Extracorporeal Shock Wave Lithotripsy Versus Single Operator Pancreatoscopy and Intraductal Lithotripsy for the Treatment of Pancreatic Duct Stones

Overview

Pancreatic duct stones can cause obstruction of the main pancreatic duct leading to abdominal pain, exocrine pancreatic insufficiency, and recurrent acute pancreatitis. By removing pancreatic duct stones, the obstruction can be relieved, and this can improve symptoms. Small stones can be removed with standard endoscopic retrograde cholangiopancreatography (ERCP) and stone removal, but larger stones may require lithotripsy to break up the stone before removal. The two current methods of lithotripsy include extracorporeal shock wave lithotripsy (ESWL) and single operator pancreatoscopy with intracorporeal lithotripsy (SOPIL).

ESWL is based on concentrating shock wave energy to the stone through an external device. SOPIL is a newer technique based on direct visualization of the stone during ERCP and targeting the stone with a shock wave catheter. There are currently no studies directly comparing ESWL to SOPIL for breaking apart stones in the pancreatic duct, so this study is designed to compare the two techniques.

Objective #1: Obtain pilot data to determine the optimal method of clearing large MPDS Objective #2: Obtain pilot data to assess how effective large MPDS clearance is in improving long term patient centered outcomes Objective #3: Obtain pilot data to measure the cost effectiveness of large MPDS clearance

Study Type

  • Study Type: Interventional
  • Study Design
    • Allocation: Randomized
    • Intervention Model: Parallel Assignment
    • Primary Purpose: Treatment
    • Masking: None (Open Label)
  • Study Primary Completion Date: November 2021

Interventions

  • Device: ESWL vs SOPIL
    • To compare the efficacy of single operator pancreatoscopy (SOP) with intracorporeal lithotripsy (SOPIL) to extracorporeal shock wave lithotripsy (ESWL) for the treatment of main pancreatic duct stones (MPDS) in patients with chronic pancreatitis.

Arms, Groups and Cohorts

  • Active Comparator: ESWL
    • Extracorporeal shock wave lithotripsy for the treatment of pancreatic duct stones
  • Active Comparator: SOPIL
    • Single Operator Pancreatoscopy and intraductal lithotripsy for the treatment of pancreatic duct stones

Clinical Trial Outcome Measures

Primary Measures

  • Technical success of complete or partial clearance (≥80% stone clearance) of large main pancreatic duct stone
    • Time Frame: Up to 24 weeks
    • This will be described as a proportion of patients with stone clearance. This is defined by the endoscopist’s interpretation of the pancreatogram during the time of ERCP and/or subsequent imaging studies. Two blinded endoscopists will review the final pancreatogram to confirm clearance of MPDS
  • Mean number of lithotripsy and ERCP procedures needed for clearance of stones or in the attempt to clear stones
    • Time Frame: Up to 24 weeks
    • Combined lithotripsy and ERCP procedures
  • Procedural related adverse events
    • Time Frame: Up to 24 weeks
    • This will be described as a proportion of patients who develop post-procedure pancreatitis, bleeding, infection, perforation, organ injury, symptomatic hematoma, or Steinstrasse resulting in acute stone impaction at the papilla

Secondary Measures

  • Change in pain: scores
    • Time Frame: through study completion, an average of 1 year
    • Change in Izbicki pain scores from baseline at 3 months, 6 months, 9 months, and 12 months
  • Change in quality of life based on chronic pancreatitis specific instruments: PANQOLI
    • Time Frame: through study completion, an average of 1 year
    • Change in the pancreatitis quality of life instrument (PANQOLI) scores from baseline at 3 months, 6 months, 9 months, and 12 months
  • Change in narcotic pain medication usage
    • Time Frame: through study completion, an average of 1 year
    • Change in daily morphine milligram equivalent usage from baseline at 3 months, 6 months, 9 months, and 12 months
  • Change in exocrine insufficiency
    • Time Frame: through study completion, an average of 1 year
    • This will be described as a proportion of patients who experience weight gain, resolution of steatorrhea, or no longer require pancreatic enzyme supplementation after stone clearance at 3 months, 6 months, 9 months, and 12 months

Participating in This Clinical Trial

Inclusion Criteria

  • MPDS located in the head, neck, or neck/body junction of the pancreas
  • MPDS > 5 mm in size
  • Abdominal CT scan, Endoscopic ultrasound, or prior ERCP demonstrating MPDS
  • Abdominal pain related to MPDS
  • Previously failed ERCP performed with intent to clear MPDS, OR MPDS determined by treating physicians to not be amenable to clearance by standard ERCP techniques

Exclusion Criteria

  • MPDS predominantly located in the body and tail of pancreas
  • Any obstructing MPDS > 5 mm located in the body and tail of pancreas
  • Known pancreatic head stricture precluding passage of the pancreatoscope with endoscopic stone extraction based on prior imaging or prior ERCP
  • Pancreatic head mass
  • Impacted MPDS located at the pancreatic duct orifice
  • Prior attempts at ESWL or SOPIL for MPDS
  • Walled off pancreatic necrosis
  • Active alcohol use, defined as any alcohol use within 2 months
  • Surgically altered anatomy (see text)
  • Gastric outlet obstruction or obstruction precluding passage of the endoscope
  • Standard contraindications to ERCP
  • Implanted cardiac pacemakers or defibrillators
  • Known calcified aneurysms in the path of the shockwave
  • Age < 18 years, pregnancy, incarceration, unwillingness/inability to provide informed consent, or anticipated inability to follow protocol

Gender Eligibility: All

Minimum Age: 18 Years

Maximum Age: N/A

Are Healthy Volunteers Accepted: No

Investigator Details

  • Lead Sponsor
    • Indiana University
  • Provider of Information About this Clinical Study
    • Principal Investigator: Ben Bick, Assitant Professor of Medicine – Indiana University
  • Overall Official(s)
    • Benjamin L Bick, MD, Principal Investigator, Indiana University
  • Overall Contact(s)
    • Amanda Sprinkle, 317-278-0210, aksprink@iu.edu

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