Recalcitrant Pancreatic Duct Stones: Successful Removal Following Mechanical Lithotripsy.

Pancreatic duct stones are usually a consequence of chronic pancreatitis. The presence of PD stones can result in acute exacerbation of pancreatitis or chronic abdominal pain. Successful removal of PD stones has been achieved in over 70% of patients from both ducts of Wirsung (ventral) and Santorini (dorsal). Limitations include adherent or large stones and the relative small size of pancreatic sphincterotomies. AIM: To determine the feasibility and effectiveness of mechanical lithotripsy of pancreatic duct stones. METHODS: Ninety-five patients with PD stones, including 28 patients with pancreas divisum in the setting of chronic pancreatitis over a 15 year period were identified using a computer data base retrieval system. Forty-two patients presented with acute pancreatitis while 53 patients presented with exacerbation of their abdominal pain. Of these, 13 patients required mechanical lithotripsy and are the subject of this report. Nine of 13 patients had single stones (8-12 mm) while 3 of 13 patients had multiple stones (6-10 mm). Ducts were dilated in all patients (6-16 mm). RESULTS: Successful stone extraction required 1-3 (mean 1.8 sessions). Endoscopic sphincterotomy was performed in all patients. Single stones were extracted in 8 of 9 patients (89%), multiple stones in 3 of 4 patients (75%). PD stents were placed after initial attempts at extraction (=5)and palliation (=2). Of the 2 patients with unsuccessful stone extraction, 1 underwent pancreaticojejunostomy with good long-term results. Of the 2 patients with failed stone extraction, both were treated intermittently with stents with recurrent symptoms (mean follow-up 3.8 years). Nine of 11 patients had complete stone extraction with 8 of these patients with good long-term (no pain/pancreatitis) results and no recurrence (mean follow-up 4.2 years). CONCLUSION: Endoscopic removal of recalcitrant PD stones can be accomplished in the majority of pts by mechanical lithotripsy with good long-term outcome. Those failing endoscopic therapy will often respond to surgical options.