Pancreatoscopy guided lithotripsy for difficult pancreatic duct stones: Evidence and treatment selection in chronic pancreatitis

Table 3 Primary pancreatoscopy guided lithotripsy studies and clinically relevant quantitative endpoints

Ref.	Design/population	Sample size	Lithotripsy modality	Technical/clearance result	Clinical result	AEs/follow-up	Major limitation/practical inference
Attwell et al[19], 2015	Multicenter United States retrospective/prospective follow-up experience in calcific CP	28	LL	Successful stone fragmentation/clearance in most patients; early evidence that LL could be performed during ERCP with POP	Pain improvement reported during follow-up	AEs occurred but were generally manageable; follow-up heterogeneous	Small nonrandomized cohort; older platforms; limited phenotype stratification
Brewer Gutierrez et al[18], 2019	International multicenter retrospective study at 17 tertiary centers	109	EHL 59; LL 50	Complete ductal clearance 899%; single-session success 73.5%; > 3 stones predicted repeat sessions	Clinical endpoints less standardized than technical endpoints	AEs 10.1%; median follow-up 210 days	Expert-center retrospective design; no randomized comparator
van der Wiel et al[20], 2022	Prospective single-center consecutive case series of first-line EHL in obstructive CP stones > 5 mm	34 included; 26 with successful duct cannulation	EHL	Complete or partial clearance in 24/34; technical success after duct cannulation 92.3%; complete clearance 80% of treated patients	Izbicki pain score improved from 62.3 to 27.5 at 6 months	Acute pancreatitis in 7 patients, all mild; median 2 ERP and 1 EHL procedure	Duct cannulation failure excluded from technical denominator; single-center expertise
Bick et al[21], 2022	Comparative retrospective cohort: Single-operator pancreatoscopy-guided intraductal lithotripsy vs ESWL	18 POP; 240 ESWL	EHL/LL	Clearance 889% vs 86.7% with ESWL	Clinical response not uniformly patient-reported	Complications 5.6% vs 6.3%; fewer total procedures and shorter cumulative procedure time with POP	Selection bias; small POP group; historical/Local practice effects
Gerges et al[22], 2023	Prospective multicenter cohort of digital single-operator pancreatoscopy for symptomatic pancreatic duct stones	40 enrolled	EHL and/or LL	High complete clearance in selected patients with limited head/body stone burden	Overall pain relief reported in most evaluable patients at 6 months	Serious AEs 12.5%, conservatively managed	Highly selected anatomy; moderate sample size; no randomized comparator
de Rijk et al[23], 2023	Long-term observational follow-up of first-line EHL compared with historical ESWL cohort	19 EHL; 18 ESWL	EHL	Long-term treatment success at least comparable to historical ESWL; recurrence 37% vs 61%	Sustained clinical success 58% in EHL group	Median follow-up 35.0 months EHL and 76.5 months ESWL; QoL not significantly different	Historical comparison; small cohorts; follow-up duration imbalance
Iwata et al[24], 2024	Multicenter retrospective cohort: Disposable POP-guided lithotripsy vs ESWL	19 POP; 47 ESWL	EHL 13; LL 4; mixed or failed in some	Treatment success 78.9% vs 70.2%; median sessions 1 vs 5	Clinical symptoms heterogeneous	Complications 21.0% vs 6.3%; POP complications included hyperamylasemia and MPD perforation	Small POP group; nonrandomized treatment assignment; era and technology effects
Conrad et al[25], 2025	Retrospective multicenter long-term study after successful digital single-operator video pancreatoscopy-guided lithotripsy	58	EHL	Sustained ductal and clinical outcomes in selected patients with initial success	Pain relief 70.7% at month 3, persisting through 24 months; QoL not consistently improved	AEs 26%, mostly mild/moderate pancreatitis	Enriched for initial technical/clinical success; limited generalizability
Yoshida et al[26], 2026	Retrospective predictor study of POP-guided EHL without ESWL	Noted in article; cohort focused on pancreatic duct stones treated with EHL	EHL	CT attenuation > 2050 HU and diameter > 12.8 mm predicted incomplete EHL	Clinical outcomes linked to clearance predictors	AE details center-specific	Thresholds require external validation before universal use

CP: Chronic pancreatitis; LL: Laser lithotripsy; ERCP: Endoscopic retrograde cholangiopancreatography; POP: Per-oral pancreatoscopy; AE: Adverse event; EHL: Electrohydraulic lithotripsy; ERP: Endoscopic retrograde pancreatography; ESWL: Extracorporeal shock wave lithotripsy; QoL: Quality of life; MPD: Main pancreatic duct; CT: Computed tomography; HU: Hounsfield units.