Introduction: Pancreatic duct stones (PDS) or pancreatolithiasis pose a significant clinical challenge, and the choice of treatment modality is crucial to achieving optimal outcomes. Extracorporeal shock wave lithotripsy (ESWL) has long been regarded as the primary intervention for PDS. However, per-oral pancreatoscopy (POP)-guided lithotripsy, encompassing both electrohydraulic lithotripsy (EHL) and laser lithotripsy (LL), has emerged as a promising endoscopic alternative. This meta-analysis aims to compare the efficacy and safety profiles of EHL, LL, and ESWL for the treatment of PDS.
Methods: A search of MEDLINE, EMBASE, and Cochrane databases until November 2023 was conducted to identify studies assessing the use of EHL, LL, or ESWL for the treatment of PDS. The primary endpoints were technical success, clinical success, and complete clearance of stones. Clinical success was defined by the improvement in abdominal symptoms and the absence of hospitalization during follow-up. Secondary endpoints included any adverse events (AEs) and the incidence of post-intervention pancreatitis. We used the inverse-variance random-effect (DerSimonian and Laird) model to pool the outcomes. Heterogeneity was explored through subsequent subgroup analyses.
Results: A total of 48 observational studies were included. Of the 9628 patients with PDS in the analysis, 471 had POP-guided lithotripsy (285 and 186 had EHL and LL, respectively), and 9157 had ESWL. The pooled technical and clinical success rates of POP-guided lithotripsy vs. ESWL were 88.1% (95%CI 75.1-94.8%) vs. 85.5% (95%CI 79.1-90.2%), p=0.66, and 81.6% (95%CI 65.1-91.4%) vs. 78.5% (95%CI 70.9-84.5%), p=0.69, respectively. Subgroup analysis revealed that EHL achieved a pooled technical success rate of 85.2% (95% CI: 68.5%-93.9%) and a pooled clinical success rate of 74.4% (95% CI 50.7%-89.2%), while LL achieved a pooled technical success rate of 92.7% (95%CI 64.4-98.9%) and 85.7% (95%CI 63.9-95.3%). In addition, both POP-guided lithotripsy and ESWL exhibited comparable complete clearance of stones rates (68.0% [95%CI 41.2-86.6%] vs. 63.3% [95%CI 56.3-69.8%]; p=0.72). Any AE and post-intervention pancreatitis rates were also not significantly different among the two groups (9.3% [95%CI 4.1-19.6%] vs. 10.1% [95%CI 5.5-17.6%]; p=0.87 and 2.8% [95%CI 1.3-6.1%] vs. 4.3% [95%CI 3.1-5.9%]; p=0.32. respectively). Subgroup differences between LL and EHL were not significantly different.
Conclusion: POP-guided lithotripsy, including both EHL and LL, emerges as a highly effective and safe alternative for managing PDS, with a comparable safety profile to ESWL. POP could be considered as an alternative first-line option to ESWL for PDS. However, more data from randomized controlled trials is required to confirm these comparisons and evaluate for differences in other outcome measurements.

<b>Figure 1. Primary Outcome and Secondary Outcome of Per-oral Pancreatoscopy (POP)-Guided Lithotripsy and Extracorporeal Shock Wave Lithotripsy (ESWL) for Pancreatic Duct Stone (PDS)</b>

Figure 1. Primary Outcome and Secondary Outcome of Per-oral Pancreatoscopy (POP)-Guided Lithotripsy and Extracorporeal Shock Wave Lithotripsy (ESWL) for Pancreatic Duct Stone (PDS)

Nawan Pornananrat

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