Figure 2.

A hilar stricture with dilatation of the left ductal system (A) requires intrahepatic access. Extrahepatic access is suitable for distal biliary obstruction in patients with native antroduodenal anatomy despite the presence of ascites or non-dilated intrahepatic ducts (B). Any prior surgery involving distal gastrectomy with gastrojejunostomy (C) precludes EUS imaging of the CBD. Some of these factors are present in 80% of carefully selected ESCP candidates, which limits the issue of “operator’s choice of approach” to 20% of cases.