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A 63-year-old man with heavy alcohol consumption was referred to our institution for upper abdominal pain, weight loss, and a computed tomography scan showing signs of chronic pancreatitis (parenchymal calcifications and atrophy of the pancreatic body/tail). A magnetic resonance cholangiopancreatography was performed, showing Wirsung dilation, namely of the tail, and an abrupt stop in the pancreatic body of unknown cause (▶Fig. 1). Endoscopic ultrasound revealed an intraductal stone in the pancreatic body (7.4mm), and a dilated Wirsung in the body and tail (▶Fig. 2). The patient underwent endoscopic retrograde cholangiopancreatography (ERCP). Pancreatography showed an irregular Wirsung contour in the head and irregularity in the body–tail transition, suggestive of an intraductal stone (▶Fig. 3). Pancreatic sphincterotomy was performed, and the calculus was crossed with the guidewire, but it was impossible to cross it with a 6-mm dilation balloon. After hydrostatic balloon dilation of the pancreatic head (up to 6mm), a pancreatoscope (Spyglass Direct Visualization System; Boston Scientific, Marlborough, Massachusetts, USA) was advanced over a 0.025-inch guidewire to reach a large intraductal stone of 7–8mm in size (▶Fig. 4, ▶Video1). After targeting the stone, laser bursts (Holmium laser, Auriga XL; Boston Scientific) of less than 5 seconds were delivered through the aqueous medium using a 365-μm diameter fiber (energy level 1200mJ; frequency of 12Hz). After stone fragmentation, ductal clearance was achieved with an 8.5-mm extraction balloon. Two pancreatic stents (12 cm, 7 Fr) were placed. ▶ Fig. 1 Magnetic resonance cholangiopancreatography, showing an abrupt stop at the pancreatic body, followed by major dilation of the remaining body and tail. ▶ Fig. 2 Endoscopic ultrasound revealed a large intraductal stone in the pancreatic body (7.4mm), and a dilated Wirsung in the body and tail.

Pancreatoscopy-guided laser lithotripsy in a patient with difficult ductal stone