AIM: To investigate the rate of complications of endoscopic retrograde cholangio-pancreatography (ERCP)performed immediately after endoscopic ultrasound fine needle aspiration (EUS-FNA) in a large series of patients.METHODS: Patients with the following conditions were considered candidates for EUS-FNA and ERCP: diagnosis of locally advanced or metastatic pancreatic lesion not eligible for surgery, and patients with pancreatic lesion of unknown nature causing jaundice. Data were prospectively collected on the following parameters:indication for FNA, EUS findings, pathological diagnosis,procedure duration of EUS-FNA and combined EUS-FNA and ERCP, and immediate and late complications.RESULTS: From January 2004 to October 2006, 72 patients were deemed eligible for combined EUS and ERCP. In 25/72 EUS-FNA was performed to obtain a pathology diagnosis of lesions causing biliary obstruction,and ERCP sequentially performed to drain the biliary system. No immediate complications occurred except for two mild bleeding episodes post sphincterotomy. No late complications were recorded except for one patient who experienced fever, promptly recovered with antibiotic therapy.CONCLUSION: Simultaneous approach appears to be feasible and safe. When possible, this can be considered the reference standard to avoid double sedation and reduce duration of the procedure and hospital stay.