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

Table 5 Scenario-based treatment selection

Clinical scenario	Preferred initial strategy	Rationale	Caveat
Small, mobile stone(s) without major downstream stricture	Conventional ERCP extraction	Fragmentation may be unnecessary when balloon or basket extraction is likely to succeed	Proceed if duct access is safe and drainage is achievable; avoid over-escalation
Limited 5-10 mm burden, favorable duct caliber, impacted or poorly fluoroscopic/radiolucent stone	Selective upfront POP-guided EHL or LL	Direct visualization can reduce targeting uncertainty and allow same-session reassessment	Best in expert centers with clear stopping rules and stent/drainage plan
Very large, high-density, radiopaque, multiple, chain-like, or diffuse burden	ESWL-centered pathway plus ERCP	Extracorporeal fragmentation may be more efficient than prolonged intraductal therapy	Consider CT attenuation and expected sessions; POP can be adjunct or rescue
Dominant downstream stricture with obstructing stone	Stricture-focused drainage strategy with dilation/stenting plus definitive fragmentation	Fragmentation without outflow correction often fails clinically	Stage therapy if necessary; reassess duct caliber and fragment clearance before repeating lithotripsy
Inflammatory head-dominant disease, complex strictures, repeated failed endotherapy, persistent opioid escalation	Early pancreatic surgery consultation	Randomized and health-economic evidence supports early surgery in selected painful obstructive CP	Do not use pancreatoscopy to postpone indicated surgery
Minor papilla access, postsurgical reconstruction, failed transpapillary access, or EUS-guided antegrade route	Individualized expert-center salvage strategy	Alternative access may enable therapy but evidence is limited and AE risk is meaningful	Reserve for high-volume centers with multidisciplinary backup

ERCP: Endoscopic retrograde cholangiopancreatography; POP: Per-oral pancreatoscopy; EHL: Electrohydraulic lithotripsy; LL: Laser lithotripsy; ESWL: Extracorporeal shock wave lithotripsy; CT: Computed tomography; CP: Chronic pancreatitis; AE: Adverse event; EUS: Endoscopic ultrasound.