Endoscopic removal of pancreatic duci stones - Better patient selection by endoscopic ultrasound?

Pancreatic duct stones are usually well visualized with endoscopic ultrasound (EUS). Acoustic shadowing indicates hard, calcific stones, and may be a predictor of failure to remove the stone endoscopically. Methods: During 12 months, 14 patients (pts) were found to have one or more stones in the main pancreatic duct (MPD) by EUS, utilizing the Olympus UM20 radial scanning echoendoscope. ERCP was done for attempted stone removal after EUS in 11pts and preEUS in 4 pts. ERCP success was recorded, as well as the EUS findings by reviewing video tapes of the procedures. Results: Twelve of the 14 stones had an unequivocal acoustic shadow, and only one of these was successfully removed at initial ERCP, utilizing a snare piecemeal-technique. The other patients were treated with pancreatic sphincterotomy and stent placement Two stones without an acoustic shadow were both successfully removed, p=0.03. This successrate was significantly higher (Fischers exact test) than for the shadowing stones. Conclusion: These preliminary data indicate that EUS may be used to aid the patient selection to ERP and endoscopic stone removal. Stones with distinct acoustic shadowing may be better managed by initial shock wave lithotripsy.