Comments on “Predictors of persistent pain after extracorporeal shockwave lithotripsy for painful chronic calcific pancreatitis”

We read with great interest the article by Gurav et al. [1] analyzing the predictors of persistent pain after extracorporeal shockwave lithotripsy (ESWL) for painful chronic calcific pancreatitis. These findings provide insightful information for selecting patients for ESWL and endoscopic retrograde cholangiopancreatography (ERCP) treatment.However, we found some points that require further clarification.

First, the underlying inclusion criteria may have influenced the results. The study did not include patients with failed stone fragmentation after four sessions of ESWL. However, these patients may possess certain unique characteristics that could potentially serve as predictors for persistent pain after ESWL. Furthermore, based on previously published data [2], the proportion of these patients may not be low. Additionally, patients with radiolucent calculi also underwent ESWL treatment in the study, whereas the international guideline recommends ERCP for radiolucent stones [3].

Second, the management of patients in this study was inconsistent with the international guideline, which recommends the insertion of a single 10-Fr plastic stent for an uninterrupted period of 1 year [3]. However, in the present study, stents were removed at 3 or 6 months’ follow-up, and restenting was considered whenever indicated.

Third, a reduction in Izbicki score by >50% was considered significant pain relief. We believe that this definition is of limited clinical guidance value because there may be patients whose Izbicki score has decreased to a relatively low level, but they are still considered to have persistent pain due to a decrease in the Izbicki score of less than 50%. Previous studies have mostly defined pain relief as Izbicki pain score ≤10 or >10 after a decrease of >50% [4] [5].

In conclusion, the research is quite meaningful, but the aforementioned points may need to be clarified.

Publication History

Article published online:
29 August 2024

• References

• 1 Gurav N, Jagtap N, Koppoju V. et al. Predictors of persistent pain after extracorporeal shockwave lithotripsy for painful chronic calcific pancreatitis. Endoscopy 2024; 56 DOI: 10.1055/a-2252-9920. (PMID: 38267001)
• 2 Tandan M, Nageshwar Reddy D, Talukdar R. et al. ESWL for large pancreatic calculi: report of over 5000 patients. Pancreatology 2019; 19: 916-921
• 3 Dumonceau JM, Delhaye M, Tringali A. et al. Endoscopic treatment of chronic pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) Guideline – updated August 2018. Endoscopy 2019; 51: 179-193 DOI: 10.1055/a-0822-0832. (PMID: 30654394)
• 4 Cahen DL, Gouma DJ, Nio Y. et al. Endoscopic versus surgical drainage of the pancreatic duct in chronic pancreatitis. N Engl J Med 2007; 356: 676-684 DOI: 10.1056/NEJMoa060610. (PMID: 17301298)
• 5 Issa Y, Kempeneers MA, Bruno MJ. et al. Effect of early surgery vs endoscopy-first approach on pain in patients with chronic pancreatitis: the ESCAPE randomized clinical trial. JAMA 2020; 323: 237-247