Main Pancreatic Duct Stones Research Articles

Endoscopic treatment of pancreatic duct stones under direct vision: Revolution or resignation? Systematic review.

The main treatment aim in chronic pancreatitis (CP) is symptom control and especially pain relief. Management of stone-predominant CP is challenging and requires a multidisciplinary approach. Extracorporeal shock wave lithotripsy (ESWL) has emerged as the cornerstone of non-surgical treatment as a result of disappointing results of available endoscopic treatment options during the last decades. With new developments in the field of direct peroral pancreatoscopy (POP) and intracorporeal lithotripsy, direct intraluminal treatment of main pancreatic duct (MPD) stones returns to the spotlight. Herein, we reviewed the current data on direct pancreatoscopic treatment of MPD stones with a focus on efficiency and safety of available technologies, endoscopes and lithotripsy devices. A systematic Medline search for relevant studies was done. Ten relevant publications meeting the inclusion criteria were identified (two prospective series, six retrospective trials, two case reports, n=87 patients). Successful ductal clearance for POP-guided treatment was reported as between 43% and 100% compared to ESWL with 59% to 80%. Adverse event rate for POP-guided therapy was reported as 0-13.5%. One study showed a noticeable higher adverse event rate of 43%. In this trial, POP was carried out after ESWL. There is no reported mortality following POP treatment. Available results are promising in terms of ductal clearance and pain relief compared to standard endoscopic techniques and ESWL as the current gold standard for lithotripsy. Interpretation of this data is limited by the small number of cases for POP and the lack of prospective randomized controlled trials.

Peroral cholangiopancreatoscopy with the SpyGlass® system: what do we know 10 years later.

Smaller endoscopes and catheters have been developed that permit direct visualization of the bile and pancreatic ducts (cholangioscopy and pancreatoscopy, respectively). These endoscopes and catheters are passed through the working channel of a standard therapeutic duodenoscope during endoscopic retrograde cholangiopancreatography (ERCP). The SpyGlass Direct Visualization System (Boston Scientific Corp, Natick, MA, USA) is currently the most widely used and studied device. Cholangioscopy with intraductal lithotripsy has become an established modality in the treatment of difficult biliary lithiasis. When used in the evaluation of indeterminate biliary strictures by experienced endoscopists in recognizing intraductal pathology, it increases the diagnostic yield of tissue sampling. Pancreatoscopy is complementary to other imaging modalities in the evaluation of intraductal papillary mucinous neoplasms of the pancreas and is emerging as a sole or adjunctive therapy to extracorporeal shock wave lithotripsy for the treatment of main pancreatic duct stones. It remains investigational in the diagnosis of pancreatic adenocarcinoma. Complications specific to the performance of cholangiopancreatoscopy include cholangitis, which is related to intraductal fluid irrigation.

Success of Extracorporeal Shock Wave Lithotripsy in Chronic Calcific Pancreatitis Management: A Meta-Analysis and Systematic Review.

This is a meta-analysis and systematic review to assess the overall utility and safety of Extracorporeal shock wave lithotripsy (ESWL) in chronic calcific pancreatitis. Primary outcomes are pain relief, narcotic usage, ductal clearance, quality of life, and pancreatic exocrine and endocrine function. Studies involving ESWL in chronic calcific pancreatitis with main pancreatic duct stones greater than 5 mm and patients that failed conservative pain management were included. Fixed and random effects models were used to calculate the pooled proportions. Initial search identified 1471 reference articles, in which 184 articles were selected and reviewed. Data were extracted from 27 studies (N = 3189) which met the inclusion criterion. The pooled proportion of patients with absence of pain at follow-up was 52.7% (95% confidence interval [95% CI], 50.85-54.56) and mild to moderate pain at follow-up was 33.43% (95% CI, 31.40-35.50). Quality of life improved in 88.21% (95% CI, 85.43-90.73) and complete ductal clearance was 70.69% (95% CI, 68.97-72.38) in the pooled patients. The ESWL is an effective and safe management option in patients with chronic calcific pancreatitis patients with main pancreatic duct stone size greater than 5 mm who did not get adequate pain relief with conservative management.

Extracorporeal Shock Wave Lithotripsy for Chinese Patients With Pancreatic Stones: A Prospective Study of 214 Cases.

This study aims to evaluate prospectively the safety and efficacy of extracorporeal shock wave lithotripsy (ESWL) in Chinese patients. A total of 214 patients with painful chronic pancreatitis and pancreatic stones who underwent ESWL followed by endoscopic retrograde cholangiopancreatography from March 2011 to February 2012 in Changhai Hospital were enrolled. The main pancreatic duct clearance rate and complications were recorded prospectively. Symptoms, weight, quality of life, and pancreatic function were assessed before and after ESWL and endotherapy. A total of 473 ESWL procedures were performed in 214 patients. Stones were fragmented in all cases. Complete clearance of main pancreatic duct stones and successful endoscopic decompression were achieved in 155 (72.4%) and 188 (90.8%) of 214 patients, respectively. Complications were observed after 20 sessions (20 of 473, 4.23%). Follow-up (n = 195) after 18.5 ± 3.3 months showed that complete and partial pain relief were achieved in 71.3% and 24.0% of the patients, respectively. The scores for the quality of life (5.8 ± 1.7 vs 8.1 ± 1.2, P < 0.05) and mental health from the Medical Outcomes Study 36-Item Short-Form General Health Survey questionnaire (62.2 ± 21.5 vs 68.5 ± 16.4, P < 0.05) improved after ESWL. Thus, ESWL is a safe and effective method to treat Chinese patients with pancreatic stones. This procedure can significantly improve the success rate of endotherapy.

Efficacy of combined endoscopic lithotomy and extracorporeal shock wave lithotripsy, and additional electrohydraulic lithotripsy using the SpyGlass direct visualization system or X-ray guided EHL as needed, for pancreatic lithiasis.

Introduction. To evaluate the efficacy of combined endoscopic lithotomy and extracorporeal shock wave lithotripsy (ESWL), and additional electrohydraulic lithotripsy (EHL) as needed, for the treatment of pancreatic duct stones, we retrospectively evaluated 98 patients with chronic pancreatitis and pancreatic lithiasis. Methods. For the management of main pancreatic duct (MPD) stones in 98 patients, we performed combined endoscopic treatment (ET)/ESWL therapy as the first treatment option. When combined ET/ESWL was unsuccessful, EHL with the SpyGlass Direct Visualization system or X-ray guided EHL was performed. Outpatient ESWL was reserved as one of the final treatment options. Results. Fragmentation was successful in 80 (81.6%) patients as follows: combined ET/ESWL: 67 cases; SpyGlass EHL: 4 cases; X-ray guided EHL: 3 cases; and outpatient ESWL: 6 cases. Successful outcome was obtained by combined ET/ESWL in 67 of the 98 patients (74.5%), by EHL in 7 of 14 patients (7.1%), and by outpatient ESWL in 6 of 6 patients (6.1%). Negotiating the guidewire through a severe MPD stricture was significantly associated with a higher rate of stone fragmentation (P = 0.0003). Conclusions. In cases where combined ET/ESWL was not successful for stone clearance, EHL using the SpyGlass system or X-ray guided EHL was effective in cases where the guidewire could be negotiated through the MPD stricture and it increased the fragmentation rate.

A novel basket catheter to facilitate endoscopic removal of pancreatic stones (with video)

Endoscopic removal of pancreatic stones in patients with chronic pancreatitis is still challenging. With a conventional basket catheter, introduction to the target area or catching pancreatic stones is sometimes difficult. To evaluate a novel double-lumen basket catheter composed of nitinol wires with fine reticular structures in the distal end and loose mesh in the proximal part. A prospective feasibility study. Tertiary-care center. This study involved 10 patients with main pancreatic duct stones of 5 mm or less in the shorter diameter of the largest stone. In the first 5 cases, a nitinol basket catheter was used as salvage after stone extraction with a conventional basket catheter and retrieval balloon (salvage group). In the following 5 cases, stones were initially removed by using a nitinol basket catheter, and the presence of residual stones was evaluated by pancreatogram along with balloon sweep (initial group). Success rate of removal of the target stones and procedure-related adverse events. A nitinol basket catheter was easily introduced to the target stone in all patients. In the salvage group, additional stones were retrieved with a nitinol basket catheter in 3 of 5 patients. In the initial group, stone extraction by a nitinol basket catheter was successful, and no residual stones were extracted by additional balloon cleaning in any patients. Basket impaction or after-ERCP pancreatitis was not observed. A small sample size without a control group. This novel nitinol basket catheter is useful for the extraction of small pancreatic stones. A randomized, controlled trial is warranted to confirm its efficacy.

Pancreatoscopy-guided intracorporeal laser lithotripsy for difficult pancreatic duct stones: a case series with prospective follow-up (with video)

Pancreatic stones develop in patients with chronic pancreatitis, with as many as 90% of alcoholic chronic pancreatitis patients bearing ductal stones during long-term follow-up. 1 Main pancreatic duct calculi can lead to an outflow obstruction with increased parenchymal pressure, upstream dilation (ie, toward the tail of the pancreas), and ischemia. Untreated stones can also trigger bouts of acute pancreatitis sometimes associated with life-threatening adverse events. Pain is the predominant symptom in most patients with obstructive chronic pancreatitis, often alleviated only by narcotics and inducing anorexia, malabsorption, and weight loss. It is only with main pancreatic duct decompression from impacted stones that such adverse events can be avoided. 2,3 Small stones can be extracted by using various endoscopic techniques during ERCP, such as pancreatic sphincterotomy with balloon or basket sweeping, pancreatic duct stricture dilation, or stent placement. Larger and impacted stones typically require lithotripsy or surgery. Endoscopic lithotripsy options include (1) mechanical lithotripsy, for which data are scarce but suggest that this procedure may carry an increased risk of adverse events when compared with lithotripsy for biliary stones 2 ; (2) extracorporeal shock wave lithotripsy (ESWL), which overcomes the problem of size by fragmenting calculi and reducing the stone burden, thus facilitating endoscopic duct clearance 3 ; (3) contact lithotripsy by using pancreatoscopy with a mother-baby endoscope system. 4 Directcontact lithotripsy of biliopancreatic stones can be achieved by means of electrohydraulic lithotripsy (EHL) or pulseddye laser, both of which must be done under direct vision. Scant clinical outcome data are available regarding the application of these methods for pancreatic duct stone fragmentation. 5 Our aim was to evaluate the endoscopic treatment at our center by intracorporeal laser lithotripsy (ILL) with a single-operator mini-endoscope (SpyGlass; Boston Scientific, Natick, Mass) during ERCP, for its performance, feasibility, and safety in the treatment of difficult main pancreatic duct stones.

Sa1560 The Accuracy of Magnetic Resonance Cholangiopancreatography (MRCP), Endoscopic Ultrasound (EUS) and Pancreatic Protocol CT (PPCT) in Diagnosing Main Pancreatic Duct Stones

well as other malignant neoplasms. One of the most common causes of elevated CA 19-9 is pancreato-biliary diseases, including gallbladder sludge. Aim: The aim of this study was to evaluate the usefulness of endoscopic ultrasonography (EUS) in patients with elevated CA 19-9 and normal abdominal CT findings. Methods: Between January 2007 and December 2009, 21 patients who visited Pusan National University Hospital because of elevated serum CA 19-9 level, were retrospectively enrolled. EUS was performed in all subjects, in whom all of the tests including routine blood tests, endoscopy, abdominal CT, and other clinical exams to detect the origin of elevated CA 19-9 showed no abnormal findings. Serum CA 19-9 was measured subsequently every 36 months. Results: Median CA 19-9 value was 63.6 U/mL (40.0381 U/mL), and median follow-up period was 10.8 months (3.050.6 months). Gallbladder sludge was identified on EUS in 19 of 21 patients, all of which was not detected on abdominal/pelvic CT. There was no overt pancreatic cancer detected. Ursodeoxycholic acid (UDCA) was administered in 14 of 19 patients, for 117.8 months (mean 6.2 months). Six patients of 12 UDCA-delivered patients (except 2 patients in whom subsequent CA 19-9 value was not checked) achieved normal CA 19-9 level after mean 5.3 months (39 months), and one of 5 UDCA not-delivered patients did after 6 months. Conclusion: EUS is useful to investigate the pancreato-biliary cause of elevated CA 19-9 level, particularly, when abdominal CT showed non-specific results. UDCA may be effective to normalize the CA 19-9 in patients with accidentally detected gallbladder sludge.

Update on endoscopic management of main pancreatic duct stones in chronic calcific pancreatitis.

Pancreatic duct stones are a common complication during the natural course of chronic pancreatitis and often contribute to additional pain and pancreatitis. Abdominal pain, one of the major symptoms of chronic pancreatitis, is believed to be caused in part by obstruction of the pancreatic duct system (by stones or strictures) resulting in increasing intraductal pressure and parenchymal ischemia. Pancreatic stones can be managed by surgery, endoscopy, or extracorporeal shock wave lithotripsy. In this review, updated management of pancreatic duct stones is discussed.

Timing of Endoscopy After Extracorporeal Shock Wave Lithotripsy for Chronic Pancreatitis

Extracorporeal shock wave lithotripsy (ESWL) and endoscopic retrograde cholangiopancreatography (ERCP) are used to clear main pancreatic duct (MPD) stones and alleviate pain in patients with chronic pancreatitis. The goal of this study was to determine if delayed ERCP after disintegration of MPD stones with ESWL improves the successful clearance of the MPD. Adult patients with chronic pancreatitis who underwent ESWL for stone disintegration were identified from an ESWL database at a single tertiary referral center. The complete clearance of stones from the MPD with ERCP performed less than 2 days after ESWL was compared to complete clearance from ERCP more than 2 days after ESWL. Nineteen patients underwent ERCP less than 2 days after ESWL, and 3 (16%) of the 19 achieved MPD clearance. Eleven patients underwent ERCP more than 2 days after ESWL, and 9 (82%) of 11 patients achieved MPD clearance (P = 0.001). In total, 19 of 30 ERCPs were performed less than 2 days after ESWL, and 84% failed to clear the MPD (P = 0.001). The timing of ERCP after ESWL may be important to successfully clear stones from the MPD. This study shows that ERCP performed less than 2 days after ESWL may be more likely to fail, possibly owing to ESWL-induced edema. Delaying ERCP after ESWL may allow tissue recovery after ESWL.

Use of Secretin During Extracorporeal Shock Wave Lithotripsy (ESWL) to Facilitate Endoscopic Clearance of Main Pancreatic Duct Stones (MPDS)

Use of Secretin During Extracorporeal Shock Wave Lithotripsy (ESWL) to Facilitate Endoscopic Clearance of Main Pancreatic Duct Stones (MPDS)

Indications for and Limitations of Extracorpareal Shock Wave Lithotripsy and Endoscopic Therapy For the Main Pancreatic Duct Stones Associated With Chronic Pancreatitis

We performed extracorporeal shock wave lithotripsy (ESWL) as the treatment of first choice in 145 patients suffering from chronic pancreatitis with main pancreatic duct stones. Forty patients required additional endoscopic therapy. Fragmentation of stones was achieved in 138 patients (95%), and the complete stone clearance rate after ESWL alone or in combination with endoscopic therapy was 82%. Pain relief was achieved in 137 patients (95%). No severe complications occurred in any of the patients. During a mean follow up period of 4.9 years, 36 patients (27%) suffered stone recurrence or growth of fragments, and pancreatitis relapsed in 29 patients (20%). Nine of these 29, whose pseudocyst of pancreas or pain was not controlled, required surgery. These results are comparable with those of surgical drainage in long-term outcome.

Efficacy of Pancreatic Stenting After Clearance of Pancreatic Stones

Treatment of strictures of the main pancreatic duct (MPD) with pancreatic stenting after endoscopic clearance of the pancreatic stones may reduce the recurrence of pancreatic symptoms. Therefore, we analyzed the efficacy of pancreatic stenting after stone extraction. Sixty-one patients with MPD stones were treated endoscopically and 24 of 41 patients with MPD strictures received stenting therapy. The recurrence of any pancreatic symptoms was seen in 28 cases (46%) in the mean follow up period of 3.3 years. The relative risk for the recurrence of pancreatic symptoms was related to the duration of chronic pancreatitis. The hazard ratio of stricture and stent for recurrence of symptoms was 2.3 (p=0.12) and 0.35 (p=0.057), respectively. Additional stenting for MPD after extraction of pancreatic stones might be effective in patients with pancreatic stones and severe strictures in MPD. A better protocol for stenting could reduce the recurrence of pancreatic symptoms.

Chronic Calcific Pancreatitis: Combination ERCP and Extracorporeal Shock Wave Lithotripsy for Pancreatic Duct Stones

Chronic pancreatitis is commonly associated with debilitating abdominal pain, in part due to pancreatic duct obstruction. Pancreatic stones are often impossible to extract from the duct with endoscopic retrograde cholangiopancreatography alone. Extracorporeal shock wave lithotripsy (ESWL) is commonly used for fragmentation of obstructing nephrolithiasis and has demonstrated effectiveness in management of pancreatic stones. Our aim was to examine the outcomes of the first 30 patients with symptomatic pancreatic stones treated with a combination of ESWL and endoscopic therapies. Patients with symptomatic chronic calcific pancreatitis referred for ESWL (2005-2009) were included. Technical success of ESWL was defined as a) stone fragmentation sufficient to allow extraction of main duct stones at ERCP or b) absence of the targeted main pancreatic duct stones on follow-up radiography. Clinical success of ESWL was defined by Patient Global Impression of Improvement (PGII) score of at least slightly improved. Thirty patients underwent ESWL. One patient was excluded due to adenocarcinoma. Technical success was achieved in 17/29 (58.6%) patients. 25 (86.2%) patients were available for follow-up (median 35 months, range 3-52 months). Fifteen of twenty-five (60%) patients experienced clinical improvement (10 patients very much improved), but there was no significant reduction in the proportion taking narcotics (50% before vs. 44.4% after ESWL). Pancreatic surgery has been avoided to date in 16 (64%) of the 25 patients. A multidisciplinary approach, combining ERCP and ESWL, to painful obstructing pancreatic duct stones provided symptomatic improvement and allowed pancreatic surgery to be avoided in the majority of patients.

The Timing of ERCP After Extracorporeal Shock Wave Lithotripsy for Chronic Pancreatitis is Critical for Clearance of Main Pancreatic Duct Stones

The Timing of ERCP After Extracorporeal Shock Wave Lithotripsy for Chronic Pancreatitis is Critical for Clearance of Main Pancreatic Duct Stones

膵石症に対するESWLと内視鏡的治療の適応と限界

膵石症に対するESWLと内視鏡的治療の適応と限界

Pancreatic duct evaluation: accuracy of portal venous phase 64 MDCT

Many patients presenting with nonspecific signs and symptoms often receive CT scans using general protocols, not optimized to evaluate for pancreatic pathology. Therefore the purpose of this study was to evaluate portal venous phase 64 multi-row detector CT (MDCT) scans for detecting pancreatic duct strictures, stones, pancreas divisum, and communication between pancreatic ducts and cystic pancreatic lesions. Institutional review board approval with waived informed consent was obtained for this HIPAA-compliant study. We included all patients that underwent abdominal, portal venous phase, intravenous contrast-enhanced 64 MDCT scans between 6/7/05 and 5/01/07 and MR cholangiopancreatography (MRCP) or endoscopic retrograde pancreatography (ERCP) within 2 months of the CT. This yielded 93 patients (42 males, 51 females) with a mean age of 59 years. In addition to CT, 75 patients underwent MRCP and 37 patients underwent ERCP. Two radiologists independently evaluated the CT images, including multiplanar and minimum intensity pixel projection reformations, for pancreatic duct strictures, stones, pancreas divisum, or cystic pancreatic lesions. The latter were classified as communicating or not communicating with the pancreatic ducts. Findings on ERCP or MRCP were used to calculate diagnostic performance parameters. On standard of reference examinations, 15 (16%) of the 93 patients had a pancreatic duct stricture. The sensitivity and the specificity for Observer 1 were 87% and 100%, respectively; for Observer 2, 100% and 100%, respectively. Six (6%) of the 93 patients had main pancreatic duct stones. The sensitivity and the specificity for Observer 1 were 83% and 100%, respectively; for Observer 2, 100% and 99%, respectively. Five (5%) patients had pancreas divisum; Observer 1 correctly identified four and Observer 2 correctly identified three cases. Eleven (12%) patients had cystic pancreatic lesions. Observer 1 correctly determined whether or not there was communication between the cystic pancreatic lesion and the pancreatic duct in ten cases; Observer 2 correctly made this determination in nine cases. Portal venous phase 64 MDCT images are moderately sensitive and highly specific for detecting pancreatic duct stricture, stones, and pancreas divisum and moderately accurate for detecting communication between pancreatic ducts and cystic pancreatic lesions.

Utility of Peroral Cholangioscope (Spy Glass System) in Treatment of Stones in Chronic Pancreatitis

Chronic pancreatitis is a difficult clinical condition to treat. Stones in the main pancreatic duct could lead to increased ductal pressure and cause pain, inflammation and other complications. Endoscopic therapy is aimed at reduction of the pressure in the main pancreatic duct. Endoscopic armamentarium is limited. Extracorporeal shock wave lithotripsy though useful is available only at a very few centers in the United States. Mechanical lithotripsy is difficult and is associated with significant complications including the inability to crush the stones, broken and captured baskets. Electro hydraulic lithotripsy (EHL) would be beneficial but could not be used earlier because of the limitation of direct visualization of the stones in the main pancreatic duct. Recently a single operator duodenoscope assisted cholagiopancreatoscopy (Spy glass system, Boston Scientific, MA) was introduced. This was primarily developed for evaluation and treatment of biliary tract disease. Aim: To evaluate the feasibility and efficacy of electrohydraulic lithotripsy of main pancreatic duct stones in chronic pancreatitis using Spy glass system. Methods: Retrospective analysis of the data of pancreatoscopies done using Spy glass. Results: Between July 07 and November 07, 16 procedures were performed with Spy glass system. 8 patients had chronic pancreatitis. Of these 8, 2 underwent cholangioscopy for evaluation of the bile duct and 6 underwent pancreatoscopy. Main pancreatic duct calcifications were seen in 5 patients and EHL was performed. In 4 of the 5 patients stones could be fragmented by EHL and subsequently stones were removed by stone/basket. All the stones could not be removed and 2 of these patients had subsequent pancreatoscopies with removal of more stone material. In one case EHL was attempted but was unsuccessful because of difficult angulation and inability to achieve adequate contact between the probe and the stone. No procedure related complications were seen. Conclusions: 1. Spy glass system allows for direct visualization of the stones in the main pancreatic duct and EHL could be safely performed to decompress the main pancreatic duct. This adds to the current armamentarium of the endoscopic accessories for therapy of pancreatic stones. 2. Limitations include use in non dilated/strictured ducts because of the current size of the catheter (7Fr) and maneuverability within the duct. 3. Currently used EHL probes are designed for urological procedures and hence the length of the probe is a limitation, moreover the probe is not rigid and can kink easily. Specially designed probes are in development and might solve this problem.

Outcomes after clearance of pancreatic stones with or without pancreatic stenting

Extracorporeal shockwave lithotripsy (ESWL) and endoscopic lithotripsy are useful for the fragmentation and extraction of pancreatic stones. However, pancreatic stones often recur, for which an adequate strategy is needed. Treatment for stricture of the main pancreatic duct (MPD) with a pancreatic stent after clearance of pancreatic stones may reduce the recurrence of pancreatic symptoms and stones. Forty patients with chronic pancreatitis with MPD stones were treated with ESWL in combination with endoscopic stone extraction. After clearance of the stones, a pancreatic stent was inserted when a stricture of MPD was observed on pancreatography. The stent was exchanged every 3 months and removed after a total of 1 year. We examined episodes of recurrent pain and pancreatitis in patients with and without stenting, as well as the MPD diameter, during follow-up. MPD stricture was seen in 27 patients, and a stent was successfully inserted in 24 of them. Pancreatic symptoms recurred in five patients (21%) in the stenting group and in three patients (23%) in the control group during a mean follow-up period of 1.5 and 1.2 years, respectively. The diameter of the MPD, before, just after, and 1 year after treatment, was 7.6, 5.4, and 5.8 mm, respectively. It was significantly decreased after 1 year of follow-up, as well as just after stent removal, compared with before treatment (P < 0.05). Additional stenting for MPD after extraction of pancreatic stones may reduce the risk of recurrence of pancreatic symptoms.

Endoscopic Treatment of an Impacted Pancreatic Duct Stone Using a Balloon Catheter for Electrohydraulic Lithotripsy Without Pancreatoscopy

Obstructing main pancreatic duct (PD) stones represent a challenge for endoscopic removal because they are frequently impacted within the duct, are hard, and process sharp edges. Multiple series have been published demonstrating that removal of obstructing stones in the main PD can improve symptoms in the majority of patients with chronic pancreatitis. Extracorporeal shock wave lithotripsy (ESWL) has become an accepted technique to facilitate stone clearance when standard endoscopic methods fail. More recently, direct contact lithotripsy with the use of smaller caliber endoscopes has been described as an alternative to ESWL. Limited experience suggests that intraductal electrohydraulic lithotripsy under direct endoscopic visualization with a small caliber pancreatoscope results in successful fragmentation of PD stones that have been refractory to standard endoscopic methods or ESWL. Herein, we report the use of intraductal electrohydraulic lithotripsy to fragment a large obstructing PD stone guided only by fluoroscopy without the utilization of a pancreatoscope.