A number of endoscopic interventions have expanded the range of treatment options in symptomatic pancreatic diseases. Early endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (ES) appear to be beneficial in patients with severe acute biliary pancreatitis. Endoscopic pancreatic sphincterotomy can be safely performed with high technical success rates in patients with chronic pancreatitis. Routine additional biliary ES or drainage procedures are not apparently necessary. Stenting can be limited to the treatment of dominant pancreatic duct strictures. In patients with sphincter of Oddi dysfunction, temporary placement of pancreatic stents reduces the morbidity associated with ES. Transpapillary or transmural endoscopic drainage achieves resolution of pancreatic pseudocysts in the majority of selected patients. Drainage procedures with endoscopic ultrasound guidance can potentially expand the indications and reduce the procedure-related morbidity. Therapeutic endoscopy should be considered in symptomatic patients with pancreas divisum, as well as in selected children with pancreatic diseases. Most of the published studies on therapeutic pancreatic endoscopy have been conducted retrospectively. Additional prospective controlled trials are warranted to allow further evaluation of the impact of these methods on the clinical outcome in comparison with alternative treatment strategies.