Safety and Effectiveness of Successive Extracorporeal Shock Wave Lithotripsy for Pancreatolithiasis under Intravenous Bolus Pethidine Administration Alone

Byung Uk Lee; Myung-Hwan Kim; Joon Hyuk Choi; Jun-Ho Choi; Hyo Jung Kim; Do Hyun Park; Sang Soo Lee; Dong-Wan Seo; Sung-Koo Lee

doi:10.4166/kjg.2014.63.4.231

Journal List > Korean J Gastroenterol > v.63(4) > 1007217

Go to TopGo to Top Go to BottomGo to Bottom

TOOLS

Lee, Kim, Choi, Choi, Kim, Park, Lee, Seo, and Lee: Safety and Effectiveness of Successive Extracorporeal Shock Wave Lithotripsy for Pancreatolithiasis under Intravenous Bolus Pethidine Administration Alone

Original Article

Korean J Gastroenterol 2014;63(4):231-238.

Published online: 4 October 2014

DOI: https://doi.org/10.4166/kjg.2014.63.4.231

Safety and Effectiveness of Successive Extracorporeal Shock Wave Lithotripsy for Pancreatolithiasis under Intravenous Bolus Pethidine Administration Alone

Byung Uk Lee, Myung-Hwan Kim¹, Joon Hyuk Choi¹, Jun-Ho Choi¹, Hyo Jung Kim¹, Do Hyun Park¹, Sang Soo Lee¹, Dong-Wan Seo¹, Sung-Koo Lee¹

Department of Gastroenterology, Ulsan University Hospital, Ulsan, Korea

¹Division of Gastroenterology, Department of Internal Medicine, Asan Medical Center, Seoul, University of Ulsan College of Medicine, Korea

Correspondence to: Myung-Hwan Kim, Department of Gastroenterology, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 138-736, Korea. Tel: +82-2-3010-3183, Fax: +82-2-476-0824, E-mail: mhkim@amc.seoul.kr

Received 14 January 2014 Revised 26 February 2014 Accepted 28 February 2014

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Background/Aims

A retrospective analysis was performed to evaluate the safety and effectiveness of extracorporeal shock wave lithotripsy (ESWL) for pancreatolithiasis on successive days under intravenous bolus of pethidine alone.

Methods

Ninety patients with calcified pancreatic stones (≥5 mm) presenting with abdominal pain were selected for ESWL. ESWL was performed with an electroconductive lithotripter under fluoroscopic target systems. Fragmented calculi after ESWL were removed by endotherapy.

Results

A mean of 4.2 ESWL sessions were performed for each patient, with a mean of 2,984 shocks at a mean power setting of 12.8 kV. Eighty-four (89.3%) patients underwent ESWL for three or more days in a row. Fragmentation of the stones were achieved in 83/90 (92.2%) patients. Complete clearance of the main pancreatic duct was achieved in 54/90 (60.0%) patients, and partial clearance was achieved in 27 (30.0%) patients. The mean dose of pethidine used during ESWL was 53.5±20.7 mg per session. As ESWLrelated complications, four (4.3%) patients developed mild acute pancreatitis.

Conclusions

In case of endoscopically difficult-to-treat pancreatic duct stones, combined therapy with ESWL is an effective method, and treatment with multiple sessions of ESWL on successive days under intravenous bolus of pethidine alone is safe and well tolerated.

Keywords: Calculi, Pancreatic ducts, Extracorporeal shockwave lithotripsy

References

1. Etemad B, Whitcomb DC. Chronic pancreatitis: diagnosis, classification, and new genetic developments. Gastroenterology. 2001; 120:682–707.

2. Ammann RW, Muench R, Otto R, Buehler H, Freiburghaus AU, Siegenthaler W. Evolution and regression of pancreatic calcification in chronic pancreatitis. A prospective long-term study of 107 patients. Gastroenterology. 1988; 95:1018–1028.

3. Bhasin DK, Singh G, Rana SS, et al. Clinical profile of idiopathic chronic pancreatitis in North India. Clin Gastroenterol Hepatol. 2009; 7:594–599.

4. Matthews K, Correa RJ, Gibbons RP, Weissman RM, Kozarek RA. Extracorporeal shock wave lithotripsy for obstructing pancreatic duct calculi. J Urol. 1997; 158:522–525.

5. Ebbehøj N, Borly L, Bülow J, Rasmussen SG, Madsen P. Evaluation of pancreatic tissue fluid pressure and pain in chronic pancreatitis. A longitudinal study. Scand J Gastroenterol. 1990; 25:462–466.

6. Widdison AL, Alvarez C, Karanjia ND, Reber HA. Experimental evidence of beneficial effects of ductal decompression in chronic pancreatitis. Endoscopy. 1991; 23:151–154.

7. Tandan M, Reddy DN, Talukdar R, et al. Longterm clinical outcomes of extracorporeal shockwave lithotripsy in painful chronic calcific pancreatitis. Gastrointest Endosc. 2013; 78:726–733.

8. Dumonceau JM, Delhaye M, Tringali A, et al. Endoscopic treatment of chronic pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy. 2012; 44:784–800.

9. Inui K, Tazuma S, Yamaguchi T, et al. Treatment of pancreatic stones with extracorporeal shock wave lithotripsy: results of a multicenter survey. Pancreas. 2005; 30:26–30.

10. Delhaye M, Vandermeeren A, Baize M, Cremer M. Extracorporeal shockwave lithotripsy of pancreatic calculi. Gastroenterology. 1992; 102:610–620.

11. Dumonceau JM, Costamagna G, Tringali A, et al. Treatment for painful calcified chronic pancreatitis: extracorporeal shock wave lithotripsy versus endoscopic treatment: a randomised controlled trial. Gut. 2007; 56:545–552.

12. Tandan M, Reddy DN, Santosh D, et al. Extracorporeal shock wave lithotripsy and endotherapy for pancreatic calculi-a large single center experience. Indian J Gastroenterol. 2010; 29:143–148.

13. McCaffery M, Pasero C. Pain: clinical manual. 2nd ed.St. Louis: Mosby;1999.

14. Banks PA, Bollen TL, Dervenis C, et al. Acute Pancreatitis Classification Working Group. Classification of acute pancreatitis–2012: revision of the Atlanta classification and definitions by international consensus. Gut. 2013; 62:102–111.

15. Choi KS, Kim MH, Lee YS, et al. Disintegration of pancreatic duct stones with extracorporeal shockwave lithotripsy. Korean J Gastroenterol. 2005; 46:396–403.

16. Pemberton RJ, Tolley DA. Comparison of a new-generation electroconductive spark lithotripter and the Dornier Compact Delta for ureteral calculi in a quaternary referral center. J Endourol. 2006; 20:732–736.

17. Schlosser W, Beger HG. Organ-preserving surgery in chronic pancreatitis: the duodenum-preserving pancreatic head resection. Ann Ital Chir. 2000; 71:65–70.

18. Sherman S, Lehman GA, Hawes RH, et al. Pancreatic ductal stones: frequency of successful endoscopic removal and improvement in symptoms. Gastrointest Endosc. 1991; 37:511–517.

19. Ohara H, Hoshino M, Hayakawa T, et al. Single application extracorporeal shock wave lithotripsy is the first choice for patients with pancreatic duct stones. Am J Gastroenterol. 1996; 91:1388–1394.

20. Suzuki Y, Sugiyama M, Inui K, et al. Management for pancreatolithiasis: a Japanese multicenter study. Pancreas. 2013; 42:584–588.

21. Lawrence C, Siddiqi MF, Hamilton JN, et al. Chronic calcific pancreatitis: combination ERCP and extracorporeal shock wave lithotripsy for pancreatic duct stones. South Med J. 2010; 103:505–508.

22. Kozarek RA, Brandabur JJ, Ball TJ, et al. Clinical outcomes in patients who undergo extracorporeal shock wave lithotripsy for chronic calcific pancreatitis. Gastrointest Endosc. 2002; 56:496–500.

23. Johanns W, Jakobeit C, Greiner L, Janssen J. Ultrasound-guided extracorporeal shock wave lithotripsy of pancreatic ductal stones: six years' experience. Can J Gastroenterol. 1996; 10:471–475.

24. Sasahira N, Tada M, Isayama H, et al. Outcomes after clearance of pancreatic stones with or without pancreatic stenting. J Gastroenterol. 2007; 42:63–69.

25. Seven G, Schreiner MA, Ross AS, et al. Longterm outcomes associated with pancreatic extracorporeal shock wave lithotripsy for chronic calcific pancreatitis. Gastrointest Endosc. 2012; 75:997–1004.

Fig. 1.

(A, B) During extracorporeal shock wave lithotripsy, the patient lies on the lithotripter table in the prone position. (C) Fluoroscopy image shows a targeted stone (arrow).

Fig. 2.

Extracorporeal shock wave lithotripsy (ESWL) sessions provided during the same admission period in an individual patient.

Fig. 3.

(A-C) Pre-extracorporeal shock wave lithotripsy (ESWL); (A, B) Abdominal CT and MRCP show an impacted pancreatic stone (arrow) with upstream duct dilatation. (C) ERCP reveals a partially opacified main pancreatic duct with contrast injection. However, the guidewire failed to advance beyond the impacted stone (arrow) into the upstream duct. (D, E) Post-ESWL; (D) Fragmented pancreatic duct stones by ESWL were removed by balloon catheter during ERCP. (E) Follow-up pancreatogram shows no residual pancreatolithiasis in the main pancreatic duct.

Table 1.

Clinical Characteristics of Enrolled Patients (n=90)

Characteristic	Data
Age (yr)	49.5 (20–87)
Sex (male)	67 (74.4)
Potential etiology
Alcohol	48 (53.3)
Idiopathic	33 (36.7)
Genetic	8 (8.9)
Trauma	1 (1.1)
Location of stones
Head	75 (83.3)
Body	15 (16.7)
Size of stones (mm)	14.0±5.0
5–10	23 (25.5)
11–20	51 (56.7)
≥21	16 (17.8)
Number of stones
Single	42 (46.7)
Multiple	48 (53.3)
Main pancreatic duct stricture	72 (80.0)
Follow-up period (mo)	20.0±16.2

Values are presented as median (range), n (%), or mean±SD.

Table 2.

Details on Extracorporeal Shock Wave Lithotripsy (ESWL) and Endotherapy (n=90)

	Data
ESWL
Shock wave number	2,984 (2,500–5,000)
Shock wave energy (kV)	12.8 (11.0–13.5)
Session number per patient	4.2 (1–9)
Analgesic use (pethidine)	53.5±20.7
One injection (50 mg)	358
Two injection (100 mg)	27
Pain score (NRS) during ESWL^a
One injection (50 mg)	1.96±1.76
Two injection (100 mg)	2.92±1.92
ERCP
Pre-ESWL pancreatic sphincterotomy	59 (65.5)
Post-ESWL ERCP with therapeutic intent	90 (100)
ERCP session for stone removal	2.0 (1–4)
Use of Soehendra stent	63 (70.0)
Pancreatic stenting	65 (72.2)
Endoscopic nasopancreatic drainage	9 (10.0)

Values are presented as median (range), mean±SD, number only, or n (%).

NRS, numeric rating scale.

^a p=0.85.

Table 3.

Extracorporeal Shock Wave Lithotripsy (ESWL)related Complications

Acute pancreatitis
Per one patient	4/90 (4.4)
Per one ESWL session	4/385 (1.0)
Skin redness and ecchymosis	2/90 (2.2)

Values are presented as n/total (%).

Table 4.

Treatment Outcomes of Extracorporeal Shock Wave Lithotripsy (ESWL) and Endotherapy (n=90)

Variable	Data
Fragmentation of stone with ESWL	83 (92.2)
Clearance of pancreatic duct stone
Complete	54 (60.0)
Partial	27 (30.0)
Failed	9 (10.0)
Change of main pancreatic duct diameter^a (mm)
Pre-treatment	7.7±3.0
Post-treatment	4.4±2.9
Pain score^a (NRS)
Before ESWL	5.9±1.5
On follow-up after ESWL/ERCP	0.5±0.7
Pain recurrence during follow-up	15 (16.7)
Surgery	5 (5.6)

Values are presented as n (%) or mean±SD.

NRS, numeric rating scale.

^a p＜0.001.

Table 5.

Results on Extracorporeal Shock Wave Lithotripsy and Endoscopic Management for Pancreatic Duct Stones Reported in the Literature

Study	Year	Patient (n)	Stone size (mm)	Shock wave energy source	Shock wave number per session	Anesthesia method	Fragmentation (%)	Complete clearance rate (%)	Need for surgery (%)	Mean follow up (mo)	Complication rates (%)
Delhaye et al.¹⁰	1992	123	7.8–13.2	Electromagnetic	2,862	Diazepam, pethidine	99	59	5	14	ND
Inui et al.⁹	2005	425	10–20	Electrohydraulic, etc.^a	2,407–5,191	ND	92	73	4	44	6.3
Sasahira et al.²⁴	2007	40	4–20	Electromagnetic	ND	Pethidine	ND	88	ND	18	15
Dumonceau et al.¹¹	2007	55	3.5–26	Electromagnetic	ND	ND	ND	ND	4	52	1.8
Tandan et al.¹²	2010	1,006	＞5	Electromagnetic	5,400–10,200	EA	ND	76	3.7	6	33.5
Lawrence et al.²¹	2010	25	8–25	Electromagnetic	4,863	GA	60	59	32	35	6.9
Seven et al.²⁵	2012	120	5–10	Electromagnetic	2,312	GA	ND	ND	16	51	ND
Present study	2013	90	5–20	Electroconductive^b	2,984	Pethidine	92	60	5.3	20	6.7

EA, epidural anesthesia; GA, general anesthesia; ND, not determined.

^a Piezoelectric generator and electromagnetic generator system

^b modified form of electrohydraulic source.

TOOLS

Similar articles