LOS ANGELES — Clinical and imaging clues provide excellent guidance as to which patients would derive the most benefit from endoscopic pancreatic calculi removal, Robert H. Hawes, M.D., said at the 12th International Symposium on Pancreatic and Biliary Endoscopy sponsored by Cedars-Sinai Medical Center.
“The main issue when you're looking at patients with pancreatic stones or calcific chronic pancreatitis is pain relief,” said Dr. Hawes, professor of gastroenterology and hepatology at the Medical University of South Carolina in Charleston.
“We can talk about improving ductal drainage. We can talk about … improving functional deficits. We can talk about weight gain. We can talk about improving quality of life. But the fact of the matter is, the main issue is pain.”
Therefore, patients with chronic calcific pancreatitis who do not have pain should not be considered candidates for stone removal, he asserted. Nor should stone removal be attempted in an effort to improve steatorrhea, which should be treated with enzymes.
Among patients who do experience pain, those living a “plateau-type existence” with chronic pancreatitis—suffering constant pain—are least likely to achieve significant relief by having calculi removed and obstructions of the main pancreatic duct alleviated, Dr. Hawes said.
The best candidates, he said, are those with chronic relapsing calcific pancreatitis.
These are patients who are “cruising along fine” until they suffer periodic acute bouts of pancreatitis, complete with an elevation of enzymes, extreme pain, and often, nausea and vomiting.
Their chances of success with endoscopic intervention improve even more if they meet certain criteria evident on imaging studies, including:
▸ A large, dilated pancreatic duct.
▸ Three or fewer stones.
▸ Stones confined to the head and/or body of the pancreas.
▸ Stone size less than 10 mm.
▸ The absence of impacted stones.
▸ The absence of downstream strictures.
Ideal candidates can achieve dramatic results from sphincterotomy with endoscopic calculi removal, ideally in conjunction with extracorporeal shock wave lithotripsy, Dr. Hawes said.
Even without the advantage of adjunctive extracorporeal shock wave lithotripsy, increasingly considered “almost indispensable” in centers treating chronic pancreatitis, endoscopic techniques can be highly effective.
A study by Dr. Hawes and his colleagues, published in 1991, showed endoscopic therapy to be effective in 83% of patients with chronic relapsing pancreatitis, compared with just 46% of those presenting with continuous pain (Gastrointest. Endosc. 1991;37:511–7).
Not every stone must be removed to achieve substantial pain relief, Dr. Hawes emphasized. He stopped short of discouraging endoscopic therapy in patients with unrelenting pain. He noted, “It's worth a try but may not help.”
Divergent rates of success for stone removal may be related to the fact that there are two underlying explanations for pain associated with chronic calcific pancreatitis.
In pancreatic duct obstruction, pain results from parenchymal hypertension. This scenario responds well to ductal decompression.
Pain associated with pancreatic and peripancreatic neural inflammation, most often associated with long-standing chronic disease, does not.
Careful imaging can point to whether endoscopic treatment should be undertaken. In some cases, careful imaging can bring to light massive stones and strictures that could be managed only by lithotripsy or surgical Whipple resection.
“I would strongly recommend that if you see patients with chronic pancreatitis, that you switch your gears from a reflex of just getting a CT scan to talking to your radiologist and getting geared up for high-quality MRI scanning … with secretin stimulation,” he said. No other modality gives such clear or important information in treatment planning for patients with chronic pancreatitis.
Dr. Hawes disclosed that he has received grants from Olympus America Inc. and research support from Wilson-Cook Medical Inc. and Boston Scientific Corp, and is a consultant for InScope.