Prophylaxis of Post-ERCP Pancreatitis: The Gap between Evidence-Based Guidelines and Clinical Practice

Endoscopic retrograde cholangiopancreatography (ERCP) remains one of the most complex and “risky” endoscopic techniques and the one with a longer learning curve. Pancreatitis is the most common serious complication of ERCP [1, 2] and a frequent legal claim for ERCPrelated malpractice. Post-ERCP pancreatitis (PEP) occurs in 2–10% of unselected patients and in up to 40% of the high-risk patients [2]. Even for experienced endoscopists, PEP is an unpredictable event, although enough data about risk factors and prophylaxis measures are available. Manipulation of pancreatic ducts is a well-known risk factor for PEP, and pancreatic stent placement is protective for PEP after pancreatic sphincterotomy [3]. The European Society of Gastrointestinal Endoscopy (ESGE) and American Society of Gastrointestinal Endoscopy (ASGE) published guidelines on PEP prevention in 2014 and 2017, respectively, where both patientand procedure-associated risk factors are identified, and prophylaxis measures are evidence-based and recommended [1, 4]. These measures may be as simple and safe as the use of rectal nonsteroidal anti-inflammatory drugs (NSAIDs; indometacin, diclofenac) or more technically demanding as the use of protective pancreatic stents. Systemic interventions, such as periprocedural vigorous hydration, may reduce not only the incidence but also the severity of PEP [1, 4]. Comparison between centers may be troublesome as the complexity of treated patients significantly varies. The definition of “personal experience” should not rely only on the number of cases encountered but also take the competence to treat according to complexity into consideration. Well-established grading scales for the degree of the difficulty of ERCP procedures are available [5, 6]. In this issue of GE – Portuguese Journal of Gastroenterology, the paper “ERCP in Portugal. A wide survey on the prevention of post-ERCP pancreatitis and papillary cannulation techniques” by Lopes and Canena [7] investigates the compliance of the Portuguese ERCP specialists with the ESGE guidelines for PEP prophylaxis. This survey of the attendants of an ERCP meeting puts the focus on four specific items: (1) technique for biliary cannulation; (2) NSAID use for PEP prophylaxis; (3) attempt to put a protective pancreatic stent after pancreatic guidewire-assisted biliary cannulation; and (4) use of precut as the first rescue technique after cannulation failure. The