Pancreatic ductal (PD) stones in patients with pancreas divisum: Success of removal and symptomatic improvement: multi-center study
PD stones can cause acute exacerbation of pancreatitis or chronic abdominal pain. Successful removal of PD stones from the duct of Wirsung (ventral duct) has been achieved in over 70% with symptomatic improvement in most pts. The anatomic variant, pancreas divisum (PDIV), may hinder suc-cessful stone removal. METHODS: Twenty-eight pts (15M, 13F, age 34-62) with PDIV and dorsal PD stones in the setting of chronic pancreatitis presented over a 10-yr period. Fifteen pts presented with acute episode of pancreatitis while 13 presented with exacerbation of their chronic abdominal pain. Etiology of pancreatitis was Idiopathic (17), ETOH (8), Familial (3). Sixteen of 28 pts had pancreatic insufficiency documented by secretin test (7) or fecal fat (9). Nine pts had a single stone, while 19 pts had multiple stones (2-10, mean 5.6 stones). Stone size ranged from 3-12mm. The dorsal duct was dilated in all pts (6-15mm). RESULTS: Successful stone extraction required 1-4 (mean 2.0) ERCPs. ES of the minor papilla was performed at the time of initial ERCP in 19 of 28 pts. Stone extraction was accomplished in 20 pts (14 complete, 6 partial). Single stones were successfully extracted in 6 of 9 pts (67%), multiple stones in 14 of 19 (74%). PD stems were placed after initial attempt at extraction (17) and palliation (4). Six pts required ESWL because of large or adherent stones (3 with subsequent complete, 3 partial removal). Of the 8 pts with unsuccessful stone extraction, 4 underwent pancreaticojejunostomy, 1 partial pancreatectomy, with good long-term results, while 2 were managed with stent therapy with reduction of symptoms and 1 no Rx with recurrent pain (mean F/U 3.8 yrs). Of the 6 pts with partial stone extraction 3 had surgical drainage procedures with good long-term response; 2 with good response with no further Rx; 1 with recurrent pain (mean F/U 2.3 yrs). Of the 14 pts with complete stone extraction; 1 underwent partial pancreatectomy because of a co-existing PD stricture; 13 had good long-term response (no pain/pancreatitis) at a mean F/U of 3.5 yrs. STONE EXTRACT LONG-TERM RESP PD STONES Pt. NO YES NO PART ENDO RX SURG RX YES NO PART ENDO RX SURG RX SINGLE 9 5 3 1 6 3 MULTIPLE 19 9 5 5 10 5 CONCLUSIONS: Endoscopic removal of PD stones in the setting of PDIV can be accomplished in the majority of pts with good long-term outcome. Those failing endoscopic therapy will often respond to surgical options.
Catalano, MF; Kozarek, R; Sherman, S; Lehman, G; Baillie, J; Geenen, J; Deitch, C; Vandervoort, J; Carr-Locke, D; Raijman, I; Jowell, P
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