Letter: Assessing the Durability of Treatment Effects: Long-Term Outcomes of ESWL and ERCP for Pancreatic Duct Stones in Chronic Pancreatitis

Abstract

After carefully examining the latest research by Liu et al. on the treatment of pancreatic duct stones [1]. We believe the study overlooked some key factors that could affect the accuracy and interpretation of the results.

Firstly, the study did not specify whether patients with a history of pancreatic surgery, diagnosis of pancreatic cancer, pain conditions other than chronic pancreatitis, long-term use of opioid analgesics, pancreatic head mass, multiple strictures, significant ascites, and/or large fluid collections were excluded, which were focal points in previous research [2, 3]. A history of pancreatic surgery may alter pancreatic anatomy, thereby affecting pancreatic fluid flow and ductal pressure, which could influence the efficacy and risk of complications from P-ESWL and ERCP. A diagnosis of pancreatic cancer is a critical exclusion criterion, as patients with cancer may require different pain management and treatment strategies. Conditions of pain other than chronic pancreatitis and long-term opioid use could affect the assessment of pain and judgement of treatment efficacy. Moreover, the presence of a pancreatic head mass, multiple strictures, significant ascites, and/or large fluid collections may indicate the severity and complexity of the disease, which could affect the applicability and outcomes of P-ESWL and ERCP.

Secondly, the study did not specifically record and adjust for the concurrent presence of pancreatic pseudocysts (PPCs). PPCs occur in approximately 20%–40% of patients with chronic pancreatitis and are often associated with large intraductal stones [4], likely due to increased ductal pressure caused by stones and/or strictures. The presence of PPCs may be closely related to chronic pain and recurrent episodes of acute pain, posing a challenge to clinical management. Not accounting for the coexistence of PPCs could introduce confounding and limitations to the study's conclusions. PPCs may require additional interventions, such as cyst drainage or surgical intervention, which, if not recorded, could be overlooked in the study [5].

Lastly, the study did not clearly record and adjust for the total number of ERCPs following P-ESWL and the total number of ESWL sessions. This information is crucial for a comprehensive evaluation of the efficacy and safety of P-ESWL and ERCP in treating pancreatic duct stones in patients with chronic pancreatitis [2, 6]. The number of ERCPs post-P-ESWL reflects the complexity of treatment and the severity of the patient's condition, with multiple ERCPs possibly indicating the need for additional interventions to clear stones or manage complications, which could affect the patient's recovery process and long-term prognosis. The total number of ESWL sessions is an important indicator of treatment intensity and patient response to initial therapy, with patients requiring multiple ESWL sessions possibly having more challenging stones, necessitating more complex treatment strategies and closer monitoring. Additionally, the study did not record and adjust for the interval between the diagnosis of chronic pancreatitis and P-ESWL, which are significant risk factors for major complications of P-ESWL [7]. Pancreatic divisum's influence on post-P-ESWL complications and the unaccounted interval from chronic pancreatitis diagnosis to treatment may obscure the study's findings on P-ESWL efficacy and risks. Addressing these factors is critical for robust scientific conclusions.

Wei-Zhen Tang: conceptualization, methodology, funding acquisition, visualization. Bo-Yuan Deng: methodology, validation, visualization, funding acquisition, writing – review and editing. Tai-Hang Liu: validation, formal analysis, project administration.

The authors declare no conflicts of interest.

This article is linked to Liu et al papers. To view these articles, visit https://doi.org/10.1111/apt.18224 and https://doi.org/10.1111/apt.18333.