Cleveland crew, I was there for a year. So, since this is a fellows course, I would like you guys to tell me what to do. It's a very simple case, but I think we go through like basics of how to manage pancreatic duct stones. So, this is a case like within my first year out of fellowship, I saw this patient, and I'm still following him, he's doing fine. So, 50 years old male, large cell lymphoma involving the abdomen, he had a bunch of lymphoma involvement around his peripancreatic region in the 1990s got treated and was in remission till we see him still in remission, but he had a 1990s biliary obstruction which had serious stenting done. It was complicated by cholangiitis, stricture, he had secondary biliary cirrhosis from the stricture, so ended up getting a choledochogenostomy in the 1990s, brutal hypertension. So, he was admitted to one of our community hospitals with septic shock, LFTs were, bilirubin was normal, blood cultures grew, strep malary, bacteremia, no obvious sores, he was treated with antibiotics, stabilized, and then he was referred to us for further workup. This is his CT scan done when he was in the hospital initial presentation. Any comments guys, sorry. You can see here, it's a non-con CT, but you can see this big stone in the pancreatic duct there. There was no biliary dilation on the scan, and then you can see a significantly dilated duct upstream. Same with your MRCP, no significant biliary dilation, but you can see a big stone up here in the genu region and a markedly dilated duct. So, what would you do next? Do the person. Oh, he was stable. Not a Friday 6 p.m. case. You think that's cholangitis still, can be cholangitis? So this is, since it wasn't a 7 p.m. case, instead we're going straight with the ERCP. We did do an EUS. And I tried to kind of go with the anatomy. So this is the head, that pancreatic duct here looks normal, uncinate process. This is the genu, the same stone that we saw on the CT scan. And we can see the duct upstream in the body and the tail is dilated with intraluminal filling defects. But again, tough to say. We couldn't evaluate his bile duct within the head of the pancreas. He already has a choledocojejunostomy. I think that's somewhere up there where the bilirubin was not dilated. So, yes. So, that's the stone in the pancreatic duct, right? Is the stone causing this? i mean i i guess i mean it's stone disease so the option is to drain you know you basically figure out how to drain him temporarily and then it's pretty large stone if you can't get to it so like you can't do i guess conventional lithotripsy like endoscopically and then extracorporeal lithotripsy and then try to i mean he has a so this is a call this is a whipple so i mean so yeah yeah so um that's right his anatomy is altered yeah yeah so i was still thinking we were still thinking it's cholangitis he's stable despite not significantly dilation we prepared for our pediatric colonoscope see if we need to do a balloon endoscopy to get there and because it was all in done in the 1990s so ajay did they just bypass the bile duct so was the stump still there distal bile duct we'll find out okay all right did i know i did i spoil it for you yeah it was in the 1990s yeah so first thing we do is uh so there was a pancreatic sphincterotomy which we must do for all pancreatic cases uh pancreatic stone cases and uh biliary sphincterotomy already there so we got got in the pancreas saw this dilated duct pusher catheter in and surprised what we when we suctioned out it was pus coming out from the pancreatic duct uh and then we were able to go in the bile duct as well and you can see the bile duct looked pretty normal the stump was still there and you could also see um this is the this is your choledocal jejunostomy at least now we have a source what do we do now if pus is coming out you gotta you gotta get rid of the obstruction so you could do like uh ehl or laser lithotripsy to get that size of a stone out mm-hmm or yeah or you could stent it yeah i like that idea get the stand in and deal with it some other day so that's what we did uh we did put uh uh as you can see here a seven french tent there and then um brought him back what got out of there he got better uh did not do anything for the stone at this attempt so what would you do next how would you plan for your next ercp when would you do it and what are there any guidelines to suggest what we should do i guess it's really up to the institution i mean depending on the size of the stone how large it is its location it's an isolated main duct stone kind of more proximal what was the size of it it's almost more than once almost once anyway so you can do introductual however if it was larger than that you can consider going straight to as well you already have a stand kind of isolating it when you do as well you can isolate it as well there um blast it and then see how much spontaneous clearance you get versus going in and removing it yourself or again institutional dependent go straight to introductal perfect so there are no esg guidelines but there are esg guidelines published in 2018 that stones less than five millimeters in size in the pancreatic you can do with ercp and conventional balloon sweeps or baskets but if they are more than five millimeters es4 should be considered the first line of therapy so he got better uh his blood his cultures from that pancreatic fluid did grow uh strep millery i think yes so the other options are surgical pancreatic eugenoscopy uh you can do pistols you can get a fry procedure done but he had total hypertension he was not a candidate for surgical that was my first thing to do call a surgeon say hey is he a candidate for because that will solve a lot of problems uh then we discussed about endoscopic options we discussed about the guidelines so these are things we we need to focus on what's the size of the stone what's the size of the downstream of the stone would you be able to even get to the stone is there a stricture below the stone and uh is there a mass or not uh that's where us becomes helpful but again us is not as sensitive in a in a patient with chronic pancreatitis and then you need to know your tools and you need to have a time for for this procedure once you start going down the pancreatic stone pathway you can't fix it it's not a one-stop shop you have to like closely follow these patients bring them back and there are good studies from europe say that it can take up to more than a year you have to leave these tensions for six months to 12 to 12 months before you bring them back know your background backup plan you should have your lithotriptor the swahili lithotriptors things can get stuck i have had them stuck in the bile duct more often than in the pancreas you should know your us guided access as dr glassing mentioned and then you should always talk to your surgeons so we brought him back one month after his uh follow-up after his first uh exam and we did do s wall one week prior to erct so again s wall is very institute dependent uh some places we we have a urologist do it and i think uh the iu group the sir the gastroenterology team was doing their s walls uh then the pancreatic duct stone s world for pancreatic duct stones is very different than pancreatic uh than uh renal stones because they you they use mainly three to five thousand shocks per session and those are sometimes not enough for your pancreatic stones i think the iu studies said that where gi people were doing it they were giving up to eleven thousand shots shocks per session and i think in india where there's so much prevalence of chronic calcific pancreatitis it's standard to do more than ten thousand shocks per session then the next question is when do you do your ercp after your s walk same session or do you do it later on why why not within the same session you want some coffee yes and if and yes and within the first 48 to 72 hours there's more swelling edema you can make yourself uh make your life difficult uh there are studies where you can just follow up with imaging and see if there is enough fragmentation if you give yourself enough time and repeat s wall before you do ercp you can do two to three sessions of asphalt before you bring them so now the s wall was done one week prior he comes back i still see the stone doesn't look very fragmented so what are my options now i wish i did that yeah so uh what are your endoscopic tools to try to remove it out would you even try to remove it out is there any way to figure out if it's fragmented or not usually i think by imaging you should see the dissipation yeah but they're not yeah it doesn't happen exactly balloons usually don't work because they burst uh unless they're like very fragmented stones so obviously this doesn't work but one other thing you should do is always upsize your stents every time you are unsuccessful so uh again um this was one month follow-up we did two stents seven french stents uh should have done in retrospect at 10 french stent uh that's what most of the european studies have shown 10 stents 10 french stents are better uh so now what he's doing clinically fine he doesn't have pain when do you bring him back in the car do you need to make these actions treating them usually it's symptomatic i mean you really have to treat this hypertension if they're not symptomatic and you also have to keep in mind the long-term implications of persistent pd obstruction which would be ductal atrophy and exocrine endocrine insufficiency so you have to counsel the patient if they're asymptomatic that would be the complication and he doesn't have diabetes he doesn't have an exocrine and the biggest thing is he's pain-free but this has happened once who knows what will happen if he gets a ductal obstruction and an infection again so this time we did uh talk to our urologist again said do more as well i think the first time they were like 3,000 to 5,000 usually in u.s uh urologists do not give anything more than 5,000 we asked them to do a little more i brought him two days after the session same thing again it's not working i did put out this time a 10 french stent and a 7 french stent across that area so those are the questions we already discussed before yes this time we were like renting the scopes and everything so no i rent having them bring that stuff so this is another case and this is i brought this this thing just because as an option to deal with tough structures and pancreatic this is a case where someone put in a stent for pancreatic stone for just bloating which should not have been done but they couldn't get much across it so they left like a five front stand and send the patient to us but now you are like the patient is very adamant they want the stone out they think that's the reason for their bloating again we are dealing with it so things to watch out uh sorry so you you can dilate the if there is any narrowing below it i haven't used it much dr chuck what is your opinion or anyone's opinion about using a stent retriever going through fibrose pancreas i always worry about it so ajay when when you try to fix the big duct you can take care of the small ducts draining in there sorry say again so so you're trying to clear the big duct right and it's a chronic calcific pancreatitis so the small ducts will get better that's that's the hope we are going by the assumption that the big duct obstruction was the reason for his sepsis and uh based on the microbiology and the imaging and drainage of cost from the pancreas and we are not trying to fix his pain because he doesn't have pain he doesn't have uh bloating he doesn't have exocrine or endocrine insufficiency the main thing is how far do we go to minimize the chances of this thing happening again just send him to india um 18 months later so we were prepared this time so first thing i'm doing is am i missing a stricture down here even though in eus i didn't see i always worry about injecting too much contrast in the pancreas to cause a scenarization here i'm kind of causing my escenarization intentionally because i want to see what exactly is going on in the duct downstream of the of my uh stone to see even if i can get my pancreatoscope easily or not and then we did ehl this time i don't have a really good video because we even were renting our uh spy equipment i think it's all post ehl whatever we could record but you could see as i go through small fragments of stones after the ehl was done but the more impressive part is this thing the first time in 18 months i have seen this guy without stones left in the duct uh left a stent single stent again this time brought him back uh six months again later which a little delayed uh then what we wanted he was a little delayed in six months but almost 24 months from his initial session um you can see uh the stones are gone the stricture is gone uh he has been without stent for three years more than three years i would say and i just saw him last night and i just saw him last year for his screening colonoscopy for his colonoscopy he has been doing fine so main thing is work on your strictures below the stone uh know your devices pancreatoscopy there have been three studies this year two from one from the german cholangioscopy pancreatoscopy group 40 patients they said uh as well as pancreatoscopy as first line has 80 chances of stone clearance so as well by guidelines is the first line still another study from marco bruno's group and also 70 to 80 i think iu published their data of 20 patients and they said that success rate for stone clearance for s wall and pancreatoscopy with the hl is similar but pancreatoscopy with ehl leads to sooner clearance of stones and sooner clearance and lesser procedures main thing patients it's not a one-stop shop once you start dealing with pancreas stones be ready to leave the stent in a 10 french stent in for 6 to 12 months costa mania's group from europe says at least 12 months but change it every six months if needed get your surgeons involved address the strictures upsize the stents and uh pancreatoscopy is is is a good good option i don't think i have time for another one

physician

case discussion

pancreatic duct stone

endoscopic retrograde cholangiopancreatography

endoscopic ultrasound