New insights on the effectiveness and clinical relevance of endoscopic examination of bile ducts and pancreas: DSOP-guided lithotripsy for chronic pancreatitis and POP for suspected IPMN – a prospective multicenter study and systematic review

2023-05-01 16:31:34

More new insights are emerging in the application and clinical relevance of endoscopic examination of the bile ducts and pancreas. For the first time, a prospective multicenter study has demonstrated the success of a DSOP-guided lithotripsy in patients with chronic pancreatitis.¹ In another study, a review of 25 articles, POP appears to be successful in the majority of patients with suspected IPMN.² Yet challenges still remain.

Retrospective studies have previously been performed on the use of digital single-operator pancreatoscopy (DSOP)-guided lithotripsy. Now a prospective study also shows that this new technique is effective and safe for the treatment of stones in the pancreatic duct (MPD) in patients with chronic pancreatitis.¹ This makes it a possible alternative to the standard Endoscopic Retrograde Cholangio- and Pancreaticography (ERCP).

Full stone clearance

In this study1 included 40 patients with chronic pancreatitis with 3 or fewer MPD stones ≥ 5 mm. The primary endpoint was a successful intervention, defined as complete stone clearance (CSC) of the MPD in 3 or fewer treatment sessions. CSC was diagnosed in 72.5% (29/40) of patients after the first procedure, in 7.5% (3/40) after 2 procedures and in 7.5% (3/40) after 3 procedures. Of patients with successful CSC in the initial DSOP procedures (34/35), 97.1% completed the 6-month follow-up period. None of the patients had residual stones.

Pain relief and side effects

Secondary endpoints were pain relief measured by the Izbicki pain score (IPS), the number of interventions and serious adverse events. Mean (SD) IPS decreased from 55.3 (46.2) to 10.9 (18.3). Pain relief was achieved in 82.4% (28/34) at 6 months follow-up, with complete pain relief in 61.8% (21/34) and partial pain relief in 20.6% (7/34).

Serious side effects were seen in 12.5% ​​of patients (5/40) and in 9.4% of treatments (5/53). All serious side effects occurred during follow-up and not during the procedure itself.

Challenging technique

Current guidelines recommend extracorporeal shock wave lithotripsy (ESWL) for MPD stones > 5 mm. The aim of this study was to demonstrate that the CSC rate of MPD stones using DSOP was higher than previously reported for ESWL. The technical success rate of DSOP at 92% was well above the 74% with ESWL as reported in previous studies (p = 0.005). However, the necessary experience is required, as it is a challenging technique that must be performed by a multidisciplinary team experienced in pancreatic pathology.

Systematic review

Another challenge is diagnosing intraductal papillary mucinous neoplasm (IPMN), a precancerous stage of pancreatic carcinoma, and determining the degree of disease. In a systematic review, 25 articles were analyzed with data from patients who received a perorale pancreatoscopie (POP) undergone for (suspected) IPMN.2 The aim of this study was to further understand the efficacy and safety of POP in the diagnosis of IPMN, including the impact of pre- and intraoperative POP on the treatment of IPMN. This is the first literature review that summarizes the current knowledge on the role of POP in the diagnostic algorithm of IPMN.

Technically successful

POP appears to be technically successful in the vast majority of patients with (suspected) IPMN and has consistently high diagnostic accuracy. POP appears to provide adequate visualization of the target area, may be valuable in the preoperative assessment of the size and exact location of the lesion and to identify skip lesions. This analysis showed that POP had a significant impact on clinical decision-making: in 13-62% of patients, POP findings prompted a different surgical approach. Side effects were reported in 12% of cases.

Diagnostic tool

Despite the fairly high diagnostic accuracy rates, the exact role of POP as a diagnostic tool still remains unclear, mainly due to methodological shortcomings and heterogeneity between studies.

References:

1. Gerges C, Albers D, Schmitz L, et al. Digital single-operator pancreatoscopy for the treatment of symptomatic pancreatic duct stones: a prospective multicenter cohort trial. Endoscopy. 2023;55:150-7.
2. De Jong DM, Stassen PMC, Groot Koerkamp B, et al. The role of pancreatoscopy in the diagnostic work-up of intraductal papillary mucinous neoplasms: a systematic review and meta-analysis. European Cholangioscopy study group. Endoscopy. 2023;55:25-35.