Endoscopy 2018; 50(06): E130-E131
DOI: 10.1055/a-0574-2278
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Pancreatoscopy-guided laser lithotripsy in a patient with difficult ductal stone

Gonçalo Alexandrino
Department of Gastroenterology, Hospital Prof. Doutor Fernando Fonseca, Amadora, Portugal
,
Luís Lourenço
Department of Gastroenterology, Hospital Prof. Doutor Fernando Fonseca, Amadora, Portugal
,
Catarina G. Rodrigues
Department of Gastroenterology, Hospital Prof. Doutor Fernando Fonseca, Amadora, Portugal
,
David Horta
Department of Gastroenterology, Hospital Prof. Doutor Fernando Fonseca, Amadora, Portugal
,
Jorge Reis
Department of Gastroenterology, Hospital Prof. Doutor Fernando Fonseca, Amadora, Portugal
,
Jorge Canena
Department of Gastroenterology, Hospital Prof. Doutor Fernando Fonseca, Amadora, Portugal
› Author Affiliations
Further Information

Corresponding author

Gonçalo Alexandrino, MD
Department of Gastroenterology
Hospital Prof. Doutor Fernando Fonseca
IC 19 Amadora 2720-276
Portugal   
Fax: +351-21-4345566   

Publication History

Publication Date:
08 March 2018 (eFirst)

 

A 63-year-old man with heavy alcohol consumption was referred to our institution for upper abdominal pain, weight loss, and a computed tomography scan showing signs of chronic pancreatitis (parenchymal calcifications and atrophy of the pancreatic body/tail).

A magnetic resonance cholangiopancreatography was performed, showing Wirsung dilation, namely of the tail, and an abrupt stop in the pancreatic body of unknown cause ([Fig. 1]). Endoscopic ultrasound revealed an intraductal stone in the pancreatic body (7.4 mm), and a dilated Wirsung in the body and tail ([Fig. 2]). The patient underwent endoscopic retrograde cholangiopancreatography (ERCP).

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Fig. 1  Magnetic resonance cholangiopancreatography, showing an abrupt stop at the pancreatic body, followed by major dilation of the remaining body and tail.
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Fig. 2 Endoscopic ultrasound revealed a large intraductal stone in the pancreatic body (7.4 mm), and a dilated Wirsung in the body and tail.

Pancreatography showed an irregular Wirsung contour in the head and irregularity in the body–tail transition, suggestive of an intraductal stone ([Fig. 3]). Pancreatic sphincterotomy was performed, and the calculus was crossed with the guidewire, but it was impossible to cross it with a 6-mm dilation balloon. After hydrostatic balloon dilation of the pancreatic head (up to 6 mm), a pancreatoscope (Spyglass Direct Visualization System; Boston Scientific, Marlborough, Massachusetts, USA) was advanced over a 0.025-inch guidewire to reach a large intraductal stone of 7 – 8 mm in size ([Fig. 4], [Video 1]). After targeting the stone, laser bursts (Holmium laser, Auriga XL; Boston Scientific) of less than 5 seconds were delivered through the aqueous medium using a 365-µm diameter fiber (energy level 1200 mJ; frequency of 12 Hz). After stone fragmentation, ductal clearance was achieved with an 8.5-mm extraction balloon. Two pancreatic stents (12 cm, 7 Fr) were placed.

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Fig. 3 Pancreatography showing irregularity in the proximal body, suggesting a large intraductal stone.
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Fig. 4 Pancreatoscopy image showing a large intraductal stone impacted on a main duct stricture.

Video 1 Intraductal pancreatoscopy with holmium laser lithotripsy was performed until complete stone fragmentation was achieved.


Quality:

At follow-up 3 months later, repeat ERCP showed frank improvement of the head stricture, without filling defects in the remaining Wirsung ([Fig. 5]). The patient remained asymptomatic during follow-up (6 months) without further interventions.

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Fig. 5 Pancreatogram image showing resolution of the pancreatic stricture after successful endotherapy.

Published experience is limited, but pancreatoscopy-guided laser lithotripsy for calcific chronic pancreatitis is a promising technique that can be used as a supplementary approach to extracorporeal shock wave lithotripsy or as a single modality in a small number of stones obstructing the main pancreatic duct [1 – 4].

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Correction

Alexandrino G, Lourenço L, Rodrigues CG et al. Pancreatoscopy-guided laser lithotripsy in a patient with difficult ductal stone. In the above mentioned article one author was missing in the authors’ list. Correct is: Gonçalo Alexandrino, Luís Lourenço, Catarina G. Rodrigues, David Horta, Jorge Reis, Jorge Canena. This was corrected in the online version on April 6, 2018.


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Competing interests

Jorge Canena is a consultant for Boston Scientific but did not receive any financial arrangements for this research or any assistance with manuscript preparation.


Corresponding author

Gonçalo Alexandrino, MD
Department of Gastroenterology
Hospital Prof. Doutor Fernando Fonseca
IC 19 Amadora 2720-276
Portugal   
Fax: +351-21-4345566   


Zoom Image
Fig. 1  Magnetic resonance cholangiopancreatography, showing an abrupt stop at the pancreatic body, followed by major dilation of the remaining body and tail.
Zoom Image
Fig. 2 Endoscopic ultrasound revealed a large intraductal stone in the pancreatic body (7.4 mm), and a dilated Wirsung in the body and tail.
Zoom Image
Fig. 3 Pancreatography showing irregularity in the proximal body, suggesting a large intraductal stone.
Zoom Image
Fig. 4 Pancreatoscopy image showing a large intraductal stone impacted on a main duct stricture.
Zoom Image
Fig. 5 Pancreatogram image showing resolution of the pancreatic stricture after successful endotherapy.