Pancreatic Duct Stones Research Articles

Recent Advances in Management of Chronic Pancreatitis

Treatment for chronic pancreatitis (CP) should be started early to prevent further pancreatic fibrosis and managed with a multidisciplinary approach to prevent complications and to maintain a good quality of life. The management strategies of CP can be divided into medical, endoscopic, and surgical treatment. The role of pancreatic enzymes and antioxidants for pain relief is not clearly defined, but their role in maintaining nutritional support by correcting exocrine insufficiency is well established. Endoscopic treatment is applied for resolution of pancreatic or bile duct strictures, clearance of pancreatic duct stones, and pseudocyst drainage. Endosonography-guided celiac plexus or celiac ganglia block for pain relief are known to be safe procedures but evidence for their effectiveness is still lacking. Surgery is commonly recommended when endoscopic therapy fails or there is suspicion of malignancy. New evidence-based guidelines for the management of CP are needed.

Chronic Pancreatitis: Laser Technologies for Double Balloon Enteroscopy of Pancreatojejunostomy Complications and Reducing the Peripheral Ductal Hypertension

Introduction: Drainage procedures are conventional modifications of surgical treatment for chronic pancreatitis (CP). Nevertheless, the relapse of chronic abdominal pain after the surgery occurs in more than 50% of cases. Aim: To explain the pathogenesis of intractable abdominal pain following the traditional surgery of CP and to propose new laser and double balloon enteroscopy (DBE) technologies for its relief. Materials and methods: Pancreatojejunoanastomosis (PJA) lumen was examined using the videoenteroscope EN-450P5/20 (Fujifilm group, Fujinon Co, Tokio, Japan) for the first time in the world. All 20 patients had had CP and underwent an elective surgery earlier. During 2010-2014, 198 resections were performed, with 159 (80,3%) being laser drainage procedures. Results: DBE revealed strictures of PJA and open common bile duct, residual pancreatoliths in PJA lumen, and PJA leakage. After DBE laser lithotripsy of pancreatoliths in tributary ducts, a free outflow of pancreatic juice from the lumen was obtained. DBE findings were supported by the morphological study of excised pancreatic specimen, CT-scans before the surgery and the staining of PJA lumen. All these data suggest that 17,7% of CP patients along with magistral ductal hypertension had peripheral ductal hypertension (PDH), which seems to be a new cause of severe abdominalgia. The latter arises when pancreatoliths block the orifices of tributary ducts. For reducing the PDH, we have developed a new surgical procedure named «laser cylindric wirsungectomy» (n=26) and proposed our own classification of pancreatic duct stones. Conclusions: DBE has great opportunities for the diagnosis of complications and their mini-invasive treatment after pancreatojejunostomy (PJ). Laser technologies are considered to be a new approach to the effective open and mini-invasive surgical treatment of CP.

膵管プレカット法が有効であった選択的膵管挿入に難渋した膵石症の1例

症例はアルコール性慢性膵炎症例の53歳の女性である．膵頭部主膵管内の膵石による腹痛発作のため，ESWLを施行したが，破砕困難なためERCPによる膵石除去を試みた．主膵管末端部の狭窄と屈曲により選択的膵管挿入が困難なため，先端長0mmの通常型パピロトームを用いて膵管プレカットを行い，深部挿入に成功した．バスケットカテーテルで膵石摘出を試みたが，把持できないため膵管ステントを挿入して一旦終了した．膵管プレカット後，軽症膵炎が発症したが，保存的治療により治癒し，5日後に再度ERCPを施行した．膵管ステントを抜去し，バスケットカテーテルで膵石除去に成功した．その後は外来で約半年間経過観察中であるが，自覚症状は認めていない．選択的膵管挿入が困難な症例をときに経験するが，その対処法に関する報告は少なく，対処法のひとつとして膵管プレカット法が有用な方法であることが示唆された．

Endoscopic therapy in chronic pancreatitis: current perspectives.

Endoscopic therapy in chronic pancreatitis (CP) aims to provide pain relief and to treat local complications, by using the decompression of the pancreatic duct and the drainage of pseudocysts and biliary strictures, respectively. This is the reason for using it as first-line therapy for painful uncomplicated CP. The clinical response has to be evaluated at 6–8 weeks, when surgery may be chosen. This article reviews the main possibilities of endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) therapies. Endotherapy for pancreatic ductal stones uses ultrasound wave lithotripsy and sometimes additional stone extractions. The treatment of pancreatic duct strictures consists of a single large stenting for 1 year. If the stricture persists, simultaneous multiple stents are applied. In case of unsuccessful ERCP, the EUS-guided drainage of the main pancreatic duct (MPD) or a rendezvous technique can solve the ductal strictures. EUS-guided celiac plexus block has limited efficiency in CP. The drainage of symptomatic or complicated pancreatic pseudocysts can be performed transpapillarily or transgastrically/transduodenally, preferably by EUS guidance. When the biliary stricture is symptomatic or progressive, multiple plastic stents are indicated. In conclusion, as in many fields of symptomatic treatment, endoscopy remains the first choice, either by using ERCP or EUS-guided procedures, after consideration of a multidisciplinary team with endoscopists, surgeons, and radiologists. However, what is crucial is establishing the right timing for surgery.

Duodenum-and bile duct-preserving pancreatic head resection

Duodenum-and bile duct-preserving pancreatic head resection is rarely carried out in China due to its complexity.From September 2013 to May 2014,5 patients (1 with mass-forming pancreatitis of the head of the pancreas,2 with mucinous cystadenoma of the pancreatic duct combined with focal cancerous,2 with chronic pancreatitis and pancreatic duct stones) received duodenum-and bile duct-preserving pancreatic head resection at the Zhangzhou Zhengxing Hospital.The lesions of the 5 patients were resected by the Takada method and then the pancreatic duct was reconstructed in situ.One patient received T-tube drainage of the bile duct.The operation time was 210-330 minutes,and the mean volume of intraoperative blood loss was 300 mL (range,100-500 mL).The stones of 2 patients were antler-shaped,and the other 3 patients were with tumor.No patients died intraoperatively.One patient was complicated by pancreatic leakage and 1 by bile leakage after the operation,respectively,and they were cured by non-surgical treatment.Patients were followed up for 3-11 months,and no abnormal glucose metabolism,common bile duct stricture,chronic indigestion and tumor recurrence occurred.The Takada method is safe and effective for the treatment of mass-forming pancreatitis of the head of the pancreas,benign lesions of the head of the pancreas and low-grade malignant tumor of the head of the pancreas. Key words: Pancreatic head resection; Duodenum preservation ; Bile duct ; Pancreatic duct

Role of ERCP SpyGlass® Electrohydraulic Lithotripsy in Patients With Chronic Pancreatitis and Pancreatic Duct Calculi Causing Duct Obstruction: A Case Series

Introduction: ERCP with SpyGlass® cholangioscopy and electrohydraulic lithotripsy (EHL) is an established treatment for large common bile duct stones. However, the role of SpyGlass® EHL in treating patients with pancreatic duct calculi has yet to be well studied. The current management of pancreatic duct stones consists of extracorporeal shock wave lithotripsy (ESWL) or surgical intervention. The purpose of this case series is to study the safety and efficacy of SpyGlass® EHL in patients with pancreatic duct calculi. Methods: In patients with chronic pancreatitis and pancreatic duct stones, we performed ERCP with SpyGlass® pancreatoscopy and EHL in an attempt to break the calculi into smaller fragments in order to relieve the pancreatic duct obstruction. Consecutive patients with pancreatic duct stones were included in the study. Pancreatic duct stents were placed following lithotripsy in all patients. The stents were later removed at a 4-6 week interval after the procedure. Results: ERCP with SpyGlass® EHL was performed in 7 patients with chronic pancreatitis and stones. Two patients were relieved of their obstruction after only 1 procedure. Four patients required 2 procedures, and 1 patient required 3 procedures. ERCP with SpyGlass® EHL was successful in relieving the main pancreatic duct obstruction in 5 patients. The remaining 2 patients were referred to a multidisciplinary pancreas team for ESWL therapy. However, both these patients ended up requiring surgery. One patient received Puestow’s procedure while the other received Berger’s operation. Two patients had pain following the ERCP and EHL treatment and required overnight hospitalization. One patient had mild pancreatitis. No other complications were reported. Conclusion: ERCP with EHL appears to be a safe and effective therapeutic procedure in the majority of patients with chronic pancreatitis and pancreatic duct calculi. Larger studies are needed to validate the results of our pilot study.

Stubborn as a Stone: A Case of Hereditary Pancreatitis Causing Difficult-to-Manage Pancreatic Stone and Review of Endoscopic and Surgical Management Options

Introduction: Cystic fibrosis is an autosomal recessive condition caused by a deletion on the cystic fibrosis transmembrane conductance regulator (CFTR) gene (F508del) on chromosome 7. While carriers of one CFTR gene mutation are often asymptomatic, compound heterozygous mutations of the CFTR gene is 1 of the 3 genetic mutations associated with hereditary pancreatitis. We present a case of a patient with CFTR gene mutation causing a large pancreatic stone requiring multidisciplinary management. A 24-year-old man presented to our clinic for a second opinion consultation for increasing frequency of acute recurrent pancreatitis since age 11. He previously underwent endoscopic retrograde cholangiopancreatography (ERCP) with failed pancreatic duct (PD) stenting due to stent migration and post-ERCP pancreatitis. Due to his frequent episodes of debilitating pain, patient had developed a dependence on hydromorphone, marijuana, and illegally obtained psychotropic medications. On subsequent work-up, patient was found to have 2 pathogenic mutations on his CFTR gene: one severely pathogenic (F508del) and one mildly pathogenic (2789+2insA). This combination is thought to cause pancreatitis or other forms of atypical cystic fibrosis. ERCP showed distal PD dilation to 9 mm with multiple filling defects. The proximal PD was obstructed by a large 29 mm PD stone within the proximal neck/distal body of the pancreas. Multiple small stones were removed via balloon sweep, but attempted pancreatoscopy of the largest stone was unsuccessful. After a subsequent attempt with stent placement failed to alleviate symptoms, repeat ERCP was done with extracorporeal shockwave lithotripsy (ESWL). Balloon sweep only delivered a small amount of stone debris but occlusion pancreatogram did not show delineation of the prior stone. The patient remained symptomatic and subsequent ERCPs were unsuccessful in advancing a guidewire into the PD across the neck/body region. The patient eventually required operative management to decompress the dilated pancreatic duct and successfully underwent a Frey procedure. On 8-month follow-up, the patient is pain free and has begun rehabilitation. He is no longer using illicit substances and has regained a BMI of 24.2 kg/m3 from a nadir of 18.5 kg/m3 prior to the procedure. Hereditary pancreatitis is an uncommon disorder caused by mutations in the SPINK, PRSS, and CFTR genes leading to significant physical and psychiatric distress from recurrent pancreatitis. Genetic testing should be undertaken in cases of undiagnosed recurrent pancreatitis. While many patients can be managed endoscopically, alternative interventions such as ESWL and surgical management must be considered in difficult cases.

PTH-099 External Shockwave Lithotripsy (eswl) Of Pancreatic Calculi Improves Pain Related To Chronic Calcific Pancreatitis

IntroductionChronic calcific pancreatitis is associated with the development of pancreatic ductal calculi. The calculi can lead to the blockage of the pancreatic duct which can increase the pressure in the...

PTH-001 Use Of Pancreatic Stents In Endoscopic Retrograde Cholangio-pancreatography

IntroductionThe indications for placing pancreatic stents (PS) during endoscopic retrograde cholangio-pancreatography (ERCP) include pancreatic duct stones and strictures, prevention of post-ERCP pancreatitis and as an aid to biliary cannulation, where...

Sa1451 Systematic Process Improvement Applied to Scheduling and Performing ESWL Followed by ERCP for Large Pancreatic Duct Calculi: Waste Reduction and Quality Improvement

Aside from surgical drainage of the pancreatic duct, extracorporeal shockwave lithotripsy (ESWL) followed by ERCP is an accepted treatment modality for large pancreatic duct stones. In our institution, ESWL is performed exclusively by the Urology service. Due to the number of services and resources involved, scheduling patients for ESWL/ERCP has been difficult and has resulted in a high defect rate, long patient wait times and increased waste, all of which negatively impact quality of care. We sought to determine whether application of an institution-wide systematic method for process improvement to the entire process of scheduling and performing ERCP/ESWL could result in decreased waste and therefore higher quality of care.

Efficacy of duodenum-preserving pancreatic head resection for the treatment of chronic pancreatitis combined with pancreatic duct stones: a prospective analysis

Objective To investigate the efficacy of duodenum-preserving pancreatic head resection (DPPHR) for the treatment of chronic pancreatitis combined with type Ⅰ and Ⅲ pancreatic duct stones.Methods The clinical data of 55 patients with chronic pancreatitis and type Ⅰ and Ⅲ pancreatic duct stones who were admitted to the People's Hospital of Hunan Province from June 2008 to June 2013 were prospectively analyzed.All the patients were randomly divided into the pancreatoduodenectomy (PD) group (27 patients) and the DPPHR group (28 patients).There were 18 patients with chronic pancreatitis and type Ⅰ pancreatic duct stones and 9 patients with chronic pancreatitis and type Ⅲ pancreatic duct stones in the PD group.There were 16 patients with chronic pancreatitis and type Ⅰ pancreatic duct stones and 12 patients with chronic pancreatitis and type Ⅲ pancreatic duct stones in the DPPHR group.Patients in the PD group received PD + Child anastomosis + end-toside pancreato jejunal anastomosis + pancreatic stent placement + end-to-side cholangiojejunostomy.Patients in the DPPHR group received free of duodenum + pancreatic duct incision + resection of pancreas at 1 cm ahead of the pancreatic duct + extraction of the pancreatic duct stones + pancreaticoduodenal Roux-en-Y anastomosis.Patients were followed up via out-patient examination till December 2013.The measurement data were analyzed using the t test or Mann-Whitney U test,and the count data were analyzed using the chi-square test.Results During the operation,2 patients in the PD group were converted to the DPPHR group and 1 patient in the DPPHR group was converted to the PD group.No patient died during the perioperative period,and the symptoms including abdominal pain and diarrhea were alleviated at postoperative week 2.The operation time,blood loss,duration of postoperative hospital stay,total expenses and incidence of complications were (7.5 ± 1.6) hours,(460 ± 88) mL,(18.0 ± 3.5) days,(7.8 ± 2.1) × 104 yuan,19.2％ (5/26) in the PD group,and (4.0 ± 1.0) hours,(120 ± 36) mL,(9.5 ± 2.9) days,(3.9 ± 1.2) × 104 yuan,3.4％ (1/29) in the DPPHR group,there were no significant differences in the operation time,blood loss,duration of hospital stay,total expenses and incidence of complications between the 2 groups (t =9.358,11.365,6.325,8.647,x2 =3.976,P ＜ 0.05).Fifty-three patients were followed up,with the median time of 33 months (range,6 months to 5 years).No patient died during the follow-up.Twenty-four patients in the PD group were followed up,2 patients had slight abdominal pain,1 patient had severe abdominal pain due to pancreatic duct stenosis,and the symptom was alleviated after resection of partial pancreas ; the condition of 12 patients was improved among the 19 patients with diabetes.Twenty-nine patients in the DPPHR group were followed up,2 patients had slight pain; the condition of 16 patients were improved among the 22 patients with diabetes.Conclusion DPPHR is an ideal surgical procedure for patients with chronic pancreatitis and type Ⅰ and Ⅲ pancreatic duct stones. Key words: Chronic pancreatitis ; Pancreatic duct stones; Typing; Duodenum-preserving pancreatic head resection; Pancreatoduodenectomy

Surgical procedure selection for chronic pancreatitis

Objective To investigate the surgical procedure selection for chronic pancreatitis.Methods The clinical data of 80 patients with chronic pancreatitis who were admitted to the Peking University First Hospital from January 2000 to August 2013 were retrospectively analyzed.Thirty-eight patients were with or without pancreatic duct stone,and the dilation of the pancreatic duct was above 7 mm,44 patients were with common bile duct dilation,32 patients were with inflammatory mass in the head of the pancreas,and 3 patients were with splenomegaly and esophagogastric varices.Surgical procedures were selected according to the symptoms and results of imaging examination.The remission or recurrence of pain was judged according to the visual analog scales.Patients were followed up via out-patient examination,mail or phone call till December 2013.Results Choledochojejunostomy was done on 27 patients,Partington-Rochelle pancreaticojejunostomy on 24 patients,PartingtonRochelle pancreaticojejunostomy + choledochojejunostomy on 6 patients,pancreaticoduodenectomy on 7 patients,resection of the body and tail of the pancreas on 4 patients,Beger's procedure on 3 patients,splenectomy on 3 patients,Frey's procedure + fenestration of bile duct in the head of the pancreas on 3 patients,Frey's procedure on 2 patients,common bile duct exploration + T tube drainage on 1 patient.The remission rate of abdominal pain was 95.2％ (60/63).One patient died of abdominal infection and multiple organ dysfunction syndrome perioperatively.Three patients were complicated with abdominal infection,2 with pancreatic fistula,1 with biliary fistula and 1 with abdominal bleeding.All the complications were cured by conservative treatment.Seventy-nine patients were followed up,and the mean time of follow-up was 58.6 months (range,4-156 months).Thirty patients had recurrence or new onset of abdominal pain,and the recurrence rate was 38.0％ (30/79).Of the 32 patients with inflammatory mass in the head of the pancreas,17 received choledochojejunostomy,and the recurrence rate of abdominal pain was 9/17 ; the other 15 patients received pancreatoduodenectomy,Beger' procedure or Frey's procedure,and the recurrence rate of abdominal pain was 1/15.Of the 41 patients without inflammatory mass,10 received choledochojejunostomy,and the recurrence rate of abdominal pain was 7/10; 30 received PartingtonRochelle pancreaticojejunostomy,and the recurrence rate of abdominal pain was 33.3％ (10/30).Conclusions Complete drainage could relieve the symptoms for patients with pancreatic duct dilation.Surgical resection or combined surgical procedure is effective for the treatment of patients with inflammatory mass in the head of the pancreas. Key words: Chronic pancreatitis; Surgical procedure, operative; Drainage; Resection

Endotherapy for chronic pancreatitis: advantages and limitations

Chronic pancreatitis (CP) is pathologically characterized by fibrosis of pancreatic parenchyma.Treatment of CP is to alleviate pain and preserve pancreatic endo-/exo-crine function.Endotherapy,as a micro-invasive method,has been testified to be efficient and safe for pancreatic duct stones and stenosis,pancreatic pseudocyst and common bile duct stenosis secondary to CP.It has partially replaced the role of surgery in CP therapy.Whether endoscopic or surgical treatment has its limitations,CP treatment needs medicine,surgery,endoscopy,anesthesia,nutrition and other disciplines together to develop the best solution to improve the quality of life. Key words: Chronic pancreatitis; Endotherapy

Su1713 Endoscopic Therapy in Chronic Pancreatitis: What Are the Factors Associated With Successful Response ?

Su1713 Endoscopic Therapy in Chronic Pancreatitis: What Are the Factors Associated With Successful Response ?

Su1711 Management of Pancreatic Ductal Leaks in Patients With Chronic Pancreatitis

Su1711 Management of Pancreatic Ductal Leaks in Patients With Chronic Pancreatitis

Successful removal of a pancreatic duct stone in a patient with Whipple resection, using a short single-balloon enteroscope with a transparent hood

Endoscopic retrograde cholangiopancreatography (ERCP) is a challenging procedure, especially in indications involving the pancreatic duct in patients with Whipple resection [1] [2] [3]. Identification of the pancreaticojejunal anastomotic site is difficult because of the location and small size of the anastomosis, and interference from the jejunal folds. We proposed that a transparent hood would be effective for retraction of the folds to a suitable distance from the intestinal wall. Here, we report on the successful removal of a pancreatic duct stone in a patient with Whipple resection, using a prototype short, single-balloon enteroscope (SBE; working length, 152 cm; outer diameter 9.2 mm; working channel diameter 3.2 mm; SIF-Y0004-V01, Olympus Medical Systems, Tokyo, Japan) with a transparent hood.

Endoscopic Retrograde Cholangiopancreatography With Per Oral Pancreatoscopy for Calcific Chronic Pancreatitis Using Endoscope and Catheter-Based Pancreatoscopes

Per oral pancreatoscopy (POP) with electrohydraulic lithotripsy (EHL) or laser lithotripsy (LL) permits stone fragmentation and removal during endoscopic retrograde cholangiopancreatography. Our study evaluates the safety and efficacy of POP in patients with main pancreatic duct (PD) stones. This was a cohort study of patients undergoing POP with EHL/LL for PD stones between January 2000 and March 2011. Technical success was defined as complete or partial stone clearance, and clinical success as greater than 50% reduction in opiate use, pain, or hospitalizations. Forty-six patients underwent POP for PD stones using a 10F cholangioscope (POP-Endo) (n = 31) or catheter-based system (POP-Cath, n = 15). Electrohydraulic lithotripsy/LL was performed in 39 (85%) of 46 patients. Stone extraction without EHL or LL was performed in 7 (15%) of 46 patients. Technical success for POP-Endo versus POP-Cath was 27 (87%) of 31 versus 15 (100%) of 15 patients (P = 0.29). Complete clearance was achieved in 21 (68%) of 31 versus 11 (73%) of 15 patients, respectively (P = 0.519). Per oral pancreatoscopy-related complications were found in 10%. Follow-up in 43 (93%) of 46 patients was a median of 18 months (range, 1-60 months). Overall clinical success was 74%. Per oral pancreatoscopy-guided endotherapy leads to partial or complete stone clearance in most patients with PD stones. The technical success rates between POP-Endo versus POP-Cath systems appear similar and are associated with clinical improvement in most patients.

Laparoscopic Frey Procedure for Chronic Pancreatitis

Chronic pancreatitis can be relentless, resulting in debilitating pain and endocrine and exocrine insufficiency. Medical interventions are used initially but when these fail, surgical therapy is often indicated. Surgical options include resection, drainage, and hybrid procedures. Hybrid procedures, such as the Frey procedure are associated with improved outcomes in select patients. These advantages are even greater when the Frey is performed laparoscopically. A patient with chronic pancreatitis was referred to our clinic. Preoperative imaging revealed a dilated main pancreatic duct with multiple large pancreatic duct stones. She subsequently underwent a laparoscopic Frey procedure. The patient did very well with no pancreatic leak, wound infection, or delayed gastric emptying. She was discharged home on postoperative day 6, symptom free with no narcotic requirement. For patients in whom the laparoscopic Frey procedure is possible, it can be used to treat chronic pancreatitis with the benefits of a minimally invasive approach.

Analysis of risk factors for pancreatic duct stones formation in patients with alcoholic chronic pancreatitis

BackgroundAlcoholic chronic pancreatitis (ACP) is the dominant cause of chronic pancreatitis (CP). As a main complication of CP, the formation of pancreatic duct stones (PDS) compromises pancreatic function and symptomatic patients are often subjected to aggressive treatments. The present study aimed to identify PDS risk factors in patients with ACP. MethodsA retrospective analysis of 93 ACP patients was performed; patients were divided into two groups: ACP with PDS (n = 48) and ACP without PDS (n = 45). Fourteen potential factors were analyzed by univariate and multivariate analyses to identify independent risk factors of PDS formation in ACP patients. A comparison of demographic and clinical characteristics between ACP patients with PDS and non-ACP patients with PDS (n = 43) was also carried out. ResultsACP accounted for 47.7% (93/195) of CP in this cohort. Among ACP patients, the morbidity of PDS was 51.6% (48/93). Significant risk factors of PDS formation for ACP patients included duration of drinking ≥24.7 years (OR, 9.036; 95% CI, 2.737–29.837; p < 0.001); daily alcohol consumption ≥147.0 g (OR, 3.147; 95% CI, 1.040–9.522; p = 0.042); and MPD narrowing (OR, 7.245; 95% CI, 2.205–23.811; p = 0.001). Shorter periods between diagnosis and PDS formation (PDP) were observed in ACP patients than non-ACP patients. ConclusionsAlcohol consumption accelerates the progression of PDS formation in patients with CP.

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.