New milestone in endoscopic retrograde cholangiopancreatography (ERCP) safety: Key insights from the 2023 Guidelines on Post-ERCP Pancreatitis Prevention and Management

Abstract

Endoscopic retrograde cholangiopancreatography (ERCP) remains a cornerstone in the management of pancreatobiliary diseases; however, it carries a major risk of post-ERCP pancreatitis (PEP). The first PEP guidelines were published in 2015, with the revised 2023 Guidelines for Post-ERCP Pancreatitis Prevention and Management released in 2024 by Mukai et al.¹ in Digestive Endoscopy.

These updated guidelines incorporate new evidence based on the Minds Guidelines and GRADE methodology. The reported incidence of PEP ranges from 3.5% to 10%, with severe pancreatitis occurring in 0.4–0.5% of cases. The mortality rate due to pancreatitis has been reported to be 0.02–0.7%.¹ Although its mortality rate has declined, this decline underscores the continued importance of refined risk assessment and prevention strategies.

Key advancements include enhanced prevention strategies. Temporary pancreatic duct stenting (PDS) remains a primary preventive measure for high-risk patients. However, there is no established consensus on the specific patient populations that should receive PDS.

A meta-analysis by Sperna Weiland et al.² found that PDS did not significantly reduce PEP incidence (relative risk 1.25), raising questions regarding its routine use. However, the 2023 Guidelines recommend considering PDS placement in carefully selected high-risk cases.² Specifically, PDS is proposed for patients with both patient-related risk factors (such as sphincter of Oddi dysfunction, history of PEP, female sex, and young age) and procedural risk factors (including pancreatic duct cannulation, multiple cannulation attempts, and precut sphincterotomy). Thus, additional preventive strategies are needed for high-risk cases.

Rectal nonsteroidal anti-inflammatory drugs (NSAIDs), such as indomethacin or diclofenac, are highly effective in reducing both the incidence and severity of PEP.² Most studies have utilized a 100 mg dose; however, in Japan, only 50 mg formulations are available, with insurance coverage limited to this dosage. The efficacy of lower-dose NSAIDs remains inconclusive, necessitating further validation.

International guidelines^{3, 4} recommend the use of rectal NSAIDs; however, some high-risk patients remain vulnerable, highlighting the need for further research. Pécsi et al.⁵ emphasized the importance of individualized prophylaxis, incorporating NSAIDs, aggressive hydration, and advanced cannulation techniques. They advocate for refining risk models, artificial intelligence (AI)-driven risk assessment, and exploring novel prophylactic approaches, such as protease inhibitors and nitrates.⁶

Recent studies have shown promising developments in AI-driven risk assessment for pancreatitis.⁵ Integration of such AI-driven approaches could enhance individualized risk stratification and optimize preventive strategies in the ERCP setting.

Diagnostic advancements include early serum amylase and lipase monitoring (2–4 h postprocedure) for PEP prediction, as well as contrast-enhanced computed tomography for suspected cases to enhance diagnostic accuracy and facilitate timely management.⁷

These Guidelines also evaluate the role of protease inhibitors in PEP prevention. While gabexate mesylate and ulinastatin have demonstrated no clear benefits, nafamostat mesylate shows potential, but lacks robust evidence for routine use. Further studies are required to establish its efficacy, optimal timing, and cost-effectiveness.

The Guidelines emphasize procedural refinements, including early precut sphincterotomy for difficult biliary cannulation, careful implementation of the double-guidewire technique, and selective biliary cannulation to improve outcomes.

A key feature of the 2023 Guidelines is the emphasis on individualized care. By categorizing patient- and procedure-related risk factors, the recommendations facilitate a tailored approach to PEP prevention, reinforcing the importance of thorough risk assessment.

Future research should focus on novel techniques such as AI-driven risk stratification, optimization of preventive strategies, and endoscopic ultrasound-guided drainage, which carries an almost negligible risk of pancreatitis.^{8, 9} Recent reviews have also emphasized the importance of addressing unresolved challenges, including the integration of multiple risk factors and the refinement of individualized preventive approaches.¹⁰

In summary, the 2023 Guidelines represent a significant advancement in PEP prevention and management. They integrate the latest evidence, emphasize personalized care, and provide clear recommendations on prevention, diagnosis, and procedural techniques. Continued research and collaboration will be essential to further optimizing ERCP safety and improving patient outcomes.

Author declares no conflict of interest for this article.

This work was supported by The National Cancer Center Research and Development Fund (2022-A-16).