Cracking the code of post-ERCP pancreatitis: predictors, prevention, and proven strategies from 3323 surgeon-led procedures

Background: Endoscopic Retrograde Cholangiopancreatography (ERCP) is a crucial yet technically demanding therapeutic procedure. Post-ERCP pancreatitis (PEP) remains one of its most significant complications, with risk influenced by both patient- and procedure-related factors. Standardised technical strategies may help reduce this risk, but published evidence from surgeon-led ERCP services is still limited. This study evaluates predictors of PEP and the effectiveness of a surgeon-led, protocol-driven approach in reducing its occurrence. 

Methods: We retrospectively analysed 3323 consecutive ERCP procedures performed by four surgical endoscopists at a UK district general hospital between September 2016 and May 2025. A uniform technical protocol including wire-guided cannulation, early needle-knife sphincterotomy, minimal papillary trauma, and NSAID prophylaxis was adopted. Prospectively collected demographic, procedural, and outcome data were reviewed. Independent predictors of PEP were identified using univariable and multivariable logistic regression. 

Results: PEP occurred in 90 cases (2.7%; 95% CI: 2.21–3.32), predominantly mild (76.5%), with moderate (15.3%) and severe (8.2%) forms less frequent. Mortality from PEP was 0.06%. Independent predictors of PEP were emergency ERCP (OR 2.07; 95% CI: 1.23–3.48), first ERCP (OR 4.79; 95% CI: 2.66–9.29), age < 60 years (OR 1.69; 95% CI: 1.08–2.62), and biliary stent placement (OR 1.61; 95% CI: 1.03–2.52). Hospital length of stay increased with PEP severity (median 5 vs 12.5 vs 32 days; p < 0.001). Operator experience had no significant effect on PEP incidence. 

Conclusions: Our surgeon-led ERCP service achieved a remarkably low PEP rate, reflecting careful technique and compliance to a structured protocol. Risk was shaped more by patient and procedural factors than by operator experience, underscoring the value of disciplined, evidence-based practice in minimising PEP.