Biliary surgery without the surgeon!

Since the introduction of endoscopic retrograde cholangiopancreatography in the 1970s and of endoscopic sphincterotomy (EST) in 1974, endoscopic techniques for the diagnosis and therapy of biliary and pancreatic disorders have proliferated. Although some procedures have become part of routine practice, for example EST for postcholecystectomy bile duct stones and stent insertion for inoperable biliary strictures, the place of others is unclear at present and should be evaluated by prospective randomized clinical trials. The choice of either an endoscopic or a transhepatic approach for biliary disease is usually dictated by local expertise, but these should be regarded as complementary rather than competing techniques, and complex biliary problems should be managed jointly by the endoscopist, interventional radiologist and hepatobiliary surgeon.