| ERCP represents the standard of care for the management of bile duct stones, palliation of malignant obstructive jaundice and evaluation of indeterminate biliary strictures. Initially, there was enthusiasm for ERCP in the management of pancreatic stones and strictures. ESWL has become the primary modality for fragmentation of pancreatic stones relegating ERCP to a complimentary role for fragment clearance. Improvement is needed in the treatment of pancreatic duct strictures. Single operator cholangioscopy has improved the diagnosis of indeterminate strictures and the management of impacted bile duct stones. EUS is an important diagnostic modality in pancreatobiliary diseases which includes evaluation for chronic pancreatitis, evaluation of cysts and staging and tissue acquisition in pancreatic masses. Therapeutically, EUS guided drainage of pancreatic fluid collections is now standard of care. Celiac plexus neurolysis is useful in the management of pain in patients with pancreatic malignancy. Most recently, EUS guided biliary drainage has supplanted PTC for biliary drainage in cases of failed ERCP. What are the future trends in pancreatobiliary endoscopy? Advances to reduce infection transmission from contaminated duodenoscopes. A single use duodenoscope is approved in the US. In parallel, manufactures are re-designing the distal tip to improve cleaning and techniques and technologies are progressing rapidly to prevent or eliminate biofilm. Improvement in the endoscopic management of pancreatic diseases is needed but it is unclear whether new stent designs will significantly improve the management of pancreatic strictures. The future of EUS is promising. Effective techniques for EUS guided treatment of pancreatic cysts would be a major advance. There will be continued refinement in EUS guided biliary drainage. Could EUS guided pancreatic drainage compete with lateral pancreatojejunostomy to improve drainage in patients with chronic obstructive pancreatitis. A critical area for future research is endoscopic intervention in acute necrotizing pancreatitis to prevent disconnected duct syndrome. Pancreatobiliary endoscopy has a very bright future. A very important trend which is fueling this progress is the full integration of the ERCP and EUS. |
