Changing our perspective in endoscopic ultrasound (EUS) and ERCP

In the last 20 years, we have observed a continuous evolution in endoscopic ultrasound (EUS) as the quality of images has markedly improved, an increasing number of endoscopists have performed the technique, and it has transitioned from a technique purely for diagnostic imaging [1] to an invasive diagnostic procedure with the advent of fine needle aspiration (FNA) [2] and, finally, to a therapeutic procedure. Therapeutic options now include EUS-guided cystgastrostomy, hepaticogastrostomy, and choledochoduodenostomy [3].

The growth of EUS is similar to that seen in endoscopic retrograde cholangiography (ERCP) over the years: the birth of a new diagnostic technique that becomes a therapeutic option. This has led some endoscopists, who were the initial pioneers of these methods, to devote themselves exclusively to either ERCP or EUS. In turn, this leads young endoscopists to define two different individuals and groups: those dedicated to ERCP and those dedicated to EUS. However, with the transformation of EUS to a therapeutic procedure, several gastrointestinal endoscopists who were previously dedicated to ERCP have begun to engage in EUS, seeking to develop its “therapeutic power.” It is certain, however, that therapeutic EUS requires skills in both ERCP and EUS. The two methods, therefore, in this era, have to walk together.

What we young people therefore see in the future development of endoscopy is a base of diagnostic endoscopy that will always remain, knowledge of which is essential to correctly unlock its therapeutic power. An endoscopist that approaches therapeutic endoscopy without having learned the fundamental aspects of diagnostics will likely not achieve excellence in therapeutic endoscopy. This is especially true for endoscopy in pancreaticobiliary diseases, which has a longer learning curve.

The fact that ERCP and EUS were born in different eras has led to the development of skills in two different “boxes” for many years. Fortunately, with the passage of time and the extinction of diagnostic ERCP by non-invasive magnetic resonance imaging/magnetic resonance cholangiopancreatography (MRI/MRCP), three-dimensional computed tomography (3D-CT), and the development of therapeutic EUS, some endoscopists have been able to bridge the gap between ERCP and EUS, merging them to create one specialty. It remains true, however, that the different boxes of skill level are still recognized and only a few have been able to truly combine ERCP and EUS into one form that can be referred to as a box of diagnostic and therapeutic pancreaticobiliary endoscopy.

Unfortunately, the upcoming generation of our young endoscopists is often forced to choose between learning ERCP or EUS, and not both. We believe this mindset will prevent the advancement of pancreaticobiliary endoscopy. We strongly believe that modern gastrointestinal fellowship training should allow one to be exposed to both the ERCP and EUS techniques to ensure that the two boxes become one big box that is no longer separable and to continue the advancement of diagnostic and therapeutic endoscopy.

• References

• 1 Yasuda K, Tanaka Y, Fujimoto S et al. Use of endoscopic ultrasonography in small pancreatic cancer. Scand J Gastroenterol Suppl 1984; 102: 9-17
• 2 Karadsheh Z, Al-Haddad M. Endoscopic ultrasound guided fine needle tissue acquisition: Where we stand in 2013?. World J Gastroenterol 2014; 20: 2176-2185
• 3 Alvarez-Sánchez MV, Jenssen C, Faiss S et al. Interventional endoscopic ultrasonography: an overview of safety and complications. Surg Endosc 2014; 28: 712-734