ERCP and beyond

ERCP was first performed in 1968 by a surgeon in the United States. However, the procedure was popularized by Professors Oi and Ogoshi in Japan. Initially conceived as a diagnostic tool, ERCP quickly evolved into a therapeutic procedure. Professors Classen and Kawai are credited with performing the first biliary sphincterotomy in 1974 and Professor Soehendra is credited with performing the first biliary stent placement in 1979. Over the past 50 years, there has been significant evolution in the management of bile duct stones that has included large balloon sphincteroplasty, mechanical lithotripsy and cholangioscopy with laser or EH lithotripsy. With the exception of diffuse intrahepatic stones (Oriental cholangiohepatitis) virtually all bile duct stones can now be managed endoscopically. There has also been an evolution in biliary stenting for benign and malignant strictures that slowly evolved from various diameters of plastic stents to metal stents. Metal stents have evolved to become the standard for the management of biliary strictures. The accuracy of the diagnosis of indeterminant biliary strictures has been greatly enhanced with the advent of single operator cholangioscopy and most benign biliary strictures can be managed with endoscopic stenting. Pancreatic interventions have proven to be more challenging. The management of pancreatic stones has significantly improved with the advent of ESWL though its availability (particularly United States) has been low. While stenting for benign pancreatic strictures is technically successful in most cases, long-term success is relatively low. Randomized trials comparing endoscopic to surgical management of patients with advanced chronic pancreatitis have generally favored a surgical approach providing few interventions and more durable improvement in symptoms. While endoscopic stenting has become the standard for palliation of malignant obstructive jaundice, attempts to treat the underlying cancer have been disappointing. In the near-term future, we will see small, incremental improvements in the procedures and techniques mentioned above, but it is unlikely that we will see profound and impactful advancements such as lifetime stents, direct treatment of cancer that significantly prolongs survival and quality of life and long-term solutions to diseases of the pancreas.