Meta-Analysis
Copyright ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Sep 14, 2020; 26(34): 5207-5219
Published online Sep 14, 2020. doi: 10.3748/wjg.v26.i34.5207
Efficacy of pancreatoscopy for pancreatic duct stones: A systematic review and meta-analysis
Syed M Saghir, Harmeet S Mashiana, Babu P Mohan, Banreet S Dhindsa, Amaninder Dhaliwal, Saurabh Chandan, Neil Bhogal, Ishfaq Bhat, Shailender Singh, Douglas G Adler
Syed M Saghir, Banreet S Dhindsa, Department of Internal Medicine, University of Nevada Las Vegas School of Medicine, Las Vegas, NV 89102, United States
Harmeet S Mashiana, Amaninder Dhaliwal, Saurabh Chandan, Neil Bhogal, Ishfaq Bhat, Shailender Singh, Division of Gastroenterology and Hepatology, University of Nebraska School of Medicine, Omaha, NE 68198-2000, United States
Babu P Mohan, Douglas G Adler, Division of Gastroenterology and Hepatology, University of Utah Health, Salt Lake City, UT 84132, United States
Author contributions: Saghir SM, Mashiana HS and Mohan BP contributed to analysis and interpretation of data; Saghir SM and Mashiana HS contributed to drafting the article; Mashiana HS, Dhindsa BS, Dhaliwal A and Bhogal N contributed to acquisition of data; Chandan S, Bhat I and Adler DG contributed to critical revision; Mashiana HS, Singh S and Adler DG contributed to final approval.
Conflict-of-interest statement: The authors deny any conflict of interest.
PRISMA 2009 Checklist statement: The authors have read the PRISMA 2009 Checklist, and the manuscript was prepared and revised according to the PRISMA 2009 Checklist.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Douglas G Adler, FACG, FASGE, MD, Professor, Division of Gastroenterology and Hepatology, University of Utah Health, 50 N Medical Dr., Salt Lake City, UT 84132, United States. douglas.adler@hsc.utah.edu
Received: May 28, 2020
Peer-review started: May 28, 2020
First decision: June 12, 2020
Revised: June 29, 2020
Accepted: August 21, 2020
Article in press: August 21, 2020
Published online: September 14, 2020
Processing time: 103 Days and 14.5 Hours
Abstract
BACKGROUND

Pancreatic duct stones can lead to significant abdominal pain for patients. Per oral pancreatoscopy (POP)-guided intracorporal lithotripsy is being increasingly used for the management of main pancreatic duct calculi (PDC) in chronic pancreatitis. POP uses two techniques: Electrohydraulic lithotripsy (EHL) and laser lithotripsy (LL). Data on the safety and efficacy are limited for this procedure. We performed a systematic review and meta-analysis with a primary aim to calculate the pooled technical and clinical success rates of POP. The secondary aim was to assess pooled rates of technical success, clinical success for the two individual techniques, and adverse event rates.

AIM

To perform a systematic review and meta-analysis of POP, EHL and LL for management of PDC in chronic pancreatitis.

METHODS

We conducted a comprehensive search of multiple electronic databases and conference proceedings including PubMed, EMBASE, Cochrane, Google Scholar and Web of Science databases (from 1999 to October 2019) to identify studies with patient age greater than 17 and any gender that reported on outcomes of POP, EHL and LL. The primary outcome assessed involved the pooled technical success and clinical success rate of POP. The secondary outcome included the pooled technical success and clinical success rate for EHL and LL. We also assessed the pooled rate of adverse events for POP, EHL and LL including a subgroup analysis for the rate of adverse event subtypes for POP: Hemorrhage, post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP), perforation, abdominal pain, fever and infections. Technical success was defined as the rate of clearing pancreatic duct stones and clinical success as the improvement in pain. Random-effects model was used for analysis. Heterogeneity between study-specific estimates was calculated using the Cochran Q statistical test and I2 statistics. Publication bias was ascertained, qualitatively by visual inspection of funnel plot and quantitatively by the Egger test.

RESULTS

A total of 16 studies including 383 patients met the inclusion criteria. The technical success rate of POP was 76.4% (95%CI: 65.9-84.5; I2 = 64%) and clinical success rate was 76.8% (95%CI: 65.2-85.4; I2 = 66%). The technical success rate of EHL was 70.3% (95%CI: 57.8-80.3; I2 = 36%) and clinical success rate of EHL was 66.5% (95%CI: 55.2-76.2; I2 = 19%). The technical success rate of LL was 89.3% (95%CI: 70.5-96.7; I2 = 70%) and clinical success rate of LL was 88.2% (95%CI: 66.4-96.6; I2 = 77%). The incidence of pooled adverse events for POP was 14.9% (95%CI: 9.2-23.2; I2 = 49%), for EHL was 11.2% (95%CI: 5.9-20.3; I2 = 15%) and for LL was 13.1% (95%CI: 6.3-25.4; I2 = 31%). Subgroup analysis of adverse events showed rates of PEP at 7% (95%CI: 3.5-13.6; I2 = 38%), fever at 3.7% (95%CI: 2-6.9; I2 = 0), abdominal pain at 4.7% (95%CI: 2.7-7.8; I2 = 0), perforation at 4.3% (95%CI: 2.1-8.4; I2 = 0), hemorrhage at 3.4% (95%CI: 1.7-6.6; I2 = 0) and no mortality. There was evidence of publication bias based on funnel plot analysis and Egger’s test.

CONCLUSION

Our study highlights the high technical and clinical success rates for POP, EHL and LL. POP-guided lithotripsy could be a viable option for management of chronic pancreatitis with PDC.

Keywords: Electrohydraulic shockwave lithotripsy; Laser lithotripsy; Chronic pancreatitis; Calculi; Extracorporeal shockwave lithotripsy; Endoscopic retrograde cholangiopancreatography; Systematic review; Meta-analysis; Outcome

Core Tip: Current management for symptomatic pancreatic duct stones is extracorporeal shock wave lithotripsy (ESWL) or endoscopic retrograde cholangiopancreatography (ERCP) followed by surgery if the former is unsuccessful. Sparse data exists regarding safety and efficacy of per oral pancreatoscopy (POP)- guided lithotripsy. This is the first systematic review and meta-analysis evaluating safety and efficacy of POP using electrohydraulic lithotripsy and laser lithotripsy. The POP procedure is of interest compared to current standard of care due to the ability to directly visualize pancreatic duct calculi, perform lithotripsy and extract the stones in the same session. ESWL and ERCP require multiple sessions and have low technical success.