Endoscopic removal of pancreatic stones

We have described endoscopic lithotripsy procedures for pancreatic stones. Endoscopic pancreatic sphincterotomy, on the other hand, is indicated for minimally invasive removal of pancreatic calculi of 6mm or less in diameter, in symptomatic patients. (When stone diameters exceed 7mm, we perform endoscopic lithotripsy after fragmentation with extracorporeal shock-wave lithotripsy.) Two approaches can be used for endoscopic pancreatic sphincterotomy: either performing it after first endoscopically widening the sphincter of Oddi, or carrying out endoscopic pancreatic sphincterotomy directly. Performing endoscopic sphincterotomy at the papilla of Vater prior to endoscopic pancreatic sphincterotomy, can avoid transient obstruction of the common bile duct by ampullary edema after the pancreatic sphincter procedure. However, safe cannulation of the pancreatic duct is easier to perform than cannulating the common bile duct, and can be performed readily by even a relatively inexperienced endoscopist. After endoscopic pancreatic sphincterotomy, we insert a basket catheter into the pancreatic duct along a guide wire in order to remove pancreatic stones while protecting the wall of the pancreatic duct. Significant adverse effects of endoscopic pancreatic sphincterotomy may include bleeding, acute pancreatitis, and perforation. Endoscopic treatment of pancreatolithiasis is well established and provides good results. However, its limitations require flexibility to convert to open surgery if necessary to avoid missing a therapeutic opportunity.