ABSTRACT Endoscopic management of symptomatic pancreatic stones (P‐Stones) with main pancreatic duct (MPD) strictures due to chronic pancreatitis remains challenging. For refractory P‐Stones, high‐quality evidence for endoscopic treatment remains limited, and endoscopic ultrasound‐guided pancreatogastrostomy (EUS‐PGS) is considered a potential salvage option. This single‐center retrospective study enrolled 16 consecutive patients with symptomatic refractory P‐Stones who underwent EUS‐PGS between June 2017 and June 2025, after failed transpapillary access or, in cases of surgically altered anatomy (SAA), with pancreatojejunal anastomotic stricture. Following EUS‐PGS, procedures via the endosonographically created route (ESCR) and conversion to transpapillary approaches were used to manage stones and strictures, with multiple plastic stents placed to maintain ESCR patency. Technical success was defined as P‐Stones treatment, and clinical success as symptom improvement after complete stone clearance. EUS‐PGS achieved 100% technical and 93.8% clinical success. Complete stone removal was achieved in 15 of 16 cases (93.8%), with 1 case still under treatment. Early adverse events (AEs) occurred in 18.8% of cases (pancreatic leakage, mild pancreatitis), and late AEs in 12.5% (bleeding, stent migration). The median stone removal time was 350 days. Procedural times were similar between the normal anatomy and SAA groups, although the puncture‐to‐stent interval tended to be longer in the normal anatomy group (40 vs. 25 min, p = 0.05). EUS‐PGS demonstrated high technical and clinical success for symptomatic P‐Stones, with an acceptable AE rate. However, the long treatment period, often related to the absence of dedicated devices, remains a limitation that warrants improvement.
