First Use of Superpulsed Fibre Thulium Laser-Based Contact Stone Ablation in Common Bile and Main Pancreatic Ducts

Aim. A clinical demonstration of the feasibility of novel superpulsed thulium fibre laser in contact intraductal lithotripsy in patients with choledocholithiasis and pancreatic lithiasis.Key points. We describe two clinically successful ablations of large biliary and pancreatic calculi using a FiberLase U2 superpulse fibre thulium laser appliance (IRE-Polus, Russia) during oral transpapillary cholangiopancreaticoscopy in patients with technically unfeasible conventional minimally invasive treatment for choledocho- and pancreatic lithiasis. A 72-yo patient was urgently admitted with acute mechanical jaundice, cholangitis and a history of endoscopic papillosphincterotomy (EPST) and bilioduodenal stenting with a plastic implant for technically impractical lithotripsy and lithoextraction. An ineffective extracorporeal lithotripsy attempt was followed on day 3 by a second retrograde intervention and endoscopic contact laser lithotripsy controlled in oral transpapillary cholangioscopy with FiberLase U2. A 50-yo patient was admitted with clinical signs of chronic calculous pancreatitis and a history of EPST, pancreatic ductotomy and plastic pancreatic stenting. The first endoscopy stage comprised the encrusted pancreatic stent removal, retrograde pancreaticography, pancreatic ductotomy, narrowed terminal Wirsung’s duct bougienage with mechanical dilators and additional balloon-assisted dilation of the excision area and pancreatic stricture. Mechanical intraductal lithotripsy was unsuccessful. Contact lithotripsy with a novel superpulsed fibre thulium laser has been rendered. The technique presented ensures a complete sanation of the duct at no mucosal damage.Conclusion. We present the fully successful first national and world experience of the superpulsed fibre thulium laser application in contact lithotripsy of large calculi in common bile and main pancreatic ducts.

A Redo of Duct-To-Mucosa Pancreaticojejunostomy for Recurrent Acute Pancreatitis Due to Intra-Pancreatic Lithiasis and Anastomotic Stricture: Is This a Reasonable Strategy?

Few studies have examined the postoperative long-term complications after partial pancreatoduodenectomy and there are mainly focused in the presence of biliary strictures. The occurrence of intra-pancreatic lithiasis secondary to the presence of late stenosis of the duct-to-mucosa pancreaticojejunostomy is an extremely rare condition. We observed that the late occurrence of a pancreaticojejunostomy stricture could be a potential cause for acute pancreatitis in long-term survivors following partial pancreatoduodenectomy. The importance of this report is to emphasize that the strategy of a redo of this difficult anastomosis is a very challenging abdominal operation but provides excellent early and long-term results

Spontaneous Common Bile Duct Perforation on The Background of Pancreatic Lithiasis: A Case Report and The Review of The Literatures

Spontaneous bile duct perforation (SBDP) is a relatively rare condition. The cause of SBDP is still speculative. Presentation , site of the perforation and management varies. Pancreatic lithiasis ( PL) is a very rare entity in childhood. Biliary perforation on the background of PL is still a rare event. This is a case report of 10 years old girl presented as acute abdomen with theclinical diagnosis of acute on chronic pancreatitis, for which conservative treatment followed by laparotomy was carried out.Common bile duct (CBD) perforation was found near it’s junction with cystic duct. T tube was instituted and a drain was kept in situ. Postoperative period ( POP )was uneventful. T Tube Cholangiogram was carried out on 12th postoperative day( POD ) that showed dye had passed to duodenum easily and patency and caliber of the CBD was found normal. Multiple stones were noted in the vicinity. No apparent cause of CBD perforation was found. After one month, in follow up visit the patient was found alright. She was asked to come after 3 months for further evaluation. The plan is to evaluate the patient’s conditions clinically and biochemically and to do an MRCP to see details ofpancreatic pathology. As SBDP in children with PL is a rare condition, high index of suspicion is needed for early diagnosis and proper management of such patient.DOI: http://dx.doi.org/10.3329/jpsb.v2i2.19553

Efficacy of Combined Endoscopic Lithotomy and Extracorporeal Shock Wave Lithotripsy, and Additional Electrohydraulic Lithotripsy Using the SpyGlass Direct Visualization System or X-Ray Guided EHL as Needed, for Pancreatic Lithiasis

Introduction. To evaluate the efficacy of combined endoscopic lithotomy and extracorporeal shock wave lithotripsy (ESWL), and additional electrohydraulic lithotripsy (EHL) as needed, for the treatment of pancreatic duct stones, we retrospectively evaluated 98 patients with chronic pancreatitis and pancreatic lithiasis.Methods. For the management of main pancreatic duct (MPD) stones in 98 patients, we performed combined endoscopic treatment (ET)/ESWL therapy as the first treatment option. When combined ET/ESWL was unsuccessful, EHL with the SpyGlass Direct Visualization system or X-ray guided EHL was performed. Outpatient ESWL was reserved as one of the final treatment options.Results. Fragmentation was successful in 80 (81.6%) patients as follows: combined ET/ESWL: 67 cases; SpyGlass EHL: 4 cases; X-ray guided EHL: 3 cases; and outpatient ESWL: 6 cases. Successful outcome was obtained by combined ET/ESWL in 67 of the 98 patients (74.5%), by EHL in 7 of 14 patients (7.1%), and by outpatient ESWL in 6 of 6 patients (6.1%). Negotiating the guidewire through a severe MPD stricture was significantly associated with a higher rate of stone fragmentation (P=0.0003).Conclusions. In cases where combined ET/ESWL was not successful for stone clearance, EHL using the SpyGlass system or X-ray guided EHL was effective in cases where the guidewire could be negotiated through the MPD stricture and it increased the fragmentation rate.