Pancreatoscopy assisted stone lithotripsy in challenging pancreatic ducts using a novel small caliber cholangioscope. Disclosures Pancreatoscopy with intraductal lithotripsy has been shown to be efficacious and safe, and when available, may be used as a primary therapeutic option for symptomatic pancreatic duct stones. Normal use cholangioscope systems used for pancreatoscopy have nevertheless been limited in patients with difficult ductal angulation and small ducts. We present two cases that illustrate the successful application of a smaller caliber cholangioscopy system in the treatment of obstructing pancreatic duct stones. The introduction of a novel cholangioscope notably allows for smaller caliber cholangioscopy as highlighted here. Our first case is that of a 65-year-old female with history of chronic calcific pancreatitis with obstructing pancreatic duct stone. The patient was without prior episode of acute pancreatitis or known risk factors, though had longstanding symptoms of epigastric abdominal pain with recent worsening and no alternative etiology. Therapeutic options were discussed, including surgery, extracorporeal shockwave lithotripsy, and endoscopic stone removal via pancreatoscopy with intraductal lithotripsy. The patient elected ERCP due to it being a minimally invasive approach. Initial cannulation with standard 4.4 French sphincter atome was unsuccessful. Cannulation was successfully accomplished with tapered-tip cannula and a 018-inch guide wire, though a wire could not navigate ductal angulation, and thus deep access was achieved with angled 025 wire. Contrast injection revealed complete pancreatic duct obstruction in the midbody of the pancreas consistent with stone. Traction pancreatic and biliary sphincterotomies were performed. The pancreatic duct orifice was then dilated with a 4-millimeter and then 6-millimeter balloon dilator. The pancreatic duct was then accessed using a 9 French caliber cholangioscope, which was chosen given the sharp angulation and small caliber of the pancreatic duct. The pancreatic duct contained an obstructing stone in the body of the pancreas, which was well visualized on pancreatoscopy. EHL was initially performed on low power with inadequate stone fracture and caused mild wall damage. EHL with higher power was performed thereafter successfully with complete obliteration of the stone, resulting in multiple stone fragments. The cholangioscope was removed to flush the stone debris and then reintroduced for continued direct visualization of the pancreatic duct. The pancreatic duct was interrogated segmentally with continued copious flushing of the duct and the cholangioscope was slowly advanced to the tail of the pancreas with continued flushing, which ultimately confirmed no residual stone burden. A 7 French 11 centimeter plastic stent with internal flap and external single pigtail was placed. The second case is that of an 18-year-old female with history of colodocal cyst status post resection with Roux-en-Y reconstruction and annular pancreas associated with chronic pancreatitis and pancreatic duck stones. She had a history of acute pancreatitis in the context of obstructing pancreatic stones and worsening of pain symptoms. Woman's prior treatment included minor papilla access and minor papillotomy which showed filling defect and ultimate stenting. She thereafter had standard caliber pancreatoscopy which was unsuccessful given inability to cannulate the small duct. This was followed by S-Wall and partial stone extraction with ERCP. Finally small caliber pancreatoscopy with laser lithotripsy was attempted with incomplete stone clearance. CT imaging showed two stones in the pancreatic duct, one in the midbody and one in the tail of the pancreas. ERCP was performed and small caliber cholangioscope was advanced through the minor papilla that was unable to access the midbody prompting dilation with a 4 millimeter balloon dilator. The small caliber cholangioscope was then reintroduced without resistance and EHL was performed. Multiple applications of lithotripsy and persistent flushing eventually resulted in the complete obliteration of the stone burden. The cholangioscope was subsequently advanced into the tail of the pancreas. The pancreatic duct tailstone was then visualized and also successfully treated with electrohydraulic lithotripsy with complete stone obliteration and clearance. Final pancreatogram confirmed complete stone clearance with contrast filling to the tail. A four French 11 centimeter soft pancreatic stent was placed at the end of the procedure. Pancreatoscopy with intraductal lithotripsy offers a safe and effective minimally invasive approach for the treatment of obstructive pancreatic stone disease in select cases. Conventional cholangioscope-based pancreatoscopy, while successful in larger pancreatic ducts, is limited in patients with angulated or small pancreatic ducts. These patients are not ideal for surgical drainage procedures, such as pancreatic logiginostomies, and may consequently require surgical resection, resulting in increased morbidity. Small caliber cholangioscopes represent a new tool in the successful management of pancreatic duct stone disease in challenging and small ductal anatomy. For more information visit www.ISGlobal.org

pancreatoscopy

cholangioscope

stone lithotripsy

pancreatic duct stones

minimally invasive