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

Figure 4 Mechanistic framework linking ductal stone therapy to patient-important outcomes. Schematic overview of how protein plugs and calcification may lead to main pancreatic duct obstruction, ductal hypertension, recurrent inflammation, neural remodeling, and peripheral or central sensitization. The figure illustrates why ductal clearance can help selected patients with obstructive disease, but may not consistently improve pain, quality of life, opioid use, or the need for later surgery. ERCP: Endoscopic retrograde cholangiopancreatography; ESWL: Extracorporeal shock wave lithotripsy.