The necessity of therapeutic ERCP after extracorporeal shockwave lithotripsy in chronic calcific pancreatitis

I read with great interest the article by Gurav et al. that retrospectively analyzed and identified independent predictors of persistent pain in patients with chronic calcific pancreatitis who underwent extracorporeal shockwave lithotripsy (ESWL) and endoscopic retrograde cholangiopancreatography (ERCP) for stone clearance [1]. In their treatment protocol, the authors routinely performed ERCP for stone fragment clearance within a few days after ESWL. Although, they excluded those with multiple pancreatic duct strictures from the study, they still found 14.5% (n = 93) of patients with pancreatic duct strictures. The study highlights the need for further investigation into stricture management within this subgroup, particularly regarding the success of endoscopic treatment and its impact on pain persistence. This is especially relevant because the study analysis identified pancreatic duct strictures as a predictor of persistent pain even after successful ESWL.

In the discussion, the authors cited a key randomized controlled trial (RCT) comparing pain control with ESWL alone versus ESWL with ERCP with/without stenting [2]. Unfortunately, this RCT only placed stents in 45% of the endoscopy group and ultimately concluded that endoscopic therapy added cost without additional pain control benefit. However, further analysis of the Gurav et al. data could be particularly enlightening. If successful pain control could be demonstrated in patients with resolved strictures after endoscopic therapy, it would challenge the notion that ERCP may be necessary in certain patients with pancreatic duct strictures following ESWL. In my opinion, endoscopic therapy should be attempted in those with only a few strictures located at the head and neck of the pancreas and in those with pancreas divisum [3].

Publication History

Received: 22 June 2024

Accepted: 28 June 2024

Article published online:
28 January 2025

• References

• 1 Gurav N, Jagtap N, Koppoju V. et al. Predictors of persistent pain after extracorporeal shockwave lithotripsy for painful chronic calcific pancreatitis. Endoscopy 2024; 56: 406-411
• 2 Dumonceau JM, Costamagna G, Tringali A. et al. Treatment for painful calcified chronic pancreatitis: extracorporeal shock wave lithotripsy versus endoscopic treatment: a randomised controlled trial. Gut 2007; 56: 545-552
• 3 Rerknimitr R. Asian chronic pancreatitis: the common and the unique. J Gastroenterol Hepatol 2011; 26 (Suppl. 02) 6-11