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PRECISION IN ACTION: SPYGLASS-ASSISTED STONE EXTRACTION VIA NEEDLE-KNIFE SPHINCTEROTOMY IN PANCREATIC DUCT OBSTRUCTION
Aziz Eshov
*1, Jayanta Datta
2, Jordan King
3, Samit Datta
11Gastroenterology, Skagit Regional Health, Mount Vernon, WA; 2The Ohio State University, Columbus, OH; 3Pacific Northwest University of Health Sciences, Yakima, WA
INTRODUCTIONPancreatic duct (PD) stones are generally caused by multifactorial etiologies and affect less than 1% of the general population, with prior pancreatitis as the most common underlying etiology. Primarily formed by calcium carbonate, PD stones can cause symptomatology from asymptomatic cases to debilitating symptoms/complications, including pain, exocrine pancreatic insufficiency (EPI), diabetes, and acute/chronic pancreatitis. Diagnosis and treatment of pancreatic duct stones can be difficult, as early in formation, there are few, if any, symptoms. CT and MRI are generally the most reliable modalities for diagnosis. Treatment generally involves ERCP, ESWL, and surgery in severe cases. The use of pancreatoscopy with lithotripsy has become more frequently utilized to reduce the need for surgery. Due to its need for highly skilled operators and higher risk, complex PD stones can be difficult to manage. We present a case of a 77-year-old male with severe EPI due to complete PD obstruction from a very large PD stone.
CASE SUMMARYOur patient is a 77yo male who presented to the ER with 20 pound weight loss, confusion, and severe fatigue. Patient had a CT scan that showed severe pancreatic atrophy and a 1.7x1.6cm PD stone (Fig 1). Patient subsequently underwent EUS and ERCP with EUS showing a large pancreatic duct stone and ERCP with presumed cannulation of the PD. On subsequent ERCPs, fluoroscopically the stone did not appear significant improved.
Given no clinical improvement, ERCP was performed, noting a mobile area at the ampulla that felt stiff on probing. As such, this was presumed to be complete PD obstruction due to the stone. Using a needle knife sphincterotome, NKS was performed in this area with careful dissection along the mobile area which showed clear PD anatomy and the large PD stone (Fig 2). Wire passage was successful and tome showed a massively dilated PD. PD dilation was performed with a Hurricane balloon and EHL was performed. A PD stent was placed. Additional ERCPs were performed with PD dilation and EHL with successful fragmentation until finally, the stone was able to be removed with a trapezoid. On follow-up, patient had gained weight with resolution of post prandial symptoms.
DISCUSSIONPD stones can cause severe symptomatology and be difficult to manage. ERCP with lithotripsy has been shown to be successful in the literature, however, complete obstruction of the PD from a large stone has not been clearly described for management. NKS has not been clearly shown for management of large PD stones causing ductal obstruction. These cases tend to be referred for Whipple surgery, which has high morbidity. This case represents a unique approach to an obstructing PD stone that ultimately prevented the need for surgery with complete symptom resolution and could lay the foundation for more aggressive management of PD stones.
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