Pancreatic duct stone is a rare disease.
Defined as stone or calcification in the pancreatic duct, the pathogenesis of
the disease remains unknown, but many theories are available for its formation.
1, 2 Chronic pancreatitis,
pancreatic duct fibrosis, malnutrition, alcohol abuse, spontaneous pancreatic
duct stone, dysthyroid, etc are associated with the formation. These conditions
cause pancreatic exocrine dysfunction and intraductal proteinaceous deposits
which subsequently lead to calcification, thus inducing chronic pancreatitis
and pancreatic duct stone formation. Meanwhile, pancreatic duct stones in
patients with chronic pancreatitis usually result from chronic inflammation or
altered metabolism. The stones perpetuate the cycle of ductal obstruction and
contribute to pain, worsening of pancreatic inflammation, ductal disruption,
and deterioration of the exocrine and endocrine function of the gland. Pancreatic
duct stone has been considered a marker of chronic pancreatitis. 3
Pancreatic
duct stone is difficult to diagnose in its early stage for the absence of
specific clinical manifestations. Clinical manifestaion of pancreatolithiasis
differ because it is complicated by chronic pancreatitis, bile duct stone or
pancreatic cancer. The main manifestations of this disease include upper
abdominal pain, fat diarrhea, diabetes mellitus, obstructive jaundice and
abdominal mass. With the advancement of radiological techniques in diagnosis
and in-depth study the incidence of the disease has appeared to be rising in
recent years. Currently, laboratory test for pancreatic duct stone has no
specific indices. To confirm the diagnosis, radiological examinations, ultrasonography,
computed tomography (CT), endoscopic retrograde cholangiopancreatography (ERCP)
and magnetic resonance cholangiopancreatography (MRCP) are used. 3
The principle of operation is to remove
pathogeny, take out stones, unchain the obstruction and relax drainage.
Operation is a major treatment of pancreatic duct stone. 4 Currently,
surgical intervention is recommended for all patients with pancreatic stones, while
individual treatment is emphasized and microinvasive surgery may be a
developing option for treating pancreatic stone. 3
Surgical therapy results in complete or
partial relief of the symptoms of the disease. Different surgical procedures
can be chosen according to the location of the stones in the pancreatic duct. 5
When the stones are mainly located in the head of pancreas, endoscopic drainage
and removal of the stones is usually the first choice of treatment. If it
fails, surgical procedure should be applied. If the stones are mainly located
in the body of the pancreas, they can be treated with Pusetow-Gillesby
procedure (pancreaticojejunostomy), Lateral pancreaticojejunostomy is suitable
for most patients with this disease. 6 Because the pathogenesis of
pancreatic stone is unknown, improvement of symptoms is a major goal. However,
the management of pancreatic duct stones continue to evolve, and it is
dependent on the available facilities. 7, 8, 9
Peustow procedure
(pankreaticojejunostomi longitudinal) were performed in both cases this is the
action of pancreatic drainage by means of pancreatic opened later retrieved the
stones there and done between pancreatic jejunal anastomosis side to side with
retrocolic Roux en Y, so that the product can flow to the pancreas jejunum.
Decompression of pressure in the pancreatic duct produces cleaning all stone
and give good results at postoperative. With this procedure, the morbidity is
also not increased. After surgery, upper abdominal pain on both the patient
becomes lost. In the post-operative laboratory tests obtained alpha amylase and
lipase was decrease. This procedure is a safe procedure with morbidity and
mortality of less than 2%. Peustow procedures can relieve pain in the long time
more than 70% of patients. 10, 11
Pancreatic duct stone is a rare disease.
With the advancement of radiological techniques in diagnosis and in-depth study
the incidence of the disease has appeared to be rising in recent years, especially
in the Western world. Defined as stone or calcification in the pancreatic duct,
the pathogenesis of the disease remains unknown, but many theories are
available for its formation.1,2Chronic pancreatitis, pancreatic duct
fibrosis, malnutrition, alcohol abuse, spontaneous pancreatic duct stone,
dysthyroid, etc are associated with the formation. These conditions cause pancreatic
exocrine dysfunction and intraductal proteinaceous deposits which subsequently
lead to calcification, thus inducing chronic pancreatitis and pancreatic duct stone
formation. Meanwhile, pancreatic duct stones in patients with chronic
pancreatitis usually result from chronic inflammation or altered metabolism. The
stones perpetuate the cycle of ductal obstruction and contribute to pain,
worsening of pancreatic inflammation, ductal disruption, and deterioration of
the exocrine and endocrine function of the gland. Pancreatic duct stone has
been considered a marker of chronic pancreatitis. 3
Formation of pancreatic
stone
Bibulosity is the main cause of
pancreatic stone, which was followed by bile duct diseases, recurrent
pancreatitis, inherited factors, hyperfunction of the parathyroid, lack of
protein 12 , and annular pancreas. 13 In 1979 De Caro
separated a kind of protein from pancreatic stone or P-glycoprotein possesing
133 kinds of amino acid peptide with a molecular weight of 14.000. it is
synthesized in the endoplasmic reticulum of gland and is secreted in to
pancreatic fluid, thus is named as pancreatic stone protein (PSP). 14
It is bbelieved that the formation of pancreatic stone is due to the decrease
of PSP in pancreatic fluid. 15 Alkohol, chronic pancreatitis, and
cacotrophia decrease the secretion of PSP, which cause the crystalication and
depotition of calcium carbonate, and further the formation of stone. 16
Another important factor is fortoferrin. High concentration fortoferrin,
dropped epithelium, mucous membrane and pancreatic enzyme can form the ner-like
structure of pancreatic stone. It is presumed that high secretion of
fortoferrin may be related to the occurrence of pancreatic stone. Clinically
inflammatory stricture of the pancreatic duct causes the stagnation of
pancreatic fluid and the formation of pancreatic stone. In patiens with
hyperfunction of the parathyroid, hypercalciumenia causes the rise of calcium
in pancreatic fluid, which acceralates the formation of pacreatic stone. 17
Relation of pancreatic
stone to chronic pancreatitis
Pancreatolithiasis is not a kind of
independent disease. It co-exsist with chronic pancreatitis. Pancreatic stone
formation is characterized by chronic pancreatitis. Chronic
pancreatitis is characterized by irreversible damage to the pancreas that leads
to pain and/or exocrine and endocrine insufficiency. 18 Abdominal pain is the most common and
distressing symptom and is the most common indication for endoscopic or
surgical intervention. 19,20 One of the mechanisms responsible for pain in
chronic pancreatitis is obstruction to the pancreatic duct by strictures or calculi
and relief of this obstruction by surgical or endoscopic drainage relieves pain
in a majority of patients. 21,22,23 The obstruction of the
pancreatic tube not only accelerated the development of chronic pancreatitis
but also speeds up the formation of pancreatic stone, which is defined as one
of the diagnostic guidelines for this disease. Recent studies have shown normal
pancreatic functions and infrequent abdominal pain in some patient. Hence the
occurence of pancreatic stone is not always the late manifestation ond the
clinical symptoms of pancreatolithiasis is mainly due to the second pathologic
change. Clinical manifestaion of pancreatolithiasis differ because it is
complicated by chronic pancreatitis, bile duct stone or pancreatic cancer. The main
manifestations of this disease include upper abdominal pain, fat diarrhea,
diabetes mellitus, obstructive jaundice and abdominal mass.
Diagnostic procedure
for pancreatic duct stone
Pancreatic duct stone is difficult to
diagnose in its early stage for the absence of specific clinical manifestations.
Currently, laboratory test for pancreatic duct stone has no specific indices.
To confirm the diagnosis, radiological examinations, ultrasonography, computed
tomography (CT), endoscopic retrograde cholangiopancreatography (ERCP) and
magnetic resonance cholangiopancreatography (MRCP) are used.
On plain X-ray of the
abdomen, pancreatic calcification can be seen in up to 30% of patients with
chronic pancreatitis. 19 The advent of newer imaging modalities like
computed tomography (CT) has improved the ability to detect pancreatic
calcification. 24 Up to 70%
of patients with alcohol-related chronic pancreatitis can have pancreatic calcification
after 10 years of disease. 25 The calcification can be either due to
parenchymal or ductal calculi. Pancreatic duct calculi have been reported in
50% to 90% of patients with chronic pancreatitis and there is higher incidence
of ductal calculi in patients with tropical pancreatitis. 26
The ductal calculi cause
obstruction leading to an increase in intraductal as well as parenchymal
pressure and ischemia, thus causing pain. 27 The factors correlating
with pain are the stone size and the diameter of the pancreatic duct. The goal
of endoscopic treatment for chronic painful pancreatitis with ductal calculi is
complete clearance of calculi from the duct, thus relieving the obstruction and
pain. 28 Endoscopic drainage
procedures for relief of pain include pancreatic sphincterotomy, dilation of
pancreatic strictures, removal of pancreatic stones and the placement of
pancreatic stents to overcome the obstruction. 23 Endoscopic extraction of pancreatic duct
calculi is usually more difficult than extraction of bile duct stones because
pancreatic stones are generally spiculated, hard and multiple, and on many
occasions are impacted behind strictures. Endoscopic sphincterotomy followed by
balloon or Dormia-assisted stone extraction is usually successful when the
stones are of small size and are located in the head or body of the pancreas,
and there is no ductal stricture. The presence of ductal stricture or large calculi
creates difficulty in endoscopic clearance and requires either decrease in the
size of calculi by breaking them into small pieces or enlarging the ampullary
orifice so as to successfully deliver intact large stones. Endoscopic balloon
sphincteroplasty of the papilla has been used to enlarge the papillary orifice
and to successfully extract intact ductal calculi >1 cm, especially
radiolucent stones. However, this technique is technically demanding, and has potentially
serious complications including bleeding, retroduodenal perforation and
pancreatitis. An alternative method is to break the large stones into small
pieces so that they can be easily extracted through the papilla. This can be done
by using mechanical lithotripsy, intraductal electrohydraulic lithotripsy (EHL)
and extracorporeal shock wave lithotripsy (ESWL). 29
ESWL, which works by concentrating
focused short waves on stones and causing their disruption, was first used in
the field of gastroenterology by Sauerbruch et al. in Germany for fragmentation
of gall bladder stones. 29 Thereafter the same authors used it for fragmentation
of pancreatic duct stones. Subsequently a number of investigators have used it
for fragmentation of pancreatic stones. Radiopaque stones can be easily targeted
by ESWL under fluoroscopy. Radiolucent stones can be targeted using
ultrasound-guided shock wave lithotripsy or by injection of contrast through
the nasopancreatic catheter. The authors concluded that ESWL is a safe and
effective preferred treatment for selected patients with painful calcified
chronic pancreatitis and combining endoscopy with ESWL adds to the cost of
patient care without improving the outcome of pancreatic pain. All these
studies have demonstrated that ESWL is a safe technique with low complication
rates. The minor complications of ESWL include skin or duodenal contusion,
exacerbation of pancreatitis, mild abdominal discomfort and asymptomatic
hyperamylasemia. Serious complications reported include hepatic sub-capsular
hematoma, splenic rupture, splenic abscess, cholangitis, pancreatitisrelated sepsis,
hemosuccus pancreaticus and fluid collections with complication rates ranging
from 0% to 20% . 30
Treatment of pancreatic
duct stone
The principle of operation is to remove
pathogeny, take out stones, unchain the obstruction and relax drainage. Currently,
surgical intervention is recommended for all patients with pancreatic stones, while
individual treatment is emphasized and microinvasive surgery may be a
developing option for treating pancreatic stone.
Operation is a major treatment of
pancreatic duct stone 4 Surgical
therapy results in complete or partial relief of the symptoms of the disease.
Different surgical procedures can be chosen according to the location of the
stones in the pancreatic duct. 13 When the stones are mainly located in the head
of pancreas, endoscopic drainage and removal of the stones is usually the first
choice of treatment. If it fails, surgical procedure should be applied. If the
stones are mainly located in the body of the pancreas, they can be treated with
Pusetow-Gillesby procedure (pancreaticojejunostomy), Lateral
pancreaticojejunostomy is suitable for most patients with this disease. 6
Resection of the tail of the pancreas or combined resection with splenectomy is
done if the stones are located in the tail of the pancreas. Sometimes the
stones are found in the head or the tail of the main duct of the pancreas. The
Pusetow-Gillesby procedure or dividing of the neck of the pancreas while
removing stones from both ends of the pancreatic duct is the choice of
management.
Successful removal of pancreatic duct
stones can reduce pain and improve pancreatic function, and patients have regressed
ductographic changes of chronic pancreatitis and decreased diameter of the
pancreatic duct. By retrospective analysis of the management of patients with pancreatic
duct stone, Li et al 31 have
also suggested that surgical therapy is the most curative method for pancreatic
duct stone in patients with severe symptoms or suspected pancreatic carcinoma. A
prospective, randomized trial 32 ,
ompared endoscopic and surgical therapy for chronic pancreatitis showed
that surgery is superior to endotherapy for long-term pain reduction in
patients with painful obstructive chronic pancreatitis and concluded that
endotherapy could be offered as a first line treatment with surgery being
performed in case of failurre and/or recurrence. But therapeutic ERCP is safe in
pediatric patients with pancreatitis. Significant clinical improvement is
achieved in patients with billiary or pancreatic stone disease.
Treatment of pancreatic
stones complicated by pancreatic cancer
The high incidence of pancreatic stone
complicated with pancreatic cancer has been varied. 33, 34 Some
scientists, 17 favored Whipple as the first choice for pancreatic
stone complicated with pancreatic cancer. Foe patients with pancreatolithiasis
associated with pancreatic cancer, surgical treatment should follow the
principles of individualized therapy. Tumors in the head or neck can be removed
by Whipple’s procedure, those in the body or tail be resected by removal of the
pancreatic body and neck. If they invilved the spleen, the spleen can be
resected. If tumors metastatic to the abdominal cavity, extended radical
incision of the pancreatic is necessary.
Abdominal X-ray
is the first choice in diagnosing pancreatic stone. CT scan of the abdomen is
still the main choice in Indonesia, although in some centers, MRCP has taken
over the role of CT scanning in the diagnosis of pancreatic stone. Surgery
remains the primary treatment and techniques Peustow (longitudinal
pancreaticojejunostomy) is still the procedure of choice for pancreatolithiasis,
which is relatively safe, with morbidity and mortality are low.
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