Optimal endoscopic techniques to reduce the risk of post-endoscopic retrograde cholangiopancreatography pancreatitis

Post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) is the most common and feared complication of endoscopic retrograde cholangiopancreatography. Patient selection is an important variable that is important when determining the risk of PEP. The factors that may increase the risk of PEP include papillary trauma, papillary edema, and pancreatic ductal injury (mechanical or hydrostatic). Proven methods to decrease the risk of PEP include wire-guided cannulation, prophylactic short-term pancreatic duct (PD) stenting, and avoiding frequent PD cannulation, injection, or overinjection. Additional measures that might decrease the risk of PEP by decreasing cannulation time include a double guidewire technique, and early precut sphincterotomy. Certain techniques are known to have an increased risk of pancreatitis and should be implemented only when necessary. When performing measures such as large-balloon papillary dilation or pancreatic sphincterotomy, the rates of pancreatitis may be decreased with small alterations in the technique. A short biliary sphincterotomy when performed with papillary large-balloon dilation and needle-knife pancreatic sphincterotomy over a PD stent have both been shown to decrease the risk of pancreatitis.