Risk assessment and reduction

Abstract

One of the most important concerns about ERCP is its high risk in comparison to other endoscopic procedures. With post-ERCP pancreatitis rates, in good hands, ranging from 2 to 5% for low-risk procedures and 10 to 20% for high-risk procedures (even after risk-reducing maneuvers), and a mortality of about 1 in 1000 (mainly due to severe pancreatitis), this seems to be an appropriate concern; bleeding (about 1%), perforation (<0.5%), infection (1-2%), and cardiorespiratory AEs can also occur [1]. The risk involved in an individual ERCP case can vary widely. Thus, a biliary stent change in a healthy middle-aged man can be orders of magnitude different than manometry, dual sphincterotomy with pancreatic stenting in a young women with prior post-ERCP pancreatitis; not all ERCPs are the same and not all ERCPists have had the same case spectrum in their training and practice. This AE profile makes it important to ensure training is appropriate for both the endoscopist and the team/unit, to ensure indications are sound, noninvasive alternatives are appropriately considered, and patients are appropriately consented with respect to the risks, benefits, and alternatives.A critical step toward reducing risks is to understand their predictors [2,3]. Some factors may be modifiable and their identification allows time for that modification to occur. For the ones that are not modifiable, identifying the risks Key points• The most common adverse events (AEs) after endoscopic retrograde cholangiopancreatography (ERCP) are pancreatitis, cardiopulmonary events, bleeding, infection, and perforation, and rarely these events can cause disability or be fatal.• The actual risks in an individual case depend upon the context of the procedure, the characteristics of the patient, the skills of the procedure team, and the appropriate use of prophylactic interventions.• Understanding these interacting issues and managing them are key to making wise clinical decisions and improving patient education and informed consent.