Therapeutic endoscopic ultrasonography in pancreatic malignancy. Is the ERCP passè?

Endoscopic biliary stenting is the most common method of treating obstructive jaundice. But, in about 3-12% of cases, selective cannulation of the major papilla fails and surgery or percutaneous biliary drainage is required. But, percutaneous drainage requires dilated intrahepatic biliary ducts, and the rate of complications reaches 20%. including cases of peritoneal bleeding. A new technique of biliary drainage using EUS and EUS guided puncture of the bile duct (common bile duct or left hepatic duct) is now possible. Using EUS guidance and specific accessories it is now possible to create bilio-digestive anastomosis. The aim of this paper is: 1. to describe the material needed for such procedures; 2. to describe the technique of choledocoduodenal anastomosis guided by EUS; 3. to describe the technique of left hepaticogastrostomy under EUS guidance; 4. the place of these techniques today in comparison with ERCP.