Endoscopic retrograde cholangiopancreatography-related adverse events: What is the role of surgery today?

Abstract

Endoscopic retrograde cholangiopancreatography (ERCP) plays a vital role in managing biliary and pancreatic diseases but carries a risk of severe complications that may require surgical intervention. This review focuses on the surgical management of key ERCP-related complications: Post-sphincterotomy bleeding, perforations, stent migration-induced perforations, and Dormia basket impaction. Although many complications can be managed endoscopically, surgery remains essential in refractory cases or when less invasive methods fail. Post-sphincterotomy bleeding, although often controlled endoscopically, may necessitate surgical ligation when hemorrhage persists. Perforations, classified by anatomical type, require tailored surgical approaches - primary repair for type I and biliary diversion with defect closure for types II and III. Stent migration-induced perforations, which may lead to peritonitis or abscess formation, often require surgery due to their variable clinical presentation and the lack of standardized management guidelines. Dormia basket impaction, although rare, may require advanced endoscopic techniques or laparoscopic retrieval if conservative measures prove ineffective. Early recognition, multidisciplinary collaboration, and individualized treatment strategies are pivotal in reducing morbidity and mortality. This review underscores evolving surgical approaches, emphasizing the importance of timely, patient-specific decisions to improve outcomes in severe ERCP-related complications.

Keywords: Endoscopic retrograde cholangiopancreatography complications; Surgical management; Post-sphincterotomy bleeding; Perforation; Stent migration; Dormia basket impaction

Core Tip: Surgical management of post-endoscopic retrograde cholangiopancreatography complications remains crucial despite advancements in endoscopic techniques. This review highlights rare but serious adverse events - post-sphincterotomy bleeding, perforation, stent migration, and Dormia basket impaction - emphasizing diagnostic strategies, therapeutic approaches, and surgical interventions when non-operative methods fail. Early recognition and tailored management, guided by the type of complication and the patient’s condition, are essential for improving outcomes. The review offers an updated, practical overview to assist clinicians in managing these challenging scenarios, particularly when surgery becomes the final - but life-saving - resort.