Endoscopic ultrasound-guided anterograde cholangiopancreatography.

Endoscopic retrograde cholangiopancreatography (ERCP) may fail in 10-15% of cases. A growing percentage of such cases are due to the inaccessible papilla after gastric bypass surgery for the treatment of obesity. Endoscopic ultrasonography (EUS) offers an alternative route of access to the bile and pancreatic ducts. Using the curved linear array echoendoscope, access to the bile and pancreatic ducts is possible under real-time EUS guidance. The route of access is 'anterograde', in contrast to the 'retrograde' approach of ERCP. We have coined the term "EUS-guided anterograde cholangiopancreatography (EACP)" to cover the spectrum of EUS-guided techniques for accessing and draining the bile and pancreatic ducts. These techniques are reviewed in this paper. The literature has validated the feasibility of EACP but complication rates have been high; the safety profile of EACP must improve. This will require tools, designed for EUS-guided applications, that enable safer transenteric access and drainage.