Post written by Hitoshi Shibuya, MD, from the Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan.

This video is a case of a large main pancreatic duct stone treated endoscopically using digital pancreatoscopy and electrohydraulic lithotripsy (EHL). Acute exacerbation of chronic pancreatitis occurred with an impacted stone in the pancreatic head. Initially, ERCP was done for the deployment of a pancreatic plastic stent for the purpose of bypassing the obstruction. After improvement of the acute symptoms, a second ERCP was done. Digital pancreatoscopy with direct EHL was performed. After successful lithotripsy, the remaining fragments were removed endoscopically with a metallic basket. Treatment was successfully achieved endoscopically.

The guidelines of some countries recommend ESWL as the first line treatment for a MPD stone over 5 mm in diameter. Endoscopic treatment is recommended for small and floating stones or fragmented stones after ESWL. However, ESWL is not widely used and equipment is uncommon in some hospitals.

Currently, large stones indicated for ESWL can be treated endoscopically because of advancements in endoscopic techniques and devices. This technique is useful for many endoscopists. The decision to use this technique should be made based on local expertise available and multidisciplinary input for patient selection. It is important to understand the characteristics of all treatment methods. Further research is needed.

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