How to perform EUS in the pancreaticobiliary area.

EUS remains mandatory in the management of the majority of pancreaticobiliary diseases. This article fully describes with details how to examine the pancreatico-biliary region using radial and linear EUS. Pancreaticobiliary examination with a radial instrument: 1) place the patient on left lateral decubitus position, tilted towards the examination table at an angle of 30° to 40°; 2) use a moderately inflated balloon; 3) begin the examination in the stomach 45 to 50 cm from the incisors, to examine the body and tail region; 4) after advancing through the pylorus under endoscopic control, proceed from the bulb to the second part of the duodenum by pushing the echoendoscope which is in opened position of the handle gently under ultrasound control, turning the handle clockwise if the superior duodenal angle is open, then push the echoendoscope in the long position towards the ampulla of Vater, adding up angulation. Use the ERCP withdrawal manoeuvre under endoscopic control, from the apex of the bulb if the superior duodenal angle is closed (thin patient), and allow the head of the echoendoscope to fall into the second duodenum, then push the tip over the ampulla of Vater, in the long position, and start the examination at this point. Pancreaticobiliary examination with a linear instrument: place the patient in the same position as with a radial instrument. 1) balloon slightly inflated or uninflated; 2) use the neutral position of the handle as a starting point in the stomach. Move from this position to the open position by turning the handle anti-clockwise and to the closed position by turning the handle clockwise while advancing or withdrawing the echoendoscope, adding clockwise torquing to the endoscope shaft when necessary (to examine the pancreatic tail); 3) almost the whole of the pancreatic gland, apart from the juxtaduodenal segment of the head and uncinate process and in particular the ampulla of Vater, can be examined through the stomach; 4) the examination is conducted exclusively by following the vascular structures and ducts, hence the importance of anatomical knowledge; 5) use constant up angulation.