Because of its efficacy, safety, and minimally invasive nature, several guidelines regard endoscopic treatment combined with extracorporeal shock wave lithotripsy (ESWL) as first-line treatment for symptomatic patients with pancreatic duct stones. Small floating stones in the main pancreatic duct can be treated by endoscopic pancreatic stenting, endoscopic nasopancreatic drainage, endosco-pic pancreatic sphincterotomy, and endoscopic stone removal alone, but in most cases endoscopic treatments are combined with ESWL as appropriate. However, since endoscopic removal of pancreatic stones is technically difficult, it should be performed by an experienced pancreatobiliary endoscopist. In addition, since surgical treatment is superior to endoscopic treatments in long-term prognosis, it should be considered when ESWL and endoscopic treatments are believed to be inappropriate and ineffective.