Endoscopic ultrasound and percutaneous access for endoscopic biliary and pancreatic drainage after initially failed ERCP

Although the success rates of endoscopic retrograde cholangiopancreatography (ERCP) in accessing the bile and pancreatic ducts are quite high, failure to achieve duct access still occurs. Options in these cases have traditionally included percutaneous access or open surgical intervention. A combination percutaneous and endoscopic approach (ie, rendezvous procedure) is often used in cases of failed biliary cannulation by ERCP and occasionally for pancreatic duct access. However, this technique often results in complications and is hampered by the difficulty in coordinating schedules between interventional radiologists and endoscopists and the lack of predictability of failed ERCP access. Several groups have described the use of endoscopic ultrasonography (EUS) in accessing the ducts in cases of failed ERCP. This technique has the potential to substantially reduce the need for a percutaneous or surgical approach in many cases. This article reviews the nonsurgical methods for accessing the biliary and pancreatic ducts after failure of ERCP as well as the current status and possible future applications of EUS-assisted drainage techniques.