Endoscopic management of chronic pancreatitis with a fully covered self-expanding metal stent and laser lithotripsy.

The patient was a 58-year-old man with a long-standing history of alcohol abuse and chronic pancreatitis leading to multiple hospitalizations. He continued to have pain despite conservative management, pain control, and alcohol cessation. His chronic pancreatitis and pancreatic duct (PD) stones resulted in a tight PD stricture at the head of the pancreas. Multiple prior attempts at conventional endoscopic retrograde cholangiopancreatography (ERCP) had failed. He presented to our institution seeking advanced therapy after extracorporeal shock wave lithotripsy (ESWL). At our index ERCP we could not get conventional transpapillary access to the PD. Instead, given his stone burden, after ESWL, we chose to treat him with an EUS-guided pancreaticogastrostomy, and placement of a fully covered self-expanding metal stent (FCSEMS) followed by a pancreatoscopy with holmium laser lithotripsy (▶Fig. 1 and ▶Fig. 2). The patient responded to treatment, with resolution of his pain at 12 months after the intervention. In chronic pancreatitis, chronic inflammation causes endocrine and exocrine insufficiency, pancreatic atrophy, calcification, and multiple pancreatic duct strictures that lead to chronic pain [1]. This chronic disease has much associated morbidity. Current therapies include pain control and supportive measures aimed at treatment of endocrine and exocrine insufficiencies. PD strictures and PD stones frequently accompany chronic pancreatitis. Endoscopic management of chronic pancreatitis includes ERCP with transpapillary plastic stent placement, PD balloon dilation, and ESWL for PD stones. FCSEMS placement has been reported as a treatment for refractory PD strictures in patients in whom other therapeutic modalities have failed [2]. However, in the patient described here, a conventional transpapillary ERCP approach for placement of the FCSEMS was not successful, and we used an EUS-guided technique to place an FCSEMS, and we then used this access for laser lithotripsy [3]. EUS-guided pancreaticogastrostomy is an option when conventional transpapillary stent placement is not possible. This case illustrates that pancreaticogastrostomy can be used as access for laser lithotripsy.