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Endoscopic retrograde cholangiopancreatography (ERCP) is a specialized endoscopic procedure that combines direct visualization with fluoroscopy to diagnose and treat disorders of the biliary and pancreatic ducts. Using a side-viewing duodenoscope, the endoscopist advances into the duodenum to access the major or minor papilla for selective cannulation of the common bile duct or pancreatic duct. Contrast injection allows delineation of ductal anatomy and facilitates therapeutic maneuvers such as sphincterotomy, stone removal, stricture dilation, and stent placement. ERCP has transitioned from a primarily diagnostic tool to a therapeutic modality, given the emergence of noninvasive imaging such as magnetic resonance cholangiopancreatography and endoscopic ultrasound. Despite its value, ERCP carries the highest complication risk of routine endoscopic procedures, with post-ERCP pancreatitis representing the most common and serious adverse event. Clinicians must demonstrate advanced technical expertise, refined patient selection, and a thorough understanding of procedural risks to ensure safe and effective outcomes. Clinicians participating in this activity expand their knowledge of ERCP indications, technical considerations, and patient-centered applications. The course strengthens competence in recognizing anatomic variations, applying evidence-based strategies for post-ERCP pancreatitis prevention, and selecting appropriate therapeutic interventions. Learners enhance their ability to anticipate and manage complications, incorporating prophylaxis, early recognition, and timely intervention into practice. Through case-based learning and procedural review, participants refine skills in sedation management, fluoroscopic interpretation, and endoscopic techniques. Collaboration with an interprofessional team—including anesthesiologists, radiologists, surgeons, gastroenterology nurses, and pharmacists—supports safer sedation practices, optimal complication prevention, and coordinated perioperative care. This interprofessional approach improves communication, standardizes workflows, and enhances long-term outcomes by reducing complications, shortening recovery, and ensuring continuity of care for patients undergoing ERCP. Objectives:

Clinicians participating in this activity expand their knowledge of ERCP indications, technical considerations, and patient-centered applications. The course strengthens competence in recognizing anatomic variations, applying evidence-based strategies for post-ERCP pancreatitis prevention, and selecting appropriate therapeutic interventions. Learners enhance their ability to anticipate and manage complications, incorporating prophylaxis, early recognition, and timely intervention into practice. Through case-based learning and procedural review, participants refine skills in sedation management, fluoroscopic interpretation, and endoscopic techniques. Collaboration with an interprofessional team—including anesthesiologists, radiologists, surgeons, gastroenterology nurses, and pharmacists—supports safer sedation practices, optimal complication prevention, and coordinated perioperative care. This interprofessional approach improves communication, standardizes workflows, and enhances long-term outcomes by reducing complications, shortening recovery, and ensuring continuity of care for patients undergoing ERCP. Objectives: Identify early and late signs of complications, including post-endoscopic retrograde cholangiopancreatography pancreatitis, bleeding, perforation, and cholangitis. Improve understanding of the techniques involved in performing an endoscopic retrograde cholangiopancreatography. Assess the potential complications of endoscopic retrograde cholangiopancreatography, identify steps that can be taken to reduce their risk, and outline strategies for managing complications should they occur. Collaborate with an interprofessional team to develop strategies to optimize care coordination and communication and advance endoscopic retrograde cholangiopancreatography's appropriate and efficacious utilization. Access free multiple choice questions on this topic.

Endoscopic retrograde cholangiopancreatography (ERCP) is a specialized endoscopic technique that combines endoscopy and fluoroscopy to diagnose and, more commonly, treat disorders of the biliary and pancreatic ducts. Using a side-viewing duodenoscope, the endoscopist advances the instrument into the second portion of the duodenum to access the major or minor papilla, allowing selective cannulation of the common bile duct (CBD) and/or pancreatic duct. Through these channels, contrast material is injected to delineate ductal anatomy under fluoroscopic guidance and to facilitate interventions such as sphincterotomy, stone extraction, stricture dilation, or placement of plastic or metal stents. Originally developed as a diagnostic modality, ERCP has evolved into a primarily therapeutic procedure, as less invasive imaging methods, such as magnetic resonance cholangiopancreatography (MRCP) and endoscopic ultrasound (EUS), have replaced its diagnostic role. Despite its essential therapeutic value, ERCP carries the highest risk of significant complications among routine endoscopic procedures, including pancreatitis, bleeding, perforation, and infection. Successful performance requires advanced endoscopic training, technical expertise, and careful patient selection to balance clinical benefits against potential risks.

ERCP is the highest-risk regularly performed procedure in gastroenterology.[28] The most common complications are acute post-ERCP pancreatitis (PEP), bleeding, infection, and perforation (see Table. Adverse Events Related to ERCP).[29] More severe complications require endoscopic or surgical intervention, blood transfusion of more than 4 units, or prolonged hospitalization (greater than 10 days). Gastrointestinal bleeding and perforation are primarily related to sphincterotomy. Although perforation is rare, it carries the highest mortality rate among ERCP complications. Other issues account for 1.3% of total complications. These include cardiovascular and analgesia-related events, such as those in patients with pacemakers and implantable cardioverter-defibrillators, as well as pneumothorax, hepatic hematoma, portal venous air embolism, splenic injury, post-sphincterotomy papillary or ampullary restenosis, duodenal obstruction, stent migration, and impaction of the basket catheter during the removal of biliary stones. Table Table. Adverse Events Related to ERCP . PEP PEP is the most commonly encountered complication of ERCP. Despite identifying risk factors and establishing guidelines to reduce its incidence, the incidence of PEP hasn't changed between 2000 and 2023.[29] In 90% of cases, pancreatitis is mild-to-moderate in severity, and early recognition provides the best opportunity to minimize morbidity and mortality. Diagnosis: The Cotton consensus and the revised Atlanta classification criteria are used to diagnose PEP: Cotton consensus criteria Pancreatitis-like abdominal pain, elevated pancreatic enzyme levels of lipase or amylase to greater than 3 times the upper limit of normal on the day following ERCP, and an unplanned hospital stay of at least 2 nights.[33] Revised Atlanta classification criteria Pancreatitis-like abdominal pain, elevated pancreatic enzyme levels of lipase or amylase to greater than 3 times the upper limit of normal on the day following ERCP, and imaging consistent with acute pancreatitis.[34] Risk factors include patient selection for ERCP, procedure-related issues, and a higher risk associated with less experienced endoscopists and at centers where the procedure is performed less frequently. Patient selection PEP is more common in younger patients, in females, in people with suspected or confirmed sphincter of Oddi dysfunction, and in people with a history of PEP.

Risk factors include patient selection for ERCP, procedure-related issues, and a higher risk associated with less experienced endoscopists and at centers where the procedure is performed less frequently. Patient selection PEP is more common in younger patients, in females, in people with suspected or confirmed sphincter of Oddi dysfunction, and in people with a history of PEP. Procedure-related risk factors Difficulty with cannulation [35] Delayed decision to perform a precut sphincterotomy Balloon dilation of an intact sphincter of Oddi of <1 minute's duration in the absence of a prior biliary sphincterotomy Any pancreatic ductal intervention, including wire passage(s) into the pancreatic duct Less likely risk factors: intraductal ultrasound and failure to remove bile duct stones With recognition of risk factors for PEP, measures should be taken to reduce the risk of this complication [36]. These include: Use of endoscopic ultrasound or MRCP instead of ERCP unless there is a high likelihood that a therapeutic intervention (sphincterotomy, balloon or basket stone extraction, or stent placement) will need to be performed. Referral of patients to tertiary care centers if the risk is high and greater experience is needed. Rectal nonsteroidal anti-inflammatory drug (NSAID) administration decreases the incidence of PEP; thus, an indomethacin or diclofenac 100 mg suppository is given immediately before, during, or promptly after the procedure. An NSAID suppository is recommended in all patients except for those in whom the risk of PEP is negligible, such as those with chronic calcific pancreatitis who have had uncomplicated ERCPs in the past or who have had a biliary sphincterotomy and require biliary endotherapy for retained stones, strictures, or bile leaks. Aggressive hydration using lactated Ringer solution. This hydration can be achieved with a preprocedural bolus of 1 liter or more in healthy but high-risk individuals. A high-flow infusion should be maintained during and after the procedure. Aggressive hydration is recommended for all patients in the United States who can tolerate it. Still, in Europe, it is limited to those in whom a pancreatic stent hasn't been placed and when rectal NSAIDs cannot be administered.[37][38]

Aggressive hydration using lactated Ringer solution. This hydration can be achieved with a preprocedural bolus of 1 liter or more in healthy but high-risk individuals. A high-flow infusion should be maintained during and after the procedure. Aggressive hydration is recommended for all patients in the United States who can tolerate it. Still, in Europe, it is limited to those in whom a pancreatic stent hasn't been placed and when rectal NSAIDs cannot be administered.[37][38] A pancreatic stent can be placed prophylactically before biliary intervention in patients at an increased risk of PEP. Pancreatic stent placement in conjunction with rectal indomethacin was found to be more effective than indomethacin alone, however in light of the potential risk of pancreatitis due to placement of the stent as well as its cost and requirement of follow-up, its use more recently has been limited to higher risk individuals in whom placement of the stent is not difficult (for example, in cases in which a wire was inadvertently passed into the pancreatic duct during an attempt at biliary cannulation).[39] When a prophylactic stent is placed, a plain abdominal x-ray should be taken 7 to 10 days after placement of a pancreatic stent, and retained stents should be removed endoscopically within 10 days of placement if they haven't passed out of the body spontaneously. Coagulopathic individuals with choledocholithiasis have the lowest risk of PEP if a biliary stent is placed and sphincterotomy is delayed until the coagulopathy is corrected. The alternative option is to perform balloon dilatation, which should be maintained for 2 to 5 minutes to reduce PEP.[40] Minimizing the number of cannulation attempts and the volume of contrast material injected. The wire-guided technique is recommended for cannulation, rather than attempting to cannulate either duct with the cannula or sphincterotome too deeply. The wire-guided technique has been demonstrated to reduce the risk of PEP by about 50%, and can usually be facilitated by minimal contrast injection when necessary.[41]

Minimizing the number of cannulation attempts and the volume of contrast material injected. The wire-guided technique is recommended for cannulation, rather than attempting to cannulate either duct with the cannula or sphincterotome too deeply. The wire-guided technique has been demonstrated to reduce the risk of PEP by about 50%, and can usually be facilitated by minimal contrast injection when necessary.[41] The double-wire technique is used if there is difficulty accessing the CBD and repeated wire passage into the pancreatic duct. This technique leaves a wire in the pancreatic duct to straighten the ductal anatomy, facilitating access to the CBD with a second wire. After the CBD has been accessed, the pancreatic duct wire can be removed unless a pancreatic intervention, such as pancreatic duct stent placement, is planned. If a precut sphincterotomy is needed, needle-knife fistulotomy is recommended over other techniques, as it carries fewer complications, including PEP. Alternative maneuvers when cannulation cannot be done easily include biliary cannulation adjacent to a pancreatic stent, placement of a pancreatic duct wire, followed by attempted wire advancement into the bile duct, and pancreatic septotomy. Biliary manometry is performed to evaluate the Sphincter of Oddi using a modified triple-lumen perfusion catheter with immediate aspiration or a non-water-perfused micro transducer catheter to reduce the risk of PEP. Bleeding This is usually due to sphincterotomy, and bleeding is usually from a vessel at the crest of the sphincterotomy. Risk factors for post-sphincterotomy bleeding include the following: Thrombocytopenia (platelet count less than 50,000/µL) Use of anticoagulants and direct antiplatelet agents (eg, clopidogrel or prasugrel) Cirrhosis (although a prolonged INR in cirrhosis may reflect hypercoagulability rather than a bleeding disorder) Chronic renal failure requiring hemodialysis Ascending cholangitis Periampullary diverticula Nonsphincterotomy causes of bleeding: Hemobilia after intraductal interventions such as biopsies or balloon dilation Intraductal photodynamic therapy Intraductal radiofrequency ablation Prevention of bleeding:

Cirrhosis (although a prolonged INR in cirrhosis may reflect hypercoagulability rather than a bleeding disorder) Chronic renal failure requiring hemodialysis Ascending cholangitis Periampullary diverticula Nonsphincterotomy causes of bleeding: Hemobilia after intraductal interventions such as biopsies or balloon dilation Intraductal photodynamic therapy Intraductal radiofrequency ablation Prevention of bleeding: Withhold antiplatelet drugs and anticoagulants before ERCP, with duration differing related to the specific drug, and ideally for 2 to 3 days after ERCP. Aspirin and other NSAIDs can be continued as they do not increase the risk of intraprocedural bleeding.[42] If anticoagulation cannot be held or reversed in the setting of ascending cholangitis in the presence of a coagulopathy, there are several options: A stent or a nasobiliary drain placed through an intact papilla can temporarily relieve the obstruction and infection. Once the coagulation factors have been normalized, a sphincterotomy and other necessary interventions can be carried out later. A small sphincterotomy can be made, then tamponaded with a fully covered metallic stent. To further reduce the risk of pancreatitis, balloon dilatation for at least 2 minutes or longer may be necessary. Control of bleeding: Endoscopic application of cauterization at the crest of the sphincterotomy Placement of a hemostatic clip, with caution to avoid the pancreatic duct Application of polysaccharide hemostatic powder or newer hemostatic gels [43][44] Placement of a fully covered metallic stent, trying to avoid obstructing the cystic duct take-off, if other measures are ineffective Angiographic embolization of the vessel if all endoscopic measures fail to achieve hemostasis Infection

Placement of a hemostatic clip, with caution to avoid the pancreatic duct Application of polysaccharide hemostatic powder or newer hemostatic gels [43][44] Placement of a fully covered metallic stent, trying to avoid obstructing the cystic duct take-off, if other measures are ineffective Angiographic embolization of the vessel if all endoscopic measures fail to achieve hemostasis Infection Bacterial contamination of duodenoscopes, due to inadequate cleaning in and around the elevator, is caused by the inability to sterilize the instruments during reprocessing. Bacterial biofilm can accumulate beneath and at the elevator channel, and infection outbreaks with MDROs on duodenoscopes have become a problem since 2012. Outbreaks of carbapenem-resistant Enterobacteriaceae (CRE) appeared in the early 2010s.[45] Another outbreak occurred in 2014 in the United States, the Netherlands, and India, with extended-spectrum beta-lactamase-producing Klebsiella pneumoniae.[46] An outbreak of New Delhi metallo-ß-lactamase-producing carbapenem-resistant Escherichia coli occurred in the United States, which only abated after reprocessing was changed from disinfection with ortho-phthalaldehyde to ethylene oxide gas sterilization.[47] An improved reprocessing technique, involving forced-air drying of duodenoscopes, may help reduce such infections.[48] The rate of infections may be reduced with: Modified duodenoscopes that can be sterilized Readily replaceable channels on reusable scopes Availability of disposable duodenoscopes [49][50]

Bacterial contamination of duodenoscopes, due to inadequate cleaning in and around the elevator, is caused by the inability to sterilize the instruments during reprocessing. Bacterial biofilm can accumulate beneath and at the elevator channel, and infection outbreaks with MDROs on duodenoscopes have become a problem since 2012. Outbreaks of carbapenem-resistant Enterobacteriaceae (CRE) appeared in the early 2010s.[45] Another outbreak occurred in 2014 in the United States, the Netherlands, and India, with extended-spectrum beta-lactamase-producing Klebsiella pneumoniae.[46] An outbreak of New Delhi metallo-ß-lactamase-producing carbapenem-resistant Escherichia coli occurred in the United States, which only abated after reprocessing was changed from disinfection with ortho-phthalaldehyde to ethylene oxide gas sterilization.[47] An improved reprocessing technique, involving forced-air drying of duodenoscopes, may help reduce such infections.[48] The rate of infections may be reduced with: Modified duodenoscopes that can be sterilized Readily replaceable channels on reusable scopes Availability of disposable duodenoscopes [49][50] Single-use duodenoscopes may be suitable only for lower-complexity procedures; they are not yet comparable in quality to reusable instruments and significantly increase preprocedure costs.[50] Various newer scopes designed to reduce the risk of infectious disease transmission have been developed and are currently being tested.[49][51] Post-ERCP ascending cholangitis is typically caused by inadequate clearance of ductal obstruction during ERCP or as a consequence of papillary edema following sphincterotomy or complicated stone extraction. Endoscopic accessories and contrast media can carry organisms into the biliary and pancreatic trees, potentially causing infection with inadequate drainage. In this setting, cholangitis can be caused by complicated strictures, such as those resulting from hilar tumors that are challenging to stent, primary sclerosing cholangitis with multiple strictures that can retain contrast, or incompletely cleared choledocholithiasis. Cholangitis may also occur after cholangioscopy, particularly if biopsies are taken and when bacteremia is documented after the procedure.[52] Measures to reduce the risk of cholangitis include the following:

Single-use duodenoscopes may be suitable only for lower-complexity procedures; they are not yet comparable in quality to reusable instruments and significantly increase preprocedure costs.[50] Various newer scopes designed to reduce the risk of infectious disease transmission have been developed and are currently being tested.[49][51] Post-ERCP ascending cholangitis is typically caused by inadequate clearance of ductal obstruction during ERCP or as a consequence of papillary edema following sphincterotomy or complicated stone extraction. Endoscopic accessories and contrast media can carry organisms into the biliary and pancreatic trees, potentially causing infection with inadequate drainage. In this setting, cholangitis can be caused by complicated strictures, such as those resulting from hilar tumors that are challenging to stent, primary sclerosing cholangitis with multiple strictures that can retain contrast, or incompletely cleared choledocholithiasis. Cholangitis may also occur after cholangioscopy, particularly if biopsies are taken and when bacteremia is documented after the procedure.[52] Measures to reduce the risk of cholangitis include the following: Attempt to drain the biliary tree entirely during ERCP. Stents or a nasobiliary drain should be placed into undrained ducts that contain contrast until complete drainage can be achieved. If stenting is not possible, percutaneous biliary drainage can be performed. Antibiotic prophylaxis is often prescribed when there is concern that complete biliary drainage may be difficult or impossible, as it reduces the risk of bacteremia. However, this has not been proven to reduce the risk of cholangitis, pancreatitis, septicemia, or mortality.[53] Post-ERCP acute cholecystitis most commonly occurs after placement of uncovered or covered metallic biliary stents that occlude the cystic duct, with the incidence being slightly higher with covered stents; however, a stricture or a retained stone can also be responsible.[44] Symptoms of cholecystitis appear at a median of 5 days after ERCP. If the cystic duct is occluded, antibiotics should be given, and options for gallbladder decompression include: Replacement of a metallic stent with 1 or more plastic stents Endoscopic transpapillary gallbladder stent placement Transmural drainage with EUS guidance Percutaneous cholecystostomy drainage Cholecystectomy, if indicated Perforation

Post-ERCP acute cholecystitis most commonly occurs after placement of uncovered or covered metallic biliary stents that occlude the cystic duct, with the incidence being slightly higher with covered stents; however, a stricture or a retained stone can also be responsible.[44] Symptoms of cholecystitis appear at a median of 5 days after ERCP. If the cystic duct is occluded, antibiotics should be given, and options for gallbladder decompression include: Replacement of a metallic stent with 1 or more plastic stents Endoscopic transpapillary gallbladder stent placement Transmural drainage with EUS guidance Percutaneous cholecystostomy drainage Cholecystectomy, if indicated Perforation Perforations during ERCP can be related to foregut (esophageal, gastric, and proximal duodenal) strictures that prevent the duodenoscope from easily reaching the post-bulbar duodenum, or to steps taken during and after accessing the bile and pancreatic ducts. The latter have been classified into 4 Stapfer types: Type I: Duodenal wall free perforation (or jejunal wall perforation after Billroth II gastrectomy) Type II: Retroperitoneal duodenal perforation due to periampullary injury; these are the most common and can often be managed endoscopically without requiring surgery [54] Type III: Perforation of either the pancreatic duct or the bile duct Type IV: Retroperitoneal air without other signs of perforation [55] Foregut (luminal) full-thickness perforations are rare. Still, morbidity and mortality are high, particularly when perforation is not immediately recognized or cannot be immediately repaired during a procedure at a nonhospital site. Esophageal perforations, for example, have a 13% mortality rate in such settings, as a consequence of infection.[32] Luminal perforations are typically associated with strictures or surgically altered anatomy. Passage of the duodenoscope into the duodenum must be done cautiously to avoid causing perforation in one of those circumstances. A forward-viewing gastroscope is prudent if the anatomy must be clarified before duodenoscopy. If it is available, carbon dioxide should be used for insufflation of the gastrointestinal tract during endoscopy to reduce the risk of perforation. Biliary or pancreatic stents infrequently may penetrate the duodenal wall, which may be asymptomatic or cause stent occlusion.

Foregut (luminal) full-thickness perforations are rare. Still, morbidity and mortality are high, particularly when perforation is not immediately recognized or cannot be immediately repaired during a procedure at a nonhospital site. Esophageal perforations, for example, have a 13% mortality rate in such settings, as a consequence of infection.[32] Luminal perforations are typically associated with strictures or surgically altered anatomy. Passage of the duodenoscope into the duodenum must be done cautiously to avoid causing perforation in one of those circumstances. A forward-viewing gastroscope is prudent if the anatomy must be clarified before duodenoscopy. If it is available, carbon dioxide should be used for insufflation of the gastrointestinal tract during endoscopy to reduce the risk of perforation. Biliary or pancreatic stents infrequently may penetrate the duodenal wall, which may be asymptomatic or cause stent occlusion. Sometimes luminal perforations can be closed primarily with endoscopically placed sutures or clips.[32] However, if the lumen is too narrow for the duodenoscope to pass, there will likely be too little room for a primary closure. In those cases, a fully covered esophageal stent can seal the rent if it can be positioned and secured above the major duodenal papilla. If that is not possible due to the type of perforation, if the patient becomes clinically unstable, if the perforation is too large, or if endoscopic expertise is not available to perform a primary closure, surgery may be necessary. In fact, surgery is necessary to repair most esophageal perforations and open gastric or duodenal perforations. When surgery is delayed because of failure of nonoperative therapy, there is greater morbidity and mortality, and hospitalizations are prolonged.[56] Biliary or pancreatic stents infrequently may penetrate the duodenal wall, which may be asymptomatic or cause stent occlusion. Perforation by a previously placed stent can often be managed by removing the stent. However, antibiotics should be administered, and clip closure should be performed if there is evidence of infection, as indicated by the presence of gas or fluid around the penetrated site. In all cases of luminal perforation, surgical consultation should be considered even if endoscopic closure can be performed successfully during the procedure.

Biliary or pancreatic stents infrequently may penetrate the duodenal wall, which may be asymptomatic or cause stent occlusion. Perforation by a previously placed stent can often be managed by removing the stent. However, antibiotics should be administered, and clip closure should be performed if there is evidence of infection, as indicated by the presence of gas or fluid around the penetrated site. In all cases of luminal perforation, surgical consultation should be considered even if endoscopic closure can be performed successfully during the procedure. In cases of periampullary or retroperitoneal perforations related to cannulation and additional biliary and pancreatic interventions, sphincterotomy is the intervention that most greatly increases the risk of such perforations, and more so if it is being extended, redone, associated with a sphincteroplasty, or if it is associated with Sphincter of Oddi dysfunction.[57] Difficult cannulations or balloon dilatation of the bile or pancreatic duct also increase the risk of perforation. Guidewires may pass through the duodenal wall, which is recognized by retroperitoneal air. The risk of perforation is minimized by recognition of the anatomical landmarks at the papilla and by choosing a stricture-dilating balloon with a diameter that is not in excess of the size of the duct proximal to it.[57] Management of pancreatic and biliary perforations includes: Antibiotic administration should be initiated when a perforation is recognized or suspected. The location and extent of the perforation should be confirmed by oral contrast-enhanced computed tomography. Perforations due to sphincterotomy or biliary/pancreatic duct leaks are best managed with a fully covered metallic stent, providing the least resistance path through the stent. Surgery is indicated if endoscopic management is ineffective or if peritonitis and systemic inflammatory response syndrome (SIRS) are present. Guidewire perforation through the duodenal wall is usually clinically inconsequential and rarely requires intervention.

Perforations due to sphincterotomy or biliary/pancreatic duct leaks are best managed with a fully covered metallic stent, providing the least resistance path through the stent. Surgery is indicated if endoscopic management is ineffective or if peritonitis and systemic inflammatory response syndrome (SIRS) are present. Guidewire perforation through the duodenal wall is usually clinically inconsequential and rarely requires intervention. Some perforations cannot be identified immediately or develop gradually after the ERCP, and peritonitis may occur. Such delayed perforations are most frequently due to electrocautery applied during sphincterotomy or sphincteroplasty, and symptoms develop over several days after the procedure. They are typically contained, but may result in peritonitis and SIRS.[58] Delayed luminal perforations without signs of significant morbidity may be managed endoscopically. Still, infection and a systemic inflammatory response necessitate surgery for abdominal washout and external drainage after the defect is closed.[59]

Successful performance of ERCP requires a combination of technical skill, strategic planning, and seamless team coordination. Clinicians must demonstrate advanced endoscopic expertise, precise fluoroscopic interpretation, and the ability to anticipate and manage complications such as post-ERCP pancreatitis, bleeding, or perforation. Advanced clinicians and nurses play a crucial role in patient preparation, sedation monitoring, and postprocedural care, ensuring the early recognition of complications and providing effective patient education on recovery and follow-up. Pharmacists contribute by guiding optimal antibiotic prophylaxis, managing anticoagulation and antiplatelet therapy, and supporting the appropriate use of medication to minimize procedural risks. Interprofessional communication and structured care coordination are crucial for optimizing patient-centered outcomes in ERCP. Preprocedural planning involves collaboration among the endoscopist, anesthesiologist, nursing staff, and radiology technicians to align on patient-specific risks and procedural strategies. Intraoperatively, real-time communication facilitates the safe navigation of complex anatomy and enables a timely response to complications. Postprocedurally, coordination with primary care clinicians, surgeons, oncologists, or hepatologists ensures continuity of care, particularly in patients requiring long-term stent management or further surgical intervention. This integrated, multidisciplinary approach enhances patient safety, maximizes therapeutic benefit, and strengthens team performance in managing complex biliopancreatic disorders.