Copyright ©The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Endosc. Mar 16, 2019; 11(3): 219-230
Published online Mar 16, 2019. doi: 10.4253/wjge.v11.i3.219
Endoscopic retrograde cholangiopancreatography, lights and shadows: Handle with care
Raffaele Salerno, Nicolò Mezzina, Sandro Ardizzone
Raffaele Salerno, Gastroenterology and Digestive Endoscopy Unit, ASST Fatebenefratelli Sacco, Milan 20121, Italy
Nicolò Mezzina, Gastrointestinal Unit, ASST Fatebenefratelli Sacco-Department of Biochemical and Clinical Sciences "L. Sacco", University of Milan, Milano 20100, Italy
Sandro Ardizzone, Gastrointestinal Unit, ASST Fatebenefratelli Sacco - Department of Biochemical and Clinical Sciences "L. Sacco", University of Milan, Milano 20100, Italy
Author contributions: All authors contributed equally to this manuscript.
Conflict-of-interest statement: All authors have no conflicts of interest to report.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Raffaele Salerno, MD, Doctor, Gastroenterology and Digestive Endoscopy Unit, ASST Fatebenefratelli Sacco, Corso Porta Nuova 23, Milan 20121, Italy.
Telephone: +39-02-63632506 Fax: +39-02-63632249
Received: January 6, 2019
Peer-review started: January 7, 2019
First decision: January 30, 2019
Revised: February 21, 2019
Accepted: March 11, 2019
Article in press: March 11, 2019
Published online: March 16, 2019

The role of endoscopic retrograde cholangiopancreatography (ERCP) has dramatically changed in the last years, mainly into that of a therapeutic procedure. The treatment of benign biliary disease, like “difficult” choledocolithiasis, with endoscopic papillary large balloon dilation combined with endoscopic sphinterotomy has proven an effective and safe technique. Moreover, safety in ERCP has improved as well, with the prevention of post-ERCP pancreatitis and patient-to-patient transmission of infections. The advent of self-expandable metal stenting has radically changed the management of biliopancreatic malignant strictures, while the role for therapy of benign strictures is still controversial. In addition, cholangioscopy (though the direct visualization of the biliopancreatic ductal system) has allowed for characterization of indeterminate biliary strictures and facilitated rescue therapy of large biliary stones deemed removable. Encouraging data from tissue ablation techniques, such as photodynamic therapy and radiofrequency ablation, need to be confirmed by large sample size clinical controlled trials. On the other hand, we have no drug-coated stents yet available to implant and evidence for the use of biodegradable stents is still weak. The competency and privileging of ERCP and endoscopic ultrasonography have been analyzed longer but the switch between the two procedures, at the same time, is becoming ordinary; as such, the endoscopist interested in this field should undergo parallel edification through training plans. Finally, the American Society for Gastrointestinal Endoscopy’s statement on non-anesthesiologist administration of propofol for gastrointestinal endoscopy is not actually endorsed by the European Society of Anaesthesiology, having many medical-legal implications in some European countries.

Keywords: Cholangiopancreatography, Endoscopic papillary large balloon dilation, Self-expandable metal stent, Cholangioscopy, Photodynamic therapy, Radiofrequency ablation, Competency, Privileging, Biodegradable stents, Drug-coated stents

Core tip: Endoscopic retrograde cholangiopancreatography (ERCP) has seen radical changes within the last three decades. The development of endoscopic ultrasonography and other imaging technologies has changed the role of ERCP from a diagnostic tool to a unique therapeutic and imaging platform. New technological developments in ERCP for diagnosis and treatment have been slow to progress, thus increasing the necessity of interest in diagnostic and therapeutic fields.