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

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

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.

References

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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).
kjg-63-231f1.tif
Fig. 2.
Extracorporeal shock wave lithotripsy (ESWL) sessions provided during the same admission period in an individual patient.
kjg-63-231f2.tif
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.
kjg-63-231f3.tif
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 ESWLa  
  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 diametera (mm)  
 Pre-treatment 7.7±3.0
 Post-treatment 4.4±2.9
Pain scorea (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 Electroconductiveb 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.

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