What would you do? Troubleshooting and prevention of complications associated with ERCP and EUS

Therapeutic ERCP and endoscopic sphincterotomy (EST) are associated with a rate of complications of up to 10 %. Post ERCP pancreatitis (PEP) is the most frequent major adverse event of EST and occurs in 3.5 % of all cases. Hemorrhage, perforation, cholangitis and cholecystitis occur less frequently and may have decreased compared with previous reports. Adverse events related to therapeutic EUS depend on the type of intervention. In particular management of walled-off pancreatic necrosis (WOPN), hepticogastrostomy and pancreaticogastrostomy are associated with potential risks. Various risk factors, prophylactic measurements, early recognition and appropriate treatment should be considered in order to decrease the procedure related morbidity of ERCP and EUS. In an individual patient it may be difficult to determine if complications due to ERCP were caused by bile duct cannulation, EST or by adjunctive therapeutic measurements. Definitive patient related risk factors for ERCP are suspected sphincter of Oddi dysfunction, female gender and previous pancreatitis. Precut sphincterotomy and pancreatic injection were analysed as definitive procedure related parameters which are associated with an increased risk of PEP. Prevention of ERCP and EUS related complications requires appropriate selection of patients with consideration of benefits and risks of specific procedures. Endoscopists should adapt their expertise to the complexity of interventions and to risk factors of the individual case. Prophylactic pancreatic stenting and application of NSAIDS have to be considered in cases with an increased risk of PEP. Expertise in advanced therapeutic endoscopy is mandatory for management of a variety of major complications. Modern endoscopic procedures include injection, placement of clips and implantation of fully covered self-expanding metal stents (SEMS) for EST related hemorrhage. Clips and SEMS do usually allow closure of iatrogenic perforations. The incidence of cholangitis can be decreased by complete ERCP- and/or EUS guided drainage of all opacified biliary segments and prophylactic application of antibiotics in particular in case of incomplete drainage and/or proximal stenosis. WPON as a complication of severe PEP may require EUS guided enteral drainage by use of SEMS, plastic stents and/or nasocystic catheters for irrigation. Access to interventional radiology and hepatico-pancreatico-biliary surgery should be available for management of severe complications that not amenable to endoscopic and conservative measurements.