How to prevent post-ERCP pancreatitis?

The incidence of post-ERCP pancreatitis (PEP) has remained constant since 30 years. During the last 10 years, large progresses have been made in the knowledge of (i) factors that predispose to PEP and (ii) measures that are effective to prevent PEP. Many of these measures have not yet been widely implemented. Complete recommendations for PEP prophylaxis are summarized in the review. For high-risk ERCPs, including ampullectomy, pancreatic sphincterotomy, precut biliary sphincterotomy, known or suspected sphincter of Oddi dysfunction, pancreatic guidewire-assisted biliary cannulation and endoscopic balloon sphincteroplasty, prophylactic pancreatic stent placement should be considered. For low-risk ERCPs, periprocedure rectal administration of NSAID is recommended. Prophylactic pancreatic stenting should be investigated in terms of education of endoscopists for insertion techniques, ease of stent insertion, reliability of spontaneous stent elimination and safety (demonstration of the absence of induced pancreatic changes).