The role of endoscopic ultrasonography in the diagnosis and management of pancreatic cancer

EUS with FNA is highly sensitive and specific for diagnosing pancreatic cancer. However, in certain situations, such as in patients with chronic pancreatitis, this high sensitivity and specificity can significantly diminish. The use of new technology, such as EUS elastography, CE-EUS, and gene mutations detection in FNA specimens, can help to differentiate chronic pancreatitis from pancreatic cancer. EUS has evolved from a diagnostic procedure to a therapeutic intervention in pancreatic cancer. EUS-guided fiducial insertion and EUS-guided delivery of antitumor agents, in addition to celiac plexus neurolysis, are the main therapeutic applications of EUS in pancreatic cancer.     

Role of pancreatic endoscopic ultrasonography in 2010

Endoscopic ultrasonography (EUS) was introduced 25 years ago aiming at better visualization of the pancreas compared to transabdominal ultrasonography. This update discusses the current evidence in 2010 concerning the role of EUS in the clinical management of patients with pancreatic disease. Major indications of EUS are: (1) Detection of common bile duct stones (e.g. in acute pancreatitis); (2) Detection of small exo- and endocrine pancreatic tumours; and (3) Performance of fine needle aspiration in pancreatic masses depending on therapeutic consequences. EUS seems to be less useful in cases of chronic pancreatitis and cystic pancreatic lesions. Moreover the constant improvement of computed tomography has limited the role of EUS in pancreatic cancer staging. On the other hand, new therapeutic options are available due to EUS, such as pancreatic cyst drainage and celiac plexus neurolysis, offering a new field in which new techniques may arise. So the main goal of this review is to determine the exact role of EUS in a number of pancreatic and biliary diseases.     

Endoscopic ultrasound guided interventional procedures

Endoscopic ultrasound (EUS) has emerged as an important diagnostic and therapeutic modality in the field of gastrointestinal endoscopy. EUS provides access to many organs and lesions which are in proximity to the gastrointestinal tract and thus giving an opportunity to target them for therapeutic and diagnostic purposes. This modality also provides a real time opportunity to target the required area while avoiding adjacent vascular and other structures. Therapeutic EUS has found role in management of pancreatic fluid collections, biliary and pancreatic duct drainage in cases of failed endoscopic retrograde cholangiopancreatography, drainage of gallbladder, celiac plexus neurolysis/blockage, drainage of mediastinal and intra-abdominal abscesses and collections and in targeted cancer chemotherapy and radiotherapy. Infact, therapeutic EUS has emerged as the therapy of choice for management of pancreatic pseudocysts and recent innovations like fully covered removable metallic stents have improved results in patients with organised necrosis. Similarly, EUS guided drainage of biliary tract and pancreatic duct helps drainage of these systems in patients with failed cannulation, inaccessible papilla as with duodenal/gastric obstruction or surgically altered anatomy. EUS guided gall bladder drainage is a useful emergent procedure in patients with acute cholecystitis who are not fit for surgery. EUS guided celiac plexus neurolysis and blockage is more effective and less morbid vis-à-vis the percutaneous technique. The field of interventional EUS is rapidly advancing and many more interventions are being continuously added. This review focuses on the current status of evidence vis-à-vis the established indications of therapeutic EUS.     

Endoscopic Ultrasound in Pancreatic Disease — Its Influence on Surgical Decision-Making An Update 2008

Endoscopic ultrasonography (EUS) was introduced about 25 years ago with the primary aim of better visualization of the pancreas as compared to transabdominal ultrasonography. This review discusses the current evidence in 2008 concerning the role of EUS in the clinical management of patients, with a special emphasis on its impact on surgical therapy. According to the literature, good indications are detection of common bileduct stones (e.g. in acute pancreatitis), the detection of small exo- and endocrine pancreatic tumors, the performance of fine-needle aspiration in pancreatic masses depending on therapeutic consequences. In other areas such as diagnosis of chronic pancreatitis and cystic pancreatic lesions, the contribution of EUS seems limited. Pancreatic cancer staging is discussed controversially due to conflicting evidence and certainly has lost grounds due to improvements in CT technology. Therapeutic EUS is, however, more widely accepted and may replace othertechniques, e.g. in pancreatic cyst drainage and celiac plexus neurolysis; further techniques of interest are being developed.     

Possibilities of interventional endoscopic ultrasound

Since endoscopic ultrasound (EUS) was developed in the 1990s, EUS has become widely accepted as an imaging tool. EUS is categorized into radial and linear in design. Radial endoscopes provide cross-sectional imaging of the mediastinum, gastrointestinal tract, liver, spleen, kidney, adrenal gland, and pancreas, which has highly accuracy in the T and N staging of esophageal, lung, gastric, rectal, and pancreatic cancer. Tumor staging is common indication of radial-EUS, and EUSstaging is predictive of surgical resectability. In contrast, linear array endoscope uses a side-viewing probe and has advantages in the ability to perform EUSguides fine needle aspiration (EUS-FNA), which has been established for cytologic diagnosis. For example, EUS-FNA arrows accurate nodal staging of esophageal cancer before surgery, which provides more accurate assessment of nodes than radial-EUS imaging alone. EUS-FNA has been also commonly used for diagnose of pancreatic diseases because of the highly accuracy than US or computed tomography. EUS and EUS-FNA has been used not only for TNM staging and cytologic diagnosis of pancreatic cancer, but also for evaluation of chronic pancreatitis, pancreatic cystic lesions, and other pancreatic masses. More recently, EUS-FNA has developed into EUS-guided fine needle injection including EUS-guided celiac plexus neurolysis, celiac plexus block, and other "interventional EUS" procedures. In this review, we have summarized the new possibilities offered by "interventional EUS".     

Endoscopic ultrasound-guided (neurolytic) celiac plexus block

Celiac plexus neurolysis is an established technique for relieving pain in cancers of the upper abdomen. This article reviews the novel technique of endoscopic ultrasound (EUS)-guided neurolytic celiac plexus block. This recently described procedure is a therapeutic extension of curvilinear array endosonographic fine needle aspiration. The indications, patient preparation, and technical aspects of the procedure are described in detail. The potential complications are mentioned and the results of the published studies are reviewed. We believe that where the expertise is available, this procedure can be integrated into the diagnostic EUS of patients with inoperable upper abdominal malignancy. As such, this would be the safest and most cost-effective approach for celiac plexus neurolysis in these patients. The role of EUS-guided celiac plexus block in patients with chronic pancreatitis may be emerging and needs further study.     

Endoscopic ultrasound-guided celiac plexus block for managing abdominal pain associated with chronic pancreatitis: a prospective single center experience

OBJECTIVE: In our previous randomized trial, we suggested a possible role for endoscopic ultrasound (EUS) guided celiac plexus block in the treatment of abdominal pain associated with chronic pancreatitis. The purpose of this study was to evaluate our prospective experience with EUS-guided celiac plexus block for controlling pain attributed to chronic pancreatitis, including follow-up on response rates and complications. METHODS: All subjects enrolled had documented chronic pancreatitis by ERCP and EUS criteria and presented with chronic abdominal pain unresponsive to current treatment options. All were treated with EUS-guided celiac plexus block under the guidance of linear array endosonography using a 22-gauge FNA needle (GIP, Mediglobe Inc., Tempe, AZ) inserted on each side of the celiac area, followed by injection of 10 cc bupivacaine (0.25%) and 3 cc (40 mg) triamcinolone on each side of the celiac plexus. Individual pain scores, based on a visual analog scale (0-10), were determined preblock and postblock by a nurse at 2, 7, 14 days and monthly thereafter. Subjects also rated their overall comfort level during the EUS procedure. RESULTS: EUS-guided celiac plexus block was performed in 90 subjects (40 males, 50 females) having a mean age of 45 yr (range 17-76 yr) between July 1, 1995 and December 30, 1996. A significant improvement in overall pain scores occurred in 55% (50/90) of patients. The mean pain score decreased from 8 to 2 post EUS celiac block at both 4 and 8 wk follow-up (p < 0.05). In 26% of patients there was persistent benefit beyond 12 wk, and 10% still had persistent benefit at 24 wk, including three patients who were pain-free between 35 and 48 wk. Younger patients (<45 yr of age) and those having previous pancreatic surgery for chronic pancreatitis were unlikely to respond to the EUS-guided celiac block. Three patients experienced diarrhea post EUS celiac block, which resolved in 7-10 days; however, it is unclear whether this diarrhea was due to the block or to refractory disease. A cost comparison between the EUS ($1200) and CT ($1400) techniques shows the EUS celiac block to be less costly and perhaps more cost efficient in a subset of subjects. CONCLUSIONS: EUS-guided celiac plexus block appears to be safe, effective, and economical for controlling pain in some patients with chronic pancreatitis. Younger patients (<45 yr) and those having prior pancreatic surgery for chronic pancreatitis do not appear to benefit from this technique. Prophylactic antibiotics should be considered if acid suppressing agents are being taken.     

Applications of endoscopic ultrasound in pancreatic cancer

Since the introduction of endoscopic ultrasound guided fine-needle aspiration(EUS-FNA),EUS has assumed a growing role in the diagnosis and management of pancreatic ductal adenocarcinoma(PDAC).The objective of this review is to discuss the various applications of EUS and EUS-FNA in PDAC.Initially,its use for detection,diagnosis and staging will be described.EUS and EUS-FNA are highly accurate modalities for detection and diagnosis of PDAC,this high accuracy,however,is decreased in specific situations particularly in the presence of chronic pancreatitis.Novel techniques such as contrast-enhanced EUS,elastography and analysis of DNA markers such as k-ras mutation analysis in FNA samples are in progress and might improve the accuracy of EUS in the detection of PDAC in this setting and will be addressed.EUS and EUS-FNA have recently evolved from a diagnostic to a therapeutic technique in the management of PDAC.Significant developments in therapeutic EUS have occurred including advances in celiac plexus interventions with direct injection of ganglia and improved pain control,EUS-guided fiducial and brachytherapy seed placement,fine-needle injection of intra-tumoral agents and advances in EUS-guided biliary drainage.The future role of EUS and EUS in management of PDAC is still emerging.     

Endoscopic ultrasound in the diagnosis and management of carcinoma pancreas

Endoscopic ultrasound(EUS) has become an important component in the diagnosis and treatment of carcinoma pancreas. With the advent of advanced imaging techniques and tissue acquisition methods the role of EUS is becoming increasingly important. Small pancreatic tumors can be reliably diagnosed with EUS. EUS guided fine needle aspiration establishes diagnosis in some cases. EUS plays an important role in staging of carcinoma pancreas and in some important therapeutic methods that include celiac plexus neurolysis, EUS guided biliary drainage and drug delivery. In this review we attempt to review the role of EUS in diagnosis and management of carcinoma pancreas.     

Therapeutic role of endoscopic ultrasound in pancreaticobiliary disease: A comprehensive review

With the development of technology and accessories,the role of endoscopic ultrasound(EUS) has evolved from diagnostics to therapeutics. In order to characterise the therapeutic role of EUS,we searched Web of Knowledge database and reviewed articles associated with therapeutic EUS. There are two modalities for the therapeutic purpose: drainage and fine-needle injection. EUS-guided drainage is a promising procedure for the treatment of peripancreatic fluid collection and biliary obstruction; EUS-guided fine-needle injections such as celiac plexus neurolysis,for the purpose of pain relief for pancreatic cancer and chronic pancreatitis,has emerged as a promising procedure. The aim of the study was to perform a comprehensive and conscientious review on the techniques,complications and clinical outcomes of those EUS-based procedures.     

Endoscopic ultrasonography for evaluating patients with recurrent pancreatitis

Acute recurrent pancreatitis （ARP） is still a complex diagnostic and therapeutic challenge in clinical practice. In up to 30% of cases of ARP, it is not possible to establish the etiology of the disease. In the other 70%, many factors play an etiological role in ARP： microlithiasis, sphincter of Oddi dysfunction （SOD）, pancreas divisum, hereditary pancreatitis, cystic fibrosis, a choledochocele, annular pancreas, an anomalous pancreatobiliary junction, pancreatic tumors or chronic pancreatitis are diagnosed. EUS should be useful in ARP as it is sensitive for diagnosing bile duct stones, gallbladder sludge, pancreatic lesions, ductal abnormalities and chronic pancreatitis. Endoscopic ultrasound （EUS） appears to be diagnostic in the majority of patients with previously unexplained pancreatitis, and offers an alternative to endoscopic retrograde cholangiopancreatography （ERCP） as the initial diagnostic test in patients with ARP.     

The Therapeutic Use of Endoscopic Ultrasonography in Pediatric Patients is Safe: A Case Series

Background/Aim:Despite the safety and high diagnostic yield of endoscopic ultrasound guided fine needle aspiration (EUS FNA) for the evaluation of gastrointestinal diseases in adults, literature discussing the therapeutic use of EUS FNA in pediatrics remains limited. This study reports our experience with the use of EUS in children with pancreaticobiliary disorders.Results:A total of 6 therapeutic EUS procedures were performed in 5 children (3 F/2 M). The mean age was 13 years (range 6–17) with a mean body mass index of 28.2 (range 18.5–38.8). The indications for EUS procedures were abdominal pain with chronic pancreatitis (3) and management of symptomatic pancreaticobiliary cysts/pseudocysts observed on previous imaging (3). All procedures were performed under general anesthesia. The 6 therapeutic procedures performed were celiac plexus block (3), cyst gastrostomy with stents placement (2), and cyst aspiration using EUS FNA (1). A celiac plexus block effectively relieved abdominal pain in 2 patients with chronic pancreatitis. Cyst gastrostomy successfully resulted in pseudocyst resolution in the follow up imaging of 2 patients (up to 6 months after the procedure). Cyst aspiration with EUS guided FNA resulted in cyst resolution and confirmation of the benign nature of the cyst in 1 patient. All the procedures were successfully completed with no reported complications.Conclusion:The therapeutic use of endoscopic ultrasound in the pediatric population is safe and has a high success rate.     

Diagnosis of early chronic pancreatitis by endoscopic ultrasound. Are we there yet?

The diagnosis of chronic pancreatitis at an early stage is a clinical challenge. A major limitation is the inability of clinicians to obtain a tissue or histological sample to confirm the clinical diagnosis. Currently available imaging modalities have limited sensitivity or specificity for diagnosing early chronic pancreatitis. Endoscopic ultrasonography (EUS), introduced in the early 1980's, was first developed to image the pancreas. It overcame many of the limitations (abdominal gas and fat) of transabdominal ultrasonography when evaluating patients for possible pancreatic diseases. To date, EUS represents the most promising imaging modality for diagnosing chronic pancreatitis. Contrary to endoscopic retrograde pancreatography (ERCP), EUS has a very low risk of complications and can detect abnormalities suggestive of chronic pancreatitis in the pancreatic parenchyma and ductal system which are not visible on any other imaging modality. The minimal changes in echotexture are difficult to interpret because there is no reliable gold standard confirmatory test. There is now some evidence in the literature suggesting that these early changes detected by EUS correlate with the histological changes of chronic pancreatitis and may predict progression to more advanced disease. The EUS diagnosis of chronic pancreatitis relies on quantitative (more than qualitative) parenchymal and ductal criteria found during evaluation of the pancreas. It is generally accepted that, in the absence of any criteria, chronic pancreatitis is unlikely, whereas in the presence of 5 or more criteria (out of 9-11) chronic pancreatitis is likely although ERCP and pancreatic function tests may still be normal. The diagnostic significance of patients with fewer (1-4) criteria found on EUS is currently unclear, particularly when other diagnostic tests such as ERCP and function testing are normal. In these cases, there is a potential for "over-diagnosis" of chronic pancreatitis, since the EUS changes cannot be confirmed by other modalities. How can we better understand the implications of EUS detected changes when other tests are normal?     

Endoscopic ultrasound in pancreatic diseases

There are many indications for the use of endoscopic ultrasound (EUS) in the management of patients with pancreatic diseases. High-resolution imaging of the pancreas is achievable due to the close proximity between luminal structures and the pancreas. Since its introduction, EUS has had a significant impact on the diagnosis of pancreatic diseases. The detection of small lesions and neuroendocrine pancreatic tumors as well as the preoperative staging of pancreatic adenocarcinoma have been improved employing EUS. For the detection of small pancreatic tumors <2 cm in diameter, EUS appears to be the most sensitive method. EUS adds significant information to the differential diagnosis between pancreatic cancer and chronic pancreatitis, and it may be further enhanced by EUS-guided fine-needle aspiration. While the role of EUS in distinguishing between benign and malignant cystic pancreatic tumors is under discussion, EUS-guided drainage of pancreatic pseudocysts is an accepted treatment option for symptomatic individuals. One of the most important advantages of EUS apart from tumor staging is the early detection of chronic pancreatitis. EUS is as good as endoscopic retrograde cholangiopancreatography in diagnosing chronic pancreatitis in advanced stages. In early stages of the disease, when the ductal system remains normal, EUS appears to be a superior diagnostic modality because it can detect features of chronic pancreatitis in the parenchyma not visible by other techniques.     

Endoscopic ultrasonography guided celiac plexus neurolysis and celiac plexus block in the management of pain due to pancreatic cancer and chronic pancreatitis

Pain is a common symptom of pancreatic disease and is frequently difficult to manage. Pain relief provided by narcotics is often suboptimal and is associated with significant side effects. An alternative approach to pain management in pancreatic disease is the use of celiac plexus block （CPB） or neurolysis （CPN）. Originally performed by anesthesiologists and radiologists via a posterior approach, recent advances in endoscopic ultrasonography （EUS） have made this technique an attractive alternative. EUS guided celiac plexus block/ neurolysis is simple to perform and avoids serious complications such as paraplegia or pneumothorax that are associated with the posterior approach. EUS guided CPN should be considered first line therapy in patients with pain due to pancreatic cancer. It provides superior pain control compared to traditional management with narcotics. A trend for improved survival in pancreatic cancer patients treated with CPN has been reported, but larger studies are needed to confirm this finding. At this time, the use of EUS guided CPB cannot be recommended as routine therapy for pain in chronic pancreatitis since only one-half of the patients experience pain reduction and the beneficial effect tends to be short lived. EUS guided CPB and CPN should be used as part of a multidisciplinary team approach for pain management.     

Initial evaluation of the efficacy and safety of endoscopic ultrasound-guided direct Ganglia neurolysis and block

BACKGROUND: Celiac plexus neurolysis and block are considered safe but provide limited pain relief. Standard techniques target the region of the celiac plexus but do not attempt injections directly into celiac ganglia. The recent recognition that celiac ganglia can be visualized by endoscopic ultrasound (EUS) now allows direct injection into celiac ganglia for neurolysis (CGN) and block (CGB). AIMS: To determine the safety and initial efficacy (at 2-4 wk) of direct ganglia injection in patients with moderate to severe pain secondary to unresectable pancreatic carcinoma or chronic pancreatitis. METHODS: An EUS database was reviewed to identify patients undergoing CGN and CGB. Data were retrieved from the medical records and phone follow-up. RESULTS: Thirty-three patients underwent 36 direct celiac ganglia injections for unresectable pancreatic cancer (CGN N = 17, CGB N = 1) or chronic pancreatitis (CGN N = 5, CGB N = 13) with bupivacaine (0.25%) and alcohol (99%) for CGN, or Depo-Medrol (80 mg/2 cc) for CGB. Cancer patients reported pain relief in 16/17 (94%) when alcohol was injected and 0/1 (00%) when steroid was injected. For chronic pancreatitis, 4/5 (80%) who received alcohol reported pain relief versus 5/13 (38%) receiving steroids. Thirteen (34%) patients experienced initial pain exacerbation, which correlated with improved therapeutic response (P < 0.05). Transient hypotension and diarrhea developed in 12 and 6 patients, respectively. CONCLUSIONS: Initial experience suggests that EUS-guided direct celiac ganglion block or neurolysis is safe. Alcohol injection into ganglia appears to be effective in both cancer and chronic pancreatitis. Prospective trials are needed to confirm the efficacy of this new approach.     

Endoscopic ultrasound celiac plexus block and neurolysis

Over the last decade, endoscopic ultrasound-guided celiac plexus block and celiac plexus neurolysis (CPN) have been established as effective and safe interventions to palliate visceral abdominal pain resulting from chronic pancreatitis and pancreatic cancer, respectively. Endoscopic ultrasound-guided approach has advantages over the percutaneous methods because it facilitates precise injection into the region owing to its more direct access. More recently, celiac ganglion neurolysis has been promoted as a safe alternative to CPN and it may be a more efficacious technique than CPN. Although large, adequately powered randomized trials are lacking, observational studies and small randomized trials support the use of celiac plexus block and CPN in palliation of pain in patients with chronic pancreatitis or pancreatic cancer, respectively. However, these interventions’ affect on quality of life and survival is unclear and further large randomized studies are needed.     

Endoscopic pancreatic duct stent placement for inflammatory pancreatic diseases

The role of endoscopic therapy in the management of pancreatic diseases is continuously evolving; at present most pathological conditions of the pancreas are successfully treated by endoscopic retrograde cholangio- pancreatography （ERCP） or endoscopic ultrasound （EUS）, or both. Endoscopic placement of stents has played and still plays a major role in the treatment of chronic pancreatitis, pseudocysts, pancreas divisum, main pancreatic duct injuries, pancreatic fistulae, complications of acute pancreatitis, recurrent idiopathic pancreatitis, and in the prevention of post-ERCP pancreatitis. These stents are currently routinely placed to reduce intraductal hypertension, bypass obstructing stones, restore lumen patency in cases with dominant, symptomatic strictures, seal main pancreatic duct disruption, drain pseudocysts or fluid collections, treat symptomatic major or minor papilla sphincter stenosis, and prevent procedure-induced acute pancreatitis. The present review aims at updating and discussing techniques, indications, and results of endoscopic pancreatic duct stent placement in acute and chronic inflammatory diseases of the pancreas.     

A prospective randomized comparison of endoscopic ultrasound- and computed tomography-guided celiac plexus block for managing chronic pancreatitis pain

OBJECTIVE: Computed tomography (CT)-guided celiac plexus neurolysis has been used for controlling the chronic abdominal pain associated with intra-abdominal malignancy and chronic pancreatitis. Endoscopic ultrasound (EUS)-guided celiac plexus neurolysis has been reported to have some success in controlling pain from pancreatic cancer. The aim of this study is to assess the efficacy of EUS-guided celiac plexus block versus CT-guided celiac plexus block for controlling the chronic abdominal pain associated with chronic pancreatitis. METHODS: Patients enrolled were randomly assigned to EUS-guided or CT-guided celiac plexus block. Pain scores were determined pre- and postceliac block for both techniques. Follow-up was obtained by a nurse at 1 day post-block, then weekly thereafter for 24 wk. Patients also rated overall experience with these procedures. The EUS celiac block was performed with a 22-gauge sterile needle inserted into the celiac region with guidance of real-time linear array endosonography followed by injection of 10 ml of bupivacaine (0.75%) and 3 ml (40 mg) of triamcinolone on both sides of the celiac area. RESULTS: Twenty-two consecutive patients (10 men, 12 women), were ultimately enrolled in this study between 7/1/95 and 12/30/95; four patients were excluded for protocol violations. We performed EUS-guided celiac block in 10 patients and CT-guided celiac block in eight. A significant improvement in pain scores with reduction in pain medication usage occurred in 50% (five of 10) of patients having the EUS block. The mean postprocedure follow-up was 15 weeks (range: 8-24 wk). Persistent benefit was experienced by 40% of patients at 8 wk and by 30% at 24 wk. In the patients with CT block, however, only 25% (two of eight) had relief. The mean follow-up was 4 wk (range: 2-6 wk). Only 12% (one of eight) had some relief at 12 wk of follow-up. There were no complications. EUS-guided celiac block was the preferred technique among patients who experienced both techniques. A cost comparison between both celiac block techniques shows EUS to be less costly than CT. CONCLUSIONS: EUS-guided celiac block provided more persistent pain relief than CT-guided block and was the preferred technique among the subjects studied. EUS-guided celiac block appears to be a safe, effective, and less costly method for controlling the abdominal pain that can accompany chronic pancreatitis in some patients.     

Current role of endoscopic ultrasound in the diagnosis and management of pancreatic cancer

Endoscopic ultrasound (EUS) has emerged as an invaluable tool for the diagnosis, staging and treatment of pancreatic ductal adenocarcinoma (PDAC). EUS is currently the most sensitive imaging tool for the detection of solid pancreatic tumors. Conventional EUS has evolved, and new imaging techniques, such as contrast-enhanced harmonics and elastography, have been developed to improve diagnostic accuracy during the evaluation of focal pancreatic lesions. More recently, evaluation with artificial intelligence has shown promising results to overcome operator-related flaws during EUS imaging evaluation. Currently, an appropriate diagnosis is based on a proper histological assessment, and EUS-guided tissue acquisition is the standard procedure for pancreatic sampling. Newly developed cutting needles with core tissue procurement provide the possibility of molecular evaluation for personalized oncological treatment. Interventional EUS has modified the therapeutic approach, primarily for advanced pancreatic cancer. EUS-guided fiducial placement for local targeted radiotherapy treatment or EUS-guided radiofrequency ablation has been developed for local treatment, especially for patients with pancreatic cancer not suitable for surgical resection. Additionally, EUS-guided therapeutic procedures, such as celiac plexus neurolysis for pain control and EUS-guided biliary drainage for biliary obstruction, have dramatically improved in recent years toward a more effective and less invasive procedure to palliate complications related to PDAC. All the current benefits of EUS in the diagnosis and management of PDAC will be thoroughly discussed.