Chronic Pancreatitis with Stones: What is the Best Way to Treat?

Pancreatic duct stones (PDS) are a common complication of chronic pancreatitis (CP). PDS can lead to duct obstruction and cause chronic abdominal pain. Ductal stone clearance, as well as short and long-term pain relief, is the cornerstone of endoscopic or surgical treatment. A step-up approach seems reasonable in pancreatic duct stone clearance. Extracorporeal shock wave lithotripsy (ESWL) combined with standard endoscopic retrograde cholangiopancreatography (ERCP) is as effective as a surgical approach for treating painful CP with less morbidity and medical costs. Therefore, endotherapy is considered a first-line therapy in selected patients. In case of insufficient pancreatic ductal clearance or strictures, advanced endoscopic techniques, per-oral pancreatoscopy (POP) with intraductal lithotripsy and/or endoscopic ultrasound-guided ductal drainage (EUS-PDD), will expand the role of the endoscopic approach. Because these new techniques are challenging, technically complex, and with high adverse events (AEs), they should be reserved for advanced tertiary care centers. Although there is increasing data that early surgical intervention may lead to better pain control and pancreatic duct stone clearance, surgery is reserved for patients failing endotherapy or patients with suspected malignancy.