A practical approach to endoscopic pancreatic and peripancreatic drainage: integrating endoscopic retrograde cholangiopancreatography and endoscopic ultrasound.

Owing to its minimally invasive nature and favorable clinical outcomes, endoscopic intervention has replaced surgical and percutaneous approaches to become the standard of care for pancreatic and peripancreatic drainage. Endoscopic retrograde cholangiopancreatography (ERCP)- and endoscopic ultrasound (EUS)-guided techniques represent the two principal modalities in endoscopic interventions and are being increasingly regarded as complementary. ERCP remains the first-line approach for pancreatic duct drainage when the papilla is accessible, particularly in cases involving ductal obstruction, strictures, stones, and leaks, where transpapillary stenting improves healing and long-term outcomes. In contrast, EUS-guided techniques, including the transmural, antegrade, and rendezvous approaches, have emerged as effective alternatives in patients with failed ERCP, surgically altered anatomy, or disconnected pancreatic duct syndrome. For peripancreatic fluid collections, EUS-guided transmural drainage is the preferred modality for mature collections such as pseudocysts and walled-off necrosis. Stent selection should be individualized according to the lesion complexity. The choice between ERCP and EUS should be guided by papillary accessibility, pancreatic duct anatomy, and the characteristics of the fluid collection. An algorithm-based patient-specific approach that integrates both modalities can provide an optimal and minimally invasive treatment strategy. This review summarizes the current evidence on this topic and proposes a practical framework for clinical decision-making in cases requiring pancreatic drainage.