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August 15, 2025, 11:47

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The strength of the article published by Tarallo et al [1] lies in its thorough analysis of the post–endoscopic retrograde cholangiopancreatography (ERCP) complications, which will serve as a valuable source of information for clinicians across the globe. The complications mentioned in the review, although less frequent, if mismanaged, can prolong the hospitalisation, exacerbate the healthcare costs, and significantly increase the morbidity and mortality. With the development and availability of advanced endoscopic techniques and interventional radiology, the role of surgery in managing ERCP-related complications has decreased. For instance, post-sphincterotomy bleeding (PSB) can be initially managed with various endoscopic methods, and angiographic embolisation is the second-line option [1,2]. Similarly, perforations (particularly, Types II and III), stent migration–induced perforations and Dormia basket impaction also benefit from endoscopic approaches [1,3,4]. Surgery plays a crucial role in severe or refractory cases. When embolisation fails, approximately 10% of the patients with PSB need surgical ligation of the bleeding artery [1,5]. With delayed surgery (>24 h), the mortality rate for Type I perforations is as high as 75% [1,6]. Similarly, stent migration–induced perforations and Dormia basket impaction not responding to endoscopic techniques require surgical intervention [1,7,8]. Early recognition is of paramount importance for improving the outcome. Furthermore, this review advocates a multidisciplinary approach that integrates endoscopists, surgeons and interventional radiologists. This collaboration is crucial, particularly when non-operative methods fail. Although this review has been very extensive, we would like to highlight the significance of risk factors and preventive measures, which the authors should have mentioned. The ERCP technique has been refined over the past five decades; however, it remains one of the endoscopic procedures with the highest rate of complications. Risk factors for ERCP-related complications are broadly classified into patient-, procedure- and operator-related factors. Although non-modifiable, patient-related risk factors allow close monitoring and initiation of preventive measures. For example, the risk of post-ERCP bleeding can be attenuated via pre-procedural optimisation and the adoption of intra-procedural techniques. Patients with thrombocytopenia and coagulopathy should receive blood product transfusions to alleviate the risk of procedure-related bleeding. Using endoscopic papillary large balloon dilatation and performing sphincterotomy in the 11 o’clock to 1 o’clock axis may also reduce the risk of PSB. The reason is that this area has the lowest concentration of arteries based on micro-dissections of cadaveric pancreatico–duodenal specimens. Future challenges and directions: While the review provides a comprehensive framework, it also indicates gaps in current practice, such as the lack of standardised guidelines for ERCP-related complications. This finding underscores the need for further research to establish evidence-based protocols. Moreover, the importance of early recognition indicates the need for the incorporation of simulation-based learning tools and multidisciplinary integration to enhance readiness for these rare yet critical complications. Conclusion: Despite extensive research and refinement of this technique, ERCP-related complications remain a major issue. Identifying risk factors for ERCP-related complications, implementing measures that alleviate the risk of complications, and promptly treating the complications are crucial to ensure favourable clinical outcomes. Predictive models can be developed in future research to identify patients at risk of severe complications, thus enabling clinicians to implement preventive strategies. References: 1. Tarallo M, Crocetti D, Coppola A, Iannone I, Lamazza A, Sapienza P, Fiori E. Endoscopic retrograde cholangiopancreatography-related adverse events: What is the role of surgery today? World J Gastrointest Surg 2025; 17(7): 107385 [PMID: 40740903 DOI: 10.4240/wjgs.v17.i7.107385] 2. Dumonceau JM, Kapral C, Aabakken L, Papanikolaou IS, Tringali A, Vanbiervliet G, Beyna T, Dinis-Ribeiro M, Hritz I, Mariani A, Paspatis G, Radaelli F, Lakhtakia S, Veitch AM, van Hooft JE. ERCP-related adverse events: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy. 2020;52:127-149. 3. Paspatis GA, Arvanitakis M, Dumonceau JM, Barthet M, Saunders B, Turino SY, Dhillon A, Fragaki M, Gonzalez JM, Repici A, van Wanrooij RLJ, van Hooft JE. Diagnosis and management of iatrogenic endoscopic perforations: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement - Update 2020. Endoscopy. 2020;52:792-810. 4. Syed IA, Hanif MF, Malik AK, Aujla UI. Cholangioscope-Guided Electrohydraulic Lithotripsy as a Rescue Technique for an Impacted Dormia Basket With Large Common Bile Duct Stone. ACG Case Rep J. 2023;10:e00981. 5. Dunne R, McCarthy E, Joyce E, McEniff N, Guiney M, Ryan JM, Beddy P. Post-endoscopic biliary sphincterotomy bleeding: an interventional radiology approach. Acta Radiol. 2013;54:1159-1164. 6. Cirocchi R, Kelly MD, Griffiths EA, Tabola R, Sartelli M, Carlini L, Ghersi S, Di Saverio S. A systematic review of the management and outcome of ERCP related duodenal perforations using a standardized classification system. Surgeon. 2017;15:379-387. 7. Zorbas KA, Ashmeade S, Lois W, Farkas DT. Small bowel perforation from a migrated biliary stent: A case report and review of literature. World J Gastrointest Endosc. 2021;13:543-554. 8. O'Brien JW, Tyler R, Shaukat S, Harris AM. Laparoscopic Common Bile Duct Exploration for Retrieval of Impacted Dormia Basket following Endoscopic Retrograde Cholangiopancreatography with Mechanical Failure: Case Report with Literature Review. Case Rep Surg. 2017;2017:5878614.

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