A case of endoscopic therapy using electrohydraulic lithotripsy under peroral pancreatoscopy via the minor papilla

Recently, peroral pancreatoscopy (POPS) and electrohydraulic lithotripsy (EHL) have been identified as useful endoscopic treatment options for refractory pancreatic calculi 1. However, owing to the technical challenges, POPS–EHL via the minor papilla has rarely been described. We report a case of refractory pancreatic calculi associated with incomplete pancreatic divisum successfully treated using POPS (eyeMAX 9 Fr; MICRO-TECH, Nanjing, China) and EHL via the minor papilla. A 66-year-old man with idiopathic chronic pancreatitis presented with obstructive pancreatitis caused by pancreatic body calculi refractory to conservative therapy (Fig. 1). Endoscopic retrograde cholangiopancreatography (ERCP) via the major papilla opacified the dorsal duct; however, neither a guidewire nor an endoscopic pancreatic stent (EPS) could initially traverse the suspected fusion segment. An EPS was placed proximally for post-ERCP pancreatitis prophylaxis. Because the stent could not cross the suspected fusion area, magnetic resonance cholangiopancreatography was subsequently performed and, in combination with ERCP findings, confirmed incomplete pancreatic divisum. Minor papilla cannulation enabled access to the Santorini duct, and pancreatography demonstrated an impacted pancreatic calculus causing ductal obstruction in the dominant dorsal duct. Although a guidewire could be advanced to the ductal segment at the level of the stone, the pancreatic stent could not be passed across the obstructed segment even after endoscopic minor papilla sphincterotomy, and it was therefore placed proximally (Fig. 2). Extracorporeal shockwave lithotripsy was attempted but failed, after which stepwise ductal preparation was performed. Following balloon dilation, POPS was smoothly advanced through the Santorini duct (Fig. 3), allowing the direct visualization of a white pancreatic calculus, which was successfully fragmented using the EHL (Video 1). Adequate lithotripsy and POPS passage were confirmed, and a prophylactic EPS was placed. No complications occurred (Fig. 4). Although POPS occasionally causes severe complications 2, careful anatomical assessment, and stepwise ductal preparation may help enhance procedural safety when performing POPS–EHL. EndoscopyUCTNCodeCCL₁AZ₂AG EndoscopyUCTNCodeTTT₁AR₂AL Article published online: 17 February 2026 © 2026. 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/). Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany