Hashimoto R. Pancreatoscopy guided lithotripsy for difficult pancreatic duct stones: Evidence and treatment selection in chronic pancreatitis. World J Gastrointest Endosc 2026; 18(8): 122451 [DOI: 10.4253/wjge.122451]
Corresponding Author of This Article
Rintaro Hashimoto, MD, PhD, Assistant Professor, Department of Internal Medicine, University of Iowa Health Care, 200 Hawkins Dr, Iowa City, IA 52242, United States. rintaro-hashimoto@uiowa.edu
Research Domain of This Article
Gastroenterology & Hepatology
Article-Type of This Article
review-article
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World J Gastrointest Endosc. Aug 16, 2026; 18(8): 122451 Published online Aug 16, 2026. doi: 10.4253/wjge.122451
Pancreatoscopy guided lithotripsy for difficult pancreatic duct stones: Evidence and treatment selection in chronic pancreatitis
Rintaro Hashimoto
Rintaro Hashimoto, Department of Internal Medicine, University of Iowa Health Care, Iowa City, IA 52242, United States
Author contributions: Hashimoto R conceived and designed the review, performed the literature search, selected and interpreted the relevant studies, drafted the manuscript, prepared the tables and figures, critically revised the manuscript for important intellectual content, approved the final version of the manuscript, and agrees to be accountable for all aspects of the work.
AI contribution statement: During the preparation of this manuscript, the author used ChatGPT (OpenAI) solely for English language editing and to improve clarity and readability.
Conflict-of-interest statement: The author reports no relevant conflicts of interest for this article.
Corresponding author: Rintaro Hashimoto, MD, PhD, Assistant Professor, Department of Internal Medicine, University of Iowa Health Care, 200 Hawkins Dr, Iowa City, IA 52242, United States. rintaro-hashimoto@uiowa.edu
Received: April 20, 2026 Revised: June 6, 2026 Accepted: July 20, 2026 Published online: August 16, 2026 Processing time: 113 Days and 2.3 Hours
Abstract
Difficult main pancreatic duct stones in chronic pancreatitis are challenging not only because they are hard to fragment, but because duct clearance does not necessarily translate into durable clinical benefit. Pain relief, freedom from repeated procedures, and avoidance of later surgery should therefore be considered separately from technical clearance. Extracorporeal shock wave lithotripsy (ESWL), usually followed by endoscopic retrograde cholangiopancreatography (ERCP), remains a guideline-supported option for radiopaque stones measuring at least 5 mm in the pancreatic head or body, as well as for large, dense, multiple, or diffuse stone burdens. Digital pancreatoscopy-guided electrohydraulic lithotripsy or laser lithotripsy offers a different advantage: Direct intraductal visualization, targeted fragmentation, and immediate assessment of residual fragments, strictures, and drainage. We reviewed English-language publications available through May 2026. Current data show high technical success in selected patients, and some observational studies suggest fewer treatment sessions than with ESWL. However, randomized comparative data remain limited, and sham controlled and surgery comparison trials show that ductal clearance alone is an incomplete measure of patient benefit. The key question is therefore which patients are most likely to benefit from pancreatoscopy-guided lithotripsy, how it should be sequenced with ESWL and ERCP, how procedural risk and treatment burden should be weighed, and when surgery should be considered earlier. This mini-review presents a practical framework in which pancreatoscopy is used selectively, not as a replacement for ESWL or only as a rescue technique.
Core Tip: Pancreatoscopy-guided lithotripsy has become a useful option for difficult pancreatic duct stones, but the available evidence does not justify replacing extracorporeal shock wave lithotripsy as the default strategy. Its role should be decided case by case. Stone size, computed tomography attenuation, radiopacity, overall stone burden, duct anatomy, downstream strictures, access route, local expertise, and the expected number of procedures all matter. Success should also be measured beyond duct clearance. Pain relief, quality of life, opioid use, hospitalizations, need for repeat intervention, nutritional status, pancreatic function, and timely referral for surgery should all be part of treatment selection. In this setting, duct clearance is only one outcome; the more important question is whether treatment changes the patient’s clinical course.
