[nternatloJ~alg'ournalof.Pancreatology, vol. 12, no. 3:227-231, December 1992 .9 Copyright 1992 by The Humana Press Inc. AlI rights of any nature whatsoever reserved. (3169-419 7/9 2/12/3 :227-231/$ 2.00
Intraoperative Endoscopic Electrohydraulic Lithotripsy of Pancreatic Stones Masao Tanaka,* Kazunori Yokohata, Hiroshi Kimura, Gen Naritomi, Hitoshi Ichimiya, and John S. Minasi Department of Surgery L Kyushu University Faculty of Medicine, Fukuoka, Japan
Summary Two male patients with complications associated with chronic pancreatitis are described. In each patient, preoperative examinations revealed a large stone obstructing the main duct in the head of the pancreas. Lateral pancreaticojejunostomy was performed to relieve pain and prevent further attacks of pancreatitis. During each operation, the stone was fragmented under direct visual control with the use of a flexible choledochoscope and a contact electrohydraulic lithotriptor. The stone was removed and ductal flow through the head of the pancreas was reestablished. Our experience shows that endoscopic electrohydraulic lithotripsy facilitates operative removal of pancreatic stones deeply located in the head of the pancreas~ Key Words: Pancreatitis; pancreatic calculi; electrohydraulic lithotripsy; pancreaticojejunostomy.
Introduction
In two patients reported here, we successfully employed intraoperative contact electrohydraulic lithotripsy under endoscopic control to remove the pancreatic stones packed in the main duct of the head of the pancreas.
Pancreatolithiasis remains a difficult problem in p a n c r e a t i c surgery (1-2). Stones in the main pancreatic duct may cause obstruction to the flow of pancreatic juice, possibly resulting in intractable pain, recurrent pancreatitis, or impaired exocrine function. Lateral pancreaticojejunostomy is an accepted method to attain pancreatic duct drainage in most cases with a dilated cluct (3-5). Although complete r e m o v a l o f the stones from at least the main pancreatic duct seems desirable for a better result, it is not always easy when irregular stones are packed in the duct or when the stones are located deeply in the head o f the pancreas.
Patients and Methods Two male patients with pancreatolithiasis associated with chronic pancreatitis were selected for this study. Patient #1 was a 37-year-old Vietnamese scholar studying in Japan. He was not an alcoholic but had a history of frequent diarrhea for 10 years and occasional epigastric pain for several years. Pancreatic stones were demonstrated on an abdominal film one year previously. Endoscopic retrograde pancreatography (ERP) performed at a local hospital visualized a cystic lesion in the body o f the pancreas with subsequent infection of the cyst. The patient was referred to us for further evaluation and
Received January 13, 1992; Revised March 2, 1992; Accepted March 10, 1992 *Author to whom all correspondence and reprint requests should be addressed: Department of Surgery I, Kyushu University Faculty of Medicine, Fukuoka 812, Japan International Journal o f P ancreatology
227
Volume 12, 1992
228 treatment. The pseudocyst infection subsided after medical treatment with antibiotics. Plain abdominal radiographs, CT scan, and subsequent ERP revealed a large U-shaped stone packed in the dilated main duct of the head of the pancreas (Fig. 1). The CT scan also showed two cysts, one in the body and one in the tail of the pancreas. Patient #2 was a 47-year-old Japanese man, who had a 10-year history of frequent hospitalizations for the treatment of alcoholism. One year previously, he had developed acute pancreatitis unresponsive to medical treatment, which progressed to peripancreatic abscess~ The patient was referred to us for further management. The abscess was effectively drained percutaneously with all inflammatory findings resolved in three weeks. An X-ray film of the abdomen and ERP revealed a large stone obliterating the dilated main duct as well as many small stones in the branches of the head of the pancreas (Fig. 2).
Electrohydraulic Lithotripsy o f Pancreatic Stones To obtain pancreatic drainage for relief of pain and prevention of further attacks of pancreatitis, these patients were offered lateral pancreaticojejunostomy. At operation, the main duct was identiffed by needle puncture to make a longitudinal incision. The incision was made as long as possible, and the pancreatic stones in the head of the pancreas, if identified, were removed using a small clamp. After removal of as many stones as possible, a sterilized choledochoscope (Olympus CHF 20Q) was inserted into the incised duct. The "knee" of the duct was passed by maneuvering the flexible tip of the choledochoscope, thereby visualizing the large stone remaining in the head portion of the duct (Fig. 3a). A 4 French electrohydraulic probe was inserted into the forceps channel of the choledochoscope. Electrohydraulic shock waves were applied to the stone under endoscopic visual control while keeping the probe in contact with the stone, thereby fragmenting the stone (Figure 3b). Irrigation of saline through the choledochoscope and via a plastic tube introduced in place of the choledochoscope facilitated an outflow of stone fragments from the duct incision. After elimination of the fragments was International Journal of Pancreatology
Tanaka et al.
Fig. 1. Endoscopic retrograde pancreatogram obtained at a local hospital showing a large U-shaped stone (curved arrow) packed in the main duct of the head of the pancreas in Patient #1. A pseudocyst (straight arrow) is filled, thus leading to infection.
confirmed by endoscopic vision (Fig. 3c), the opened pancreatic duct was anastomosed to a Rouxen-Y jejunal limb in two layers.
Results Lithotripsy was successfully accomplished in both patients. The pancreatic stones were fragmented and large fragments, if any, were broken into very small fragments by repeating the procedure. Flushing out of these fragments was performed without difficulty by saline irrigation of the duct via the choledochoscope or a plastic tube inserted into the duct in place of the choledochoscope. In Patient #1, a pseudocyst, 4 cm in diameter, in the pancreatic tail involving the spleen and containing necrotic tissue was resected together with the spleen. Two stones obliterating the duct just proximal to the cyst were included. Another pseudocyst in the pancreatic body measuring 3.5 cm in diameter was opened with the duct and anastomosed to the jejunal loop. In Patient #2, the fibrous scar of the previously drained peripancreatic abscess involved the spleen; Volume 12, 1992
Lithotripsy of Pancreatic Stones
Fig. 2. Endoscopic retrograde pancreatogram demonstrafing a large stone in the dilated main duct as well as small stones in the branches in the head of the pancreas in Patient #2. therefore, the spleen and the pancreatic tail were resected~ The longitudinally opened main duct was anastomosed to the jejunum. The postoperative courses were uneventful in both patients. An abdominal film revealed the lower portion of the large pancreatic stone remaining in the descending branch of the duct in the head of the pancreas in Patient #1. The large stone in the main duct was completely eliminated in Patient #2. The small stones in the branches remained in place. Both patients were free of pain during followup after 18 months (Patient #1) and 12 months (Patient #2) postoperatively.
Discussion The present report describes that pancreatic stones can be fragmented by contact electrohydraulic lithotripsy under visual control with the use of a flexible choledochoscope during surgery. This procedure greatly facilitated operative removal of stones from the main pancreatic duct. Pancreatic stones are composed of calcium carbonate (6). Medical dissolution of pancreatic stones has been attempted with citrate (7) or trimethadione (8). This therapy may prove effective but requires a long treatment time. The result is not yet defini-
InternationalJournal of PancreatoIogy
229 rive, and discontinuation of these drugs may cause reappearance of the stones. Nonoperative extraction of pancreatic stones can be achieved by endoscopic sphincterotomy (9-11). However, this technique can be applied only to selected cases where the stones are floating in the pancreatic duct near the papilla. Moreover, since pancreatic sphincterotomy carries a greater risk of inducing pancreatitis than standard sphincterotomy, this treatment should be performed with caution and only in patients with a good chance for relief of pain. Operative removal of pancreatic stones is usually performed at the time of pancreaticojejunostomy (12). However, it is difficult to remove stones packed in the pancreatic duct deeply in the head of the pancreas. Rumpf and Bunzendahl (13) proposed a combination of transduodenai biliary and pancreatic papilloplasty together with long pancreaticojejunostomy for removal of the pancreatic stones in the head of the pancreas and more complete drainage of the duct. Endoscopic laser or ultrasound lithotripsy was successfully used by Schildberg et alo (I4) to remove stones located deeply in the pancreatic head in two patients during pancreaticojejunostomy, obviating the need for transduodenal sphincteroplasty. The contact appl!cation of electrohydraulic shock waves has proved effective in pulverizing biliary stones (15-18). Stones in the common bile duct, intrahepatic ducts, and gallbladder have been successfully fragmented under fluoroscopic or choledochoscopic control. To our knowledge, however, there has been no previous description of lithotripsy of pancreatic stones with this method. Since this study showed that the pancreatic stones could be fragmented by electrohydraulic shock waves, extracorporeal shock wave lithotripsy for the treatment of pancreatic stones may deserve more consideration in clinical practice. A preliminary result reported by Sauerbruch et al. (19) seems promising. Although there is no definite evidence that removal of pancreatic stones will relieve pancreatic pain or arrest deterioration of exocrine and endocrine functions, the better drainage achieved by elimination of the stones in the main pancreatic duct with the intraoperative use of endoscopic electro-
Volume 12, 1992
230
Tanaka et al.
eD
"r. e=
oD
9 ,9 r.~ aZl
.~ ~d
b~
~'~
International Journal of Pancreatology
Volume 12, 1992
Lithotripsy of Pancreatic Stones hydraulic lithotripsy is technically feasible and may benefit the patient.
References 1 Pitchumoni CS, Mohan AT. Pancreatic stones. Gastroenterol CIin North Am 1990; 19: 873-893. 2 Multigner L, Montalto G, Sarles H. New aspects of stone formation in chronic pancreatitis. Gyr KE, Singer MV, Sarles H, eds. Pancreatitis: Concepts and Classification. Amsterdam: Elsevier Science, p. 171, 1984. 3 Morrow CE, Cohen JI, Sutherland DER, Najarian JS. Chronic pancreatitis: long-term surgical results of pancreatic duct drainage, pancreatic resection, and near-total pancreatectomy and islet autotransplantation. Surgery 1984; 96: 608-614. 4 Warshaw AL. Conservation of pancreatic tissue by combined gastric, bitiary, and pancreatic duct drainage for pain from chronic pancreatitis. Am J Surg 1985; 149: 563-569. 5 Nelson WH, Townsend CM, Jr, Thompson JC. Operative drainage of the pancreatic duct delays functional impairment in patients with chronic pancreatitis. Ann Surg 1988; 208: 321-329. 6 Hoefs J. The carbon and oxygen isotope composition of pancreatic stones. In: Beger HG, Buchler M, Ditschuneit H, Malfertheiner P, eds. Chronic Pancreatitis. Heidelberg: Springer-Verlag, pp. 454--459, 1990. 7 Sahel J Sarles H. Citrate therapy in chronic calcifying pancreatitis: preliminary results. Mitchell C J, Kelleher J, eds. Pancreatic Disease in Clinical Practice. London: Pitman, pp. 346-353, 1981. 8 Noda A, Shibata T, Hamano H, Murase T, Hayakawa T, Horiguchi Y, Takayama T. Trimethadione (Trixidone) dissolves pancreatic stones. Lancet 1984; 8398:351-353. 9 Fuji T, Arnano H, Harima K, Aibe T, Asagami F, Kinukawa K, Ariyama S, Takemoto T. Pancreatic sphincterotomy and pancreatic endoprosthesis. Endoscopy 1985; 17: 69-72,
International Journal of Pancreatology
231 10
11
12
13
14
15
16
17
t8
19
Schneider MU, Lux G. Floating pancreatic duct concrements in chronic pancreatitis. Pain relief by endoscopic removal. Endoscopy 1985; 17: 8-10. Huibregste K, Schneider B, Vrij AA, Tytgat GNJ. Endoscopic pancreatic drainage in chronic pancreatitis. Gastrointest Endosc 1988; 34: 9-15. Howard JM. Surgical treatment of chronic pancreatitis: Principles, applications and results. Howard JM, Jordan GL Reiber HA, eds. Surgical Diseases of the Pancreas. Philadelphia: Lea & Febiger, pp. 496-521, 1987. Rumpf KD, Bunzendahl H. Pancreatojejunostomy in combination with transduodenal pancreatic sphincter-oplasty. Beger HG, Buchler M, Ditschuneit H, Malfertheiner P, eds. Chronic Pancreatitis. Heidelberg: Springer-Verlag, pp. 454--459, 1990. Schildberg FW, Lange V, Wenk H, Schuller J. Die intraoperative, endoskopische Lithotripsie yon Pankreasgangkonkrementen. Ein beitrag zur chirurgischen Behandlung der chronisch-calcifizierenden Pankreatitis. Chirurg t987; 58: 239-242. Tanaka M, Yoshimoto H, Ikeda S, Matsumoto S, Guo RX. Two approaches for electrohydrautic lithotripsy in the common bile duct. Surgery 1985; 98: 313-318. Matsumoto S, Tanaka M, Yoshimoto H, Miyazaki K, Ikeda S, Nakayama F. Electrohydraulic lithotripsy of intrahepafic stones during choledochoscopy. Surgery 1987; I02: 852856. Matsumoto S, Ikeda S, Tanaka M, Yashimoto H, Nakayama F. Nonoperative removal of giant common bile duct calculi. Am J Surg 1988; 155: 780-782. Yoshimoto H, Ikeda S, Tanaka M, Matsumoto S, Kuroda Y. Cbotedochoscopic electrohydraulic lithotripsy and lithotomy for stones in the common bile duct, intrahepatic ducts, and gallbladder. Ann Surg t989; 210: 576-582. Sauerbruch T, Holl J, Sackmann M, Paumgartner G. Extracorporeal shock wave lithotripsy of pancreatic stones. Gut 1989; 30: 1406-1411.
Volume 12, 1992
Intraoperative Endoscopic Electrohydraulic Lithotripsy of Pancreatic Stones Masao Tanaka,* Kazunori Yokohata, Hiroshi Kimura, Gen Naritomi, Hitoshi Ichimiya, and John S. Minasi Department of Surgery L Kyushu University Faculty of Medicine, Fukuoka, Japan
Summary Two male patients with complications associated with chronic pancreatitis are described. In each patient, preoperative examinations revealed a large stone obstructing the main duct in the head of the pancreas. Lateral pancreaticojejunostomy was performed to relieve pain and prevent further attacks of pancreatitis. During each operation, the stone was fragmented under direct visual control with the use of a flexible choledochoscope and a contact electrohydraulic lithotriptor. The stone was removed and ductal flow through the head of the pancreas was reestablished. Our experience shows that endoscopic electrohydraulic lithotripsy facilitates operative removal of pancreatic stones deeply located in the head of the pancreas~ Key Words: Pancreatitis; pancreatic calculi; electrohydraulic lithotripsy; pancreaticojejunostomy.
Introduction
In two patients reported here, we successfully employed intraoperative contact electrohydraulic lithotripsy under endoscopic control to remove the pancreatic stones packed in the main duct of the head of the pancreas.
Pancreatolithiasis remains a difficult problem in p a n c r e a t i c surgery (1-2). Stones in the main pancreatic duct may cause obstruction to the flow of pancreatic juice, possibly resulting in intractable pain, recurrent pancreatitis, or impaired exocrine function. Lateral pancreaticojejunostomy is an accepted method to attain pancreatic duct drainage in most cases with a dilated cluct (3-5). Although complete r e m o v a l o f the stones from at least the main pancreatic duct seems desirable for a better result, it is not always easy when irregular stones are packed in the duct or when the stones are located deeply in the head o f the pancreas.
Patients and Methods Two male patients with pancreatolithiasis associated with chronic pancreatitis were selected for this study. Patient #1 was a 37-year-old Vietnamese scholar studying in Japan. He was not an alcoholic but had a history of frequent diarrhea for 10 years and occasional epigastric pain for several years. Pancreatic stones were demonstrated on an abdominal film one year previously. Endoscopic retrograde pancreatography (ERP) performed at a local hospital visualized a cystic lesion in the body o f the pancreas with subsequent infection of the cyst. The patient was referred to us for further evaluation and
Received January 13, 1992; Revised March 2, 1992; Accepted March 10, 1992 *Author to whom all correspondence and reprint requests should be addressed: Department of Surgery I, Kyushu University Faculty of Medicine, Fukuoka 812, Japan International Journal o f P ancreatology
227
Volume 12, 1992
228 treatment. The pseudocyst infection subsided after medical treatment with antibiotics. Plain abdominal radiographs, CT scan, and subsequent ERP revealed a large U-shaped stone packed in the dilated main duct of the head of the pancreas (Fig. 1). The CT scan also showed two cysts, one in the body and one in the tail of the pancreas. Patient #2 was a 47-year-old Japanese man, who had a 10-year history of frequent hospitalizations for the treatment of alcoholism. One year previously, he had developed acute pancreatitis unresponsive to medical treatment, which progressed to peripancreatic abscess~ The patient was referred to us for further management. The abscess was effectively drained percutaneously with all inflammatory findings resolved in three weeks. An X-ray film of the abdomen and ERP revealed a large stone obliterating the dilated main duct as well as many small stones in the branches of the head of the pancreas (Fig. 2).
Electrohydraulic Lithotripsy o f Pancreatic Stones To obtain pancreatic drainage for relief of pain and prevention of further attacks of pancreatitis, these patients were offered lateral pancreaticojejunostomy. At operation, the main duct was identiffed by needle puncture to make a longitudinal incision. The incision was made as long as possible, and the pancreatic stones in the head of the pancreas, if identified, were removed using a small clamp. After removal of as many stones as possible, a sterilized choledochoscope (Olympus CHF 20Q) was inserted into the incised duct. The "knee" of the duct was passed by maneuvering the flexible tip of the choledochoscope, thereby visualizing the large stone remaining in the head portion of the duct (Fig. 3a). A 4 French electrohydraulic probe was inserted into the forceps channel of the choledochoscope. Electrohydraulic shock waves were applied to the stone under endoscopic visual control while keeping the probe in contact with the stone, thereby fragmenting the stone (Figure 3b). Irrigation of saline through the choledochoscope and via a plastic tube introduced in place of the choledochoscope facilitated an outflow of stone fragments from the duct incision. After elimination of the fragments was International Journal of Pancreatology
Tanaka et al.
Fig. 1. Endoscopic retrograde pancreatogram obtained at a local hospital showing a large U-shaped stone (curved arrow) packed in the main duct of the head of the pancreas in Patient #1. A pseudocyst (straight arrow) is filled, thus leading to infection.
confirmed by endoscopic vision (Fig. 3c), the opened pancreatic duct was anastomosed to a Rouxen-Y jejunal limb in two layers.
Results Lithotripsy was successfully accomplished in both patients. The pancreatic stones were fragmented and large fragments, if any, were broken into very small fragments by repeating the procedure. Flushing out of these fragments was performed without difficulty by saline irrigation of the duct via the choledochoscope or a plastic tube inserted into the duct in place of the choledochoscope. In Patient #1, a pseudocyst, 4 cm in diameter, in the pancreatic tail involving the spleen and containing necrotic tissue was resected together with the spleen. Two stones obliterating the duct just proximal to the cyst were included. Another pseudocyst in the pancreatic body measuring 3.5 cm in diameter was opened with the duct and anastomosed to the jejunal loop. In Patient #2, the fibrous scar of the previously drained peripancreatic abscess involved the spleen; Volume 12, 1992
Lithotripsy of Pancreatic Stones
Fig. 2. Endoscopic retrograde pancreatogram demonstrafing a large stone in the dilated main duct as well as small stones in the branches in the head of the pancreas in Patient #2. therefore, the spleen and the pancreatic tail were resected~ The longitudinally opened main duct was anastomosed to the jejunum. The postoperative courses were uneventful in both patients. An abdominal film revealed the lower portion of the large pancreatic stone remaining in the descending branch of the duct in the head of the pancreas in Patient #1. The large stone in the main duct was completely eliminated in Patient #2. The small stones in the branches remained in place. Both patients were free of pain during followup after 18 months (Patient #1) and 12 months (Patient #2) postoperatively.
Discussion The present report describes that pancreatic stones can be fragmented by contact electrohydraulic lithotripsy under visual control with the use of a flexible choledochoscope during surgery. This procedure greatly facilitated operative removal of stones from the main pancreatic duct. Pancreatic stones are composed of calcium carbonate (6). Medical dissolution of pancreatic stones has been attempted with citrate (7) or trimethadione (8). This therapy may prove effective but requires a long treatment time. The result is not yet defini-
InternationalJournal of PancreatoIogy
229 rive, and discontinuation of these drugs may cause reappearance of the stones. Nonoperative extraction of pancreatic stones can be achieved by endoscopic sphincterotomy (9-11). However, this technique can be applied only to selected cases where the stones are floating in the pancreatic duct near the papilla. Moreover, since pancreatic sphincterotomy carries a greater risk of inducing pancreatitis than standard sphincterotomy, this treatment should be performed with caution and only in patients with a good chance for relief of pain. Operative removal of pancreatic stones is usually performed at the time of pancreaticojejunostomy (12). However, it is difficult to remove stones packed in the pancreatic duct deeply in the head of the pancreas. Rumpf and Bunzendahl (13) proposed a combination of transduodenai biliary and pancreatic papilloplasty together with long pancreaticojejunostomy for removal of the pancreatic stones in the head of the pancreas and more complete drainage of the duct. Endoscopic laser or ultrasound lithotripsy was successfully used by Schildberg et alo (I4) to remove stones located deeply in the pancreatic head in two patients during pancreaticojejunostomy, obviating the need for transduodenal sphincteroplasty. The contact appl!cation of electrohydraulic shock waves has proved effective in pulverizing biliary stones (15-18). Stones in the common bile duct, intrahepatic ducts, and gallbladder have been successfully fragmented under fluoroscopic or choledochoscopic control. To our knowledge, however, there has been no previous description of lithotripsy of pancreatic stones with this method. Since this study showed that the pancreatic stones could be fragmented by electrohydraulic shock waves, extracorporeal shock wave lithotripsy for the treatment of pancreatic stones may deserve more consideration in clinical practice. A preliminary result reported by Sauerbruch et al. (19) seems promising. Although there is no definite evidence that removal of pancreatic stones will relieve pancreatic pain or arrest deterioration of exocrine and endocrine functions, the better drainage achieved by elimination of the stones in the main pancreatic duct with the intraoperative use of endoscopic electro-
Volume 12, 1992
230
Tanaka et al.
eD
"r. e=
oD
9 ,9 r.~ aZl
.~ ~d
b~
~'~
International Journal of Pancreatology
Volume 12, 1992
Lithotripsy of Pancreatic Stones hydraulic lithotripsy is technically feasible and may benefit the patient.
References 1 Pitchumoni CS, Mohan AT. Pancreatic stones. Gastroenterol CIin North Am 1990; 19: 873-893. 2 Multigner L, Montalto G, Sarles H. New aspects of stone formation in chronic pancreatitis. Gyr KE, Singer MV, Sarles H, eds. Pancreatitis: Concepts and Classification. Amsterdam: Elsevier Science, p. 171, 1984. 3 Morrow CE, Cohen JI, Sutherland DER, Najarian JS. Chronic pancreatitis: long-term surgical results of pancreatic duct drainage, pancreatic resection, and near-total pancreatectomy and islet autotransplantation. Surgery 1984; 96: 608-614. 4 Warshaw AL. Conservation of pancreatic tissue by combined gastric, bitiary, and pancreatic duct drainage for pain from chronic pancreatitis. Am J Surg 1985; 149: 563-569. 5 Nelson WH, Townsend CM, Jr, Thompson JC. Operative drainage of the pancreatic duct delays functional impairment in patients with chronic pancreatitis. Ann Surg 1988; 208: 321-329. 6 Hoefs J. The carbon and oxygen isotope composition of pancreatic stones. In: Beger HG, Buchler M, Ditschuneit H, Malfertheiner P, eds. Chronic Pancreatitis. Heidelberg: Springer-Verlag, pp. 454--459, 1990. 7 Sahel J Sarles H. Citrate therapy in chronic calcifying pancreatitis: preliminary results. Mitchell C J, Kelleher J, eds. Pancreatic Disease in Clinical Practice. London: Pitman, pp. 346-353, 1981. 8 Noda A, Shibata T, Hamano H, Murase T, Hayakawa T, Horiguchi Y, Takayama T. Trimethadione (Trixidone) dissolves pancreatic stones. Lancet 1984; 8398:351-353. 9 Fuji T, Arnano H, Harima K, Aibe T, Asagami F, Kinukawa K, Ariyama S, Takemoto T. Pancreatic sphincterotomy and pancreatic endoprosthesis. Endoscopy 1985; 17: 69-72,
International Journal of Pancreatology
231 10
11
12
13
14
15
16
17
t8
19
Schneider MU, Lux G. Floating pancreatic duct concrements in chronic pancreatitis. Pain relief by endoscopic removal. Endoscopy 1985; 17: 8-10. Huibregste K, Schneider B, Vrij AA, Tytgat GNJ. Endoscopic pancreatic drainage in chronic pancreatitis. Gastrointest Endosc 1988; 34: 9-15. Howard JM. Surgical treatment of chronic pancreatitis: Principles, applications and results. Howard JM, Jordan GL Reiber HA, eds. Surgical Diseases of the Pancreas. Philadelphia: Lea & Febiger, pp. 496-521, 1987. Rumpf KD, Bunzendahl H. Pancreatojejunostomy in combination with transduodenal pancreatic sphincter-oplasty. Beger HG, Buchler M, Ditschuneit H, Malfertheiner P, eds. Chronic Pancreatitis. Heidelberg: Springer-Verlag, pp. 454--459, 1990. Schildberg FW, Lange V, Wenk H, Schuller J. Die intraoperative, endoskopische Lithotripsie yon Pankreasgangkonkrementen. Ein beitrag zur chirurgischen Behandlung der chronisch-calcifizierenden Pankreatitis. Chirurg t987; 58: 239-242. Tanaka M, Yoshimoto H, Ikeda S, Matsumoto S, Guo RX. Two approaches for electrohydrautic lithotripsy in the common bile duct. Surgery 1985; 98: 313-318. Matsumoto S, Tanaka M, Yoshimoto H, Miyazaki K, Ikeda S, Nakayama F. Electrohydraulic lithotripsy of intrahepafic stones during choledochoscopy. Surgery 1987; I02: 852856. Matsumoto S, Ikeda S, Tanaka M, Yashimoto H, Nakayama F. Nonoperative removal of giant common bile duct calculi. Am J Surg 1988; 155: 780-782. Yoshimoto H, Ikeda S, Tanaka M, Matsumoto S, Kuroda Y. Cbotedochoscopic electrohydraulic lithotripsy and lithotomy for stones in the common bile duct, intrahepatic ducts, and gallbladder. Ann Surg t989; 210: 576-582. Sauerbruch T, Holl J, Sackmann M, Paumgartner G. Extracorporeal shock wave lithotripsy of pancreatic stones. Gut 1989; 30: 1406-1411.
Volume 12, 1992
