Endoscopic retrograde cholangiopancreatography(ERCP)-related perforations represent rare but often severe conditions. While lesions with intraperitoneal perforation have an almost imperative indication to surgery, whether or not to manage retroperitoneal perforations surgically is still an area of debate. The aim of the present work was to review the available clinical evidence on the operatively and medi cally treated ERCP-related retroperitoneal perforations. From MEDLINE/Pub Med databases 137 patients with retroperito neal perforation were included from 12 studies that met the selection criteria for data investigation and analysis. Twenty four patients were treated by prompt surgery; 113 were primarily managed conservatively and about 20% of these patients required surgery subsequently. Overall, the morbid ity and mortality were 15.4% and 6.6%, respectively. Although most patients with retroperitoneal perforation may benefit from a non-operative management, a considerable number of patients fail to respond to medical treatment and require sur gery afterwards. Identifying those patients who are at highest risk of poor outcome after conservative treatment should be considered a research priority. Endoscopic retrograde cholangiopancreatography (ERCP) -related perforations represent rare but often severe conditions. While lesions with intraperitoneal perforation have an almost imperative indication to surgery, whether or not to manage retroperitoneal perforations surgically is still an area of ​​debate. The aim of the present work was to review the available clinical evidence on the operatively and medi c cially treated ERCP-related retroperitoneal perforations. From MEDLINE / Pub Med databases 137 patients with retroperito neal perforation were included from 12 studies that met the selection criteria for data investigation and analysis. Twenty four Overall, the morbid ity and mortality were 15.4% and 6.6%, respectively. Although most patients with managed perperation may benefit from a non-surgical -operative management, a considerable number of patients fail to respond to medical treatment and require sur gery afterwards. Identifying those patients who are at highest risk of poor outcome after conservative treatment should be considered a research priority.