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

Table 4 Extracorporeal shock wave lithotripsy centered therapy vs pancreatoscopy guided lithotripsy

Domain	ESWL-centered therapy	Pancreatoscopy-guided lithotripsy	Clinical interpretation
Evidence maturity	Longer experience base, guideline-supported for radiopaque obstructive MPD stones ≥ 5 mm in pancreatic head/body	Growing evidence base with prospective and multicenter cohorts but fewer randomized data	Treat as complementary modalities; avoid claims of routine replacement
Best-fit stone phenotype	Large, dense, multiple, chain-like, radiopaque, or diffuse burden; favorable radiographic targeting	Limited stone burden; impacted or radiolucent/poorly fluoroscopic target; favorable duct access; realistic same-session clearance	Stone size alone is insufficient; CT attenuation, radiopacity, duct caliber, and strictures matter
Procedure burden	Often staged; may require multiple ESWL and ERCP sessions	May reduce total sessions in selected cohorts but can increase single-session complexity	Discuss expected session burden and anesthesia exposure before treatment
Advantages	Nonintraductal fragmentation; broad historical evidence; useful for large radiopaque burdens	Direct visualization, targeted fragmentation, immediate reassessment of fragments/strictures, potential same-session clearance	Choose by phenotype and local capability
Limitations	Availability, targeting of radiolucent stones, multiple sessions, modest link between clearance and durable pain benefit	Requires advanced pancreatic ERCP, adequate duct caliber/access, irrigation control, expertise, device cost, AE monitoring	Referral is preferable to low-volume improvisation
Safety profile	Pancreatitis, bleeding, pain flare, steinstrasse/fragment obstruction, need for staged ERCP; pooled AE rates generally around 10% in meta-analyses	PEP, hyperamylasemia, bleeding, infection, ductal trauma/perforation, stent-related events; cohort AE rates range from below 10% to > 20% depending on definitions and follow-up	Use standardized AE definitions and PEP prevention bundle
Patient-centered endpoints	Pain relief may occur but sham-controlled data show only modest short-term benefit in some populations	Pain improvement reported in selected cohorts; QoL improvement inconsistent	Clearance is a technical endpoint; pain, QoL, opioids, admissions, nutrition, and later surgery must be tracked
When surgery should enter	Early when head-dominant inflammatory disease, complex strictures, repeated ESWL/ERCP failure, opioid escalation, or low chance of durable drainage	Early when POP would require repeated high-risk sessions, access is unsafe, or ductal clearance is unlikely to reverse pain biology	Surgery should be parallel-consulted in red-flag phenotypes, not delayed until all endoscopy fails

ESWL: Extracorporeal shock wave lithotripsy; MPD: Main pancreatic duct; CT: Computed tomography; ERCP: Endoscopic retrograde cholangiopancreatography; AE: Adverse event; PEP: Post-endoscopic retrograde cholangiopancreatography pancreatitis; QoL: Quality of life.