Endoscopic retrograde cholangiopancreatography, lights and shadows: Handle with care

Table 1 Summary of current evidence for each topic

Topic	Current evidence
Management of " difficult" choledocolithiasis	EST plus EPLBD
Cholangioscopy	Electrohydraulic or laser lithotripsy/tissue sampling
Safety in ERCP: complications and infections
PEP	Rectal administration of 100 mg of diclofenac or indomethacin and pancreatic duct stenting in high-risk and average-risk patients/aggressive intravenous hydration/wire-guided cannulation
Multi-drug resistant bacteria and duodenoscopes	Single-use disposable elevator
Management of malignant and benign biliary strictures	Bilateral drainage for hilar strictures with uSEMS /“multi-stenting” treatment for benign biliary strictures
Tissue ablation techniques	PDT with biliary stenting in advanced cholangiocarcinoma (more studies are needed)
	RFA for advanced cholangiocarcinoma (more studies are needed)
Training in biliopancreatic endoscopy	ERCP: at least 200 procedures under supervision of a tutor with 80 sphincterotomies and 60 stent insertions
	EUS: at least 225 hands-on cases under supervision
Biodegradable and drug-coated stents	BDBSs with polylactide or polydioxanone showed good biocompatibility (more studies are needed)
	Only paclitaxel has been trialed in humans with malignant obstruction (more studies are needed)
Sedation in ERCP	Propofol and standard sedation by non-anesthesiologists is equivalent in terms of efficacy and safety in a setting of properly trained staff and accurate patient selection (ASGE): ESA retracted its endorsement to ESGE and ESGENA

ASGE: American Society for Gastrointestinal Endoscopy; BDBSs: Self-expanding biodegradable biliary stents; EPLBD: Endoscopic papillary large balloon dilation; ESA: European Society of Anaesthesiology; ESGE: European Society of Gastrointestinal Endoscopy; ESGENA: European Society of Gastroenterology and Endoscopy Nurses and Associates; EST: Endoscopic sphincterotomy; PDT: Photodynamic therapy; PEP: Post-ERCP pancreatitis; uSEMS: Uncovered self-expandable metal stent; RFA: Radiofrequency ablation.