Towards safe ERCP: selection, experience and prophylaxis

Abstract

Since its conception (1), endoscopic retrograde cholangio-pancreatography (ERCP) has been notorious due to the presence of complications. All steps in this technique entail a rate of undesired outcomes above that of the remaining endoscopy types (sedation, diagnosis, and therapeutic procedures), and every individual action is associated with a host of specific adverse effects, which seldom coincide with those in other steps and are often linked to individual patient characteristics. Even though ERCP represents a serious mechanical, chemical, hydrostatic, enzymatic, microbiological, and thermal insult in itself for the papilla, it is considered a relatively safe endoscopic procedure, once its potential to induce serious, life-threatening complications is assumed (2). In addition to training, ERCP requires a lot of cognitive effort on the performer's part: clinical judgement and decision making are essential items to confront the successive crossroads one is daily brought at by this technique. Factors such as the explorer's personality, restfulness, pressure level, and stress influence results obtained, as does the total amount of procedures performed (lifetime accumulation), current training level (daily practice), or simply time elapsed since the last similar case (3). On the other hand, ERCP is marked by an evaluation that is almost exclusively based on its complication rate, and many other axes exist that may influence a technique's results, such as the extent of technical success, extent and duration of beneficial effects, patient satisfaction, and cost. ERCP has evolved along the same lines as the rest of diagnostic and therapeutic modalities, mainly cholangioresonance and laparoscopic cholecystectomy, and its appropriate use has thus constantly changed. ERCP equipment and tools have also changed and improved, and retrospective studies face a mixture of cases, which hinders the assessment of risk factors for complication development. Such risk factors are specific for each complication and seldom overlap. This is in addition true for both patient-and explorer-dependent factors, as well as for post-ERCP care (4). A huge number of factors has been involved in the development of complications. Risk factors common to all complications include precut, combined or "rendezvous" access, difficult cannulation, and failed stone removal. All these are surrogate markers of simply a difficult ERCP and of the way in which each endoscopist or center faces it (4). Pancreatitis is the most common complication following ERCP. It is defined as the development or worsening of abdominal pain, with amylasemia rising above 3 times its normal value, within 24 hours after the procedure and requiring at least a 2-day stay in hospital, and represents a true scourge on a daily basis.