LAUSR

Figure 2. Preoperative CT scan showing a significantly dilated pancreatic duct (arrow). Figure 1. Endoscopic retrograde pancreatography showing multiple stones in the pancreatic duct (arrows). Chronic pancreatitis is a progressive inflammatory disease, which leads to intraductal stones in up to 90% of patients with this disease. Intraductal stones can cause ductal obstruction with subsequent intraductal hypertension, resulting in chronic pancreatic pain. The aim of interventional endoscopy is to alleviate pain through restoration of pancreatic flow by extracting pancreatic duct (PD) stones. However, the success rates of endoscopic retrograde pancreatography (ERP) and mechanical lithotripsy are disappointing (w9%), especially if large stones are present. Recently, per-oral transpapillary pancreatoscopy was successfully combined with electrohydraulic lithotripsy (EHL) to achieve a ductal clearance rate of 43% to 100%. Here, we report the case of an 18-year-old woman with chronic hereditary pancreatitis (SPINK1 mutated). Given her recurrent episodes of acute pancreatitis, chronic pancreatic pain, and PD stones in the prepapillary region, ERP was performed with sphincterotomy and extraction of 3 small stones (Fig. 1). Her pain persisted, with ongoing PD dilation and a large stone remaining in the pancreatic head; therefore, a duodenal-preserving pancreatic head resection was performed 9 months later (Figs. 2 and 3). After a symptom-free interval of 22 months, the patient’s pain recurred with a new onset of acute pancreatitis episodes. MRI and EUS showed a PD of almost 10 mm with several intraductal stones distal to a causative anastomotic stricture (Fig. 4). An EUS-guided pancreaticogastrostomy was performed, and a 7F transgastric stent was inserted. Six weeks later, the access tract was dilated with a balloon up to 8 mm, and a 10F 5-cm plastic stent was placed to secure the transgastric access (Fig. 5, Video 1, available online at www.VideoGIE.org). Two months later, the PD was transgastrically accessed with a spyscope, and a large intraductal stone was clearly identified (Fig. 6). EHL was used to completely fragment the PD stone, after which a guidewire could be passed through the main PD and the papilla into the duodenum. This route was secured with two 7F stents that were placed through the stone fragments to the prepapillary region (Fig. 7).