Risk Management in ERCP and Endoscopic Ultrasound

Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) are essential for the diagnosis and treatment of pancreatobiliary disease but also carry risks of clinical adverse events (AEs). Acute pancreatitis, bleeding, perforation, and cholangitis are the main AEs associated with ERCP. Acute pancreatitis is the most frequent AE and can become severe and even fatal. Diagnostic EUS is relatively safe, although events such as pancreatitis, bleeding, infection, and needle tract seeding via the puncture site have been reported with EUS-guided tissue acquisition. In addition, therapeutic EUS has specific AEs, including peritonitis due to leakage of bile or pancreatic fluid, stent migration, and bleeding. Risk management in pancreatobiliary endoscopy requires a multifaceted approach, including sedation strategies appropriate to the patient's background and procedural difficulty, antithrombotic management, and preventive measures for and early response to procedure-specific AEs. In recent years, safety has steadily improved with the establishment of post-ERCP pancreatitis preventive measures such as rectal nonsteroidal anti-inflammatory drugs administration and pancreatic duct stent placement. In therapeutic EUS, recent advances include the development of metal stents with thin-diameter delivery systems and lumen-apposing metal stents, as well as technical refinements in stent deployment. This review summarizes the latest evidence and guidelines regarding anesthesia management, AEs, prevention strategies, and management approaches related to ERCP and diagnostic and therapeutic EUS. Systematic risk assessment and standardized techniques are key to ensuring safe, high-quality endoscopic pancreatobiliary care.