Pancreatic duct stone management strategies: Advances and clinical practice in chronic pancreatitis

Table 1 Summary of benefits and risks of endoscopic procedures for pancreatic duct stones

	Key benefits	Key risks/limitations
ERCP for stone extraction	Primary intervention for PDS; enables direct removal of small stones (≤ 0.5 cm); provides access for fragment removal post-ESWL	Risk of PEP; ineffective for large/impacted stones without prior fragmentation (requiring ESWL); risk of procedure failure (e.g., guidewire placement increasing risk of residual stones)
Pancreatic duct stenting	Achieves decompressive drainage; alleviates pain associated with chronic pancreatitis and ductal obstruction; bridges obstructed segments when immediate stone removal is not feasible	Risk of stent-induced ductal changes (strictures/dilatation); complications include proximal/distal migration, stent occlusion, and rare events like jejunal obstruction; may require subsequent removal procedure

PDS: Pancreatic duct stones; ERCP: Endoscopic retrograde cholangiopancreatography; ESWL: Extracorporeal shock wave lithotripsy; PEP: Post-endoscopic retrograde cholangiopancreatography pancreatitis.

Table 2 Summary of benefits and risks of extracorporeal shock wave lithotripsy for pancreatic duct stones

Procedure	Key benefits	Key risks/limitations
ESWL	Non-invasive fragmentation of large stones into fragments ≤ 3 mm. High success rate for complete/near-complete fragmentation and clearance. Effective for pain relief by decompressing the obstructed duct. Generally safe with a low incidence of severe adverse events	Incomplete fragmentation can occur; predictors include high stone CT attenuation and large stone volume. May require multiple sessions. Common side effects: Cutaneous ecchymosis, sinus bradycardia. Post-procedural acute pancreatitis occurs in approximately 3.7% of patients. Efficacy is reduced by a concomitant main pancreatic duct stricture

ESWL: Extracorporeal shock wave lithotripsy; CT: Computed tomography.

Table 3 Summary of benefits and risks of direct intracorporeal lithotripsy techniques

Technique	Key benefits	Key risks/limitations
LL	High-precision, effective strategy for complex or ESWL-resistant stones. Allows fragmentation under direct visualization via POP. High pooled technical (88.1%) and clinical (81.6%) success rates. No ionizing radiation	Technically challenging and requires advanced endoscopic expertise. High cost and limited availability, restricted to specialized centers. Risks include pancreatic duct trauma, perforation, and PEP. Pooled adverse event rate for POP-guided lithotripsy is approximately 12%
EHL & electromechanical lithotripsy	Highly effective for fragmenting impacted main pancreatic duct stones. High technical success rate (e.g., 91.18% for POP-guided intracorporeal lithotripsy). Serves as a robust alternative or adjunct to other lithotripsy modalities	Efficacy is influenced by stone characteristics; high CT attenuation (> 2050 HU) or large diameter (> 12.8 mm) predict incomplete fragmentation. Requires precise electrode placement to avoid ductal wall contact, preventing barotrauma or perforation. Pooled adverse event rate is approximately 14.9%, with PEP being the most frequent complication (approximately 7%)

LL: Laser lithotripsy; ESWL: Extracorporeal shock wave lithotripsy; POP: Peroral pancreatoscopy; PEP: Post-endoscopic retrograde cholangiopancreatography pancreatitis; EHL: Electrohydraulic lithotripsy; CT: Computed tomography.

Table 4 Summary of surgical approaches for pancreatic duct stones

Surgical approach	Key benefits	Key risks/limitations
Pancreaticojejunostomy (e.g., Puestow, Frey procedures)	Provides effective decompression of the obstructed MPD. Achieves high rates of long-term pain relief and stone clearance. Aims to restore pancreatic juice flow and reduce intraductal pressure	Risk of postoperative pancreatic fistula, particularly if the MPD diameter is < 8 mm. Primarily indicated for patients with a significantly dilated MPD
Local pancreatic head resection with drainage (e.g., Beger, Frey procedures)	Excises diseased tissue (e.g., inflamed head, stones) while preserving duodenal integrity. Addresses concurrent biliary or duodenal obstruction. Reported long-term success rates for pain relief are high (e.g., approximately 90% for Frey procedure)	Technically more complex than drainage alone. Requires surgical expertise, especially for minimally invasive or robotic approaches
Pancreatectomy (pancreaticoduodenectomy or distal pancreatectomy)	Definitive resection for severe localized disease, suspected malignancy, or when less aggressive options fail. Eliminates the diseased pancreatic segment	Radical procedure with associated morbidity. May lead to endocrine or exocrine insufficiency, and the underlying chronic pancreatitis may progress in the remnant gland

MPD: Main pancreatic duct.