnosis of CCP, and the presence of stones in the PD has been regarded as the most reliable feature (6). This case illustrates the usefulness of exclusive ESWL-based therapy for long term PD stones management, as well as the value of EUS for post-ESWL documentation of stones clearance.

 

Alberto Herreros-de-Tejada1, Ignacio Sola2, José Luis Calleja1,
Miguel Pastrana3, Jennifer Chennat4, Joaquín Carballido2 and Luis Abreu1

Departments of 1Gastroenterology, 2Urology, and 3Radiology. IDIPHIM. Hospital Universitario Puerta de Hierro. Madrid, Spain.
4Division of Gastroenterology, Hepatology, & Nutrition. Department of Medicine. University of Pittsburgh Medical Center. Pittsburgh, USA

 

References

1. Sala T, Pertejo V, Berenguer M, Higon M, Boronat F, Berenguer J. Combined endoscopic treatment with extracorporeal lithotripsy in chronic calcifying pancreatitis. Rev Esp Enferm Dig 1994;86:596-9.         [ Links ]

2. Guda NM, Partington S, Freeman ML. Extracorporeal shock wave lithotripsy in the management of chronic calcific pancreatitis: A meta-analysis. JOP 2005;6:6-12.         [ Links ]

3. Sauerbruch T, Holl J, Sackmann M, Werner R, Wotzka R, Paumgartner G. Disintegration of a pancreatic duct stone with extracorporeal shock waves in a patient with chronic pancreatitis. Endoscopy 1987;19:207-8.         [ Links ]

4. Dumonceau JM, Costamagna G, Tringali A, Vahedi K, Delhaye M, Hittelet A, et al. Treatment for painful calcified chronic pancreatitis: Extracorporeal shock wave lithotripsy versus endoscopic treatment: A randomised controlled trial. Gut 2007;56:545-52.         [ Links ]

5. Parsi MA, Stevens T, Lopez R, Vargo JJ. Extracorporeal shock wave lithotripsy for prevention of recurrent pancreatitis caused by obstructive pancreatic stones. Pancreas 2010;39:153-5.         [ Links ]

6. Wallace MB, Hawes RH, Durkalski V, Chak A, Mallery S, Catalano MF, et al. The reliability of EUS for the diagnosis of chronic pancreatitis: interobserver agreement among experienced endosonographers. Gastrointest Endosc 2001;53:294-9.         [ Links ]

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