Reply to Liu and Hu

We appreciate the insights from Drs. Liu and Hu [1]. Initially, it is pertinent to note that our study excluded patients who did not achieve stone fragmentation after four sessions of extracorporeal shockwave lithotripsy (ESWL) [2]. We agree with the comment on the distinct characteristics of such patients, which have been investigated previously. Computed tomography-based pancreatic stone density may be a major determinant of ESWL failure [3] [4]. Our research focused on identifying predictors of persistent pain despite successful ESWL, rather than following unsuccessful ESWL. Patients with large radiolucent stones that could not be cleared with endoscopic retrograde cholangiopancreatography underwent nasopancreatic tube insertion followed by ESWL for fragmentation, aligning with the extensive literature on this subject [5].

The guideline recommending the insertion of a single 10-Fr plastic stent for an uninterrupted duration of 1 year applies specifically to cases with dominant main pancreatic duct (MPD) strictures, not universally to all patients. This recommendation is based on low-quality evidence and is considered a weak recommendation [6].

Additionally, after redefining significant pain reduction to an Izbicki Pain Score of ≤10 or >10 following a decrease of more than 50%, we found that 196 patients (30.6%) continued to experience persistent pain. The agreement between the two definitions of pain relief was remarkably strong (kappa 0.971; 95%CI 0.951–0.991). Employing this revised definition, our multivariate analysis through binary logistic regression and the conditional forward method revealed that alcohol consumption (odds ratio [OR] 1.80, 95%CI 1.17–2.77), tobacco use (OR 3.56, 95%CI 2.14–5.94), older age (OR 1.02, 95%CI 1.00–1.04), MPD size (OR 1.14, 95%CI 1.05–1.25), and MPD stricture (OR 6.48, 95%CI 3.89–10.81) are independent predictors of persistent pain following ESWL.

Publication History

Article published online:
29 August 2024

• References

• 1 Liu M, Hu L. Comments on “Predictors of persistent pain after extracorporeal shockwave lithotripsy for painful chronic calcific pancreatitis”. Endoscopy 2024; 56 DOI: 10.1055/a-2307-6320.
• 2 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.
• 3 Liu R, Su W, Gong J. et al. Noncontrast computed tomography factors predictive of extracorporeal shock wave lithotripsy outcomes in patients with pancreatic duct stones. Abdom Radiol (NY) 2018; 43: 3367-3373
• 4 Bush N, Lahooti I, Singh A. et al. S1149. CT-based pancreatic stone density evaluation is a determinant of the number of sessions for ESWL success in patients with chronic calculous pancreatitis. Am J Gastroenterol 2022; 117: e837-e838
• 5 Tandan M, Nageshwar Reddy D, Talukdar R. et al. ESWL for large pancreatic calculi: report of over 5000 patients. Pancreatology 2019; 19: 916-921
• 6 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)