Prevention and Management of Endoscopic Retrograde Cholangiopancreatography-Related Perforation: A Guideline-Based Narrative Review

Endoscopic retrograde cholangiopancreatography (ERCP) is important for the therapeutic management of pancreatobiliary diseases, but it carries a risk of perforation, an infrequent yet life-threatening adverse event. We summarize contemporary evidence on the prevention and management of ERCP-related perforation, aligning with current society guidelines (European Society of Gastrointestinal Endoscopy 2020, American Society for Gastrointestinal Endoscopy 2017, and Japan Gastroenterological Endoscopy Society 2018). We conducted a comprehensive narrative review by searching the PubMed, EMBASE, and Cochrane Library databases for articles published between January 2010 and October 2025. We prioritized current society guidelines, recent systematic reviews and meta-analyses, and landmark original studies, focusing on incidence, classification, risk factors, prevention strategies, and outcomes. Evidence was narratively synthesized to provide guideline-aligned recommendations. Perforation occurs in approximately 0.1% to 1.8% of ERCPs and is associated with substantial morbidity and mortality. The Stapfer system can be used to stratify injury severity and guide management. Most periampullary (Stapfer type II) and ductal (type III) injuries can be managed nonoperatively with endoscopic closure and/or diversion (e.g., fully covered self-expandable metal stents), whereas large, free-wall duodenal perforations (type I) often require early surgery. Early recognition, the use of CO2insufflation, careful sphincterotomy and dilation, and multidisciplinary care are associated with improved outcomes. Prevention through meticulous technique and appropriate case selection is important. When a perforation does occur, prompt classification and a stratified intervention approach (conservative, endoscopic, or surgical) can optimize treatment outcomes. Advances in endoscopic closure and diversion have significantly reduced the need for surgical intervention in many patients. However, prompt surgical management remains critical in select cases.