Biliary and pancreatic ESWL

Abstract

Extraction of large pancreatic and common bile duct (CBD) calculi has always challenged the therapeutic endoscopy. Extracorporeal shock wave lithotripsy (ESWL) is an excellent tool for patients with large pancreatic and CBD calculi that are not amenable to routine endotherapy. Pancreatic calculi in the head and body are targeted directly by ESWL, with an aim to fragment them to <3 mm diameter so that they can be extracted by subsequent endoscopic retrograde cholangiopancreatography (ERCP). From the data available in the literature, complete clearance of the pancreatic duct was achieved in 76-84% and partial clearance in 17-20% of patients. For large CBD calculi, a nasobiliary tube is placed to help target the calculi, as well as bathe the calculi in saline-a simple maneuver which helps to facilitate fragmentation. The aim is to fragment calculi to <5 mm size and clear the same during ERCP. Complete clearance of the CBD was achieved in 84-95% of and partial clearance in 12-15% of patients in the many available studies. In view of its high efficiency, noninvasive nature, and low complication rates, ESWL can be offered as the first-line therapy for selected patients with large pancreatic and CBD calculi.