Pancreatoscopic Laser Lithotripsy as Salvage Endotherapy in Therapeutic Exhaustion: Outcomes from a Pancreatic Endotherapy Cohort—The PanClear Study
Year: 2026
Type: article
Study design: Observational Study
Abstract: Background Obstructing pancreatic calculi refractory to standard endoscopic retrograde cholangiopancreatography (ERCP) represent a therapeutic challenge, particularly in patients who decline surgery. We report outcomes of pancreatoscopy-guided holmium laser lithotripsy as salvage endotherapy in patients with therapeutic exhaustion during pancreatic ERCP. Methods Retrospective analysis of 47 patients undergoing pancreatic endotherapy at a tertiary center. Therapeutic exhaustion was defined as failure to achieve guidewire or accessory advancement beyond the obstructing calculus despite standard ERCP techniques. All patients meeting this criterion underwent pancreatoscopy-guided holmium laser lithotripsy. Primary outcome was laser-assisted technical success (cannulation and pancreatic stent placement). Secondary outcomes included stone clearance, pain response (Numeric Rating Scale, NRS 0–10), adverse events, and surgical crossover. Results Of 47 patients (mean age 37.2 years, M:F 33:14) undergoing pancreatic endotherapy, 16 (34%) met criteria for therapeutic exhaustion and underwent laser lithotripsy. The laser group had significantly larger stones than the standard endotherapy group (mean 10.8 vs. 4.6 mm, p < 0.001). Surgery was declined due to patient preference (62.5%) or comorbidities (37.5%). Laser-assisted technical success was achieved in 14/16 (87.5%). Complete stone clearance improved from 31.2% after the index procedure to 43.8% at last follow-up (mean 12.1 months). Proximal + distal distribution predicted incomplete clearance (12.5% vs. 71.4% proximal-only, p = 0.041). Baseline NRS improved from 7.2 to 0.5. Complete clinical response was achieved in 15/16 (93.8%); all technically successful cases achieved complete response. Adverse events occurred in 3/16 (18.8%): postprocedure pancreatitis in 1, pancreatic infection in 2. Conclusion Pancreatoscopy-guided laser lithotripsy is an effective salvage strategy in chronic pancreatitis patients with therapeutic exhaustion who decline surgery. Despite incomplete stone clearance in the majority, clinically meaningful symptom control was achieved in 93.8%. Proximal + distal stone distribution predicted incomplete clearance without compromising symptom outcomes, supporting ductal decompression rather than complete stone eradication as the primary therapeutic goal. Publication History Article published online: 27 August 2026 © 2024. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/) Thieme Medical and Scientific Publishers Private Limited A-13A, Graphix Tower 1, 6th floor, Sector 62, Noida 201309, Uttar Pradesh, India
Source: Journal of Digestive Endoscopy
Institution: Rajagiri Hospital
Language: English
Subfield: Surgery
Field: Medicine
Domain: Health Sciences
Open Access status: diamond
OpenAlex ID: W7204437296