ERCP with per-oral pancreatoscopy–guided laser lithotripsy for calcific chronic pancreatitis: a multicenter U.S. experience

Background In patients with chronic pancreatitis, laser lithotripsy (LL) permits stone fragmentation and removal during ERCP with some advantages over extracorporeal shock-wave lithotripsy (ESWL) and surgery. Objectives To evaluate the technical success of LL in pancreatic duct (PD) stones. Design Retrospective cohort. Setting Four tertiary referral centers. Patients Patients undergoing endotherapy for PD stones. Interventions ERCP with per-oral pancreatoscopy (POP)-guided LL. Main Outcome Measurement Technical success was defined as complete stone clearance. Results Over 3 years, 28 patients (16 men, 51 years [mean age]) underwent a median of 1 (range, 1-4) POP-LL for PD stones. Baseline parameters included pain requiring hospitalization (n = 19, 68%), opiate use (n = 14, 50%), or weight loss (n = 11, 39%). Before POP-LL, 22 of 28 patients (79%) had a median of 1 (range, 1-5) ERCP, 9 of 28 (32%) underwent a median of 2 (range, 1-3) ESWL sessions, and 5 underwent a median of 1 (range, 1-3) POP-guided electrohydraulic lithotripsy with failed (n = 2) or partial (n = 3) fragmentation. A median of 2 (range, 1-3) stones sized 15 mm (range, 4-32 mm) were identified in the head (n = 9, 32%), neck (n = 3, 11%), body (n = 9, 32%), tail (n = 1, 4%), or multiple sites (n = 6, 21%). Technical success occurred in 22 patients (79%) with complete clearance. Partial clearance occurred in 3 (11%). Clinical success at a median of 13 (range, 1-25) months of follow-up was noted in 25 of 28 patients (89%) by improvement in pain (n = 25), decreased narcotic use (n = 25), or reduced hospitalizations (n = 19). Mild adverse events occurred in 8 of 28 (29%). Conclusions POP-LL is feasible at expert centers in patients with accessible stones. Although intensive endotherapy is required, most patients achieve stone clearance and clinical improvement.