Operative treatment of periampullary retroperitoneal perforation complicating endoscopic sphincterotomy

Diagnosis and management of iatrogenic endoscopic perforations: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement - Update 2020

1:  ESGE recommends that each center implements a written policy regarding the management of iatrogenic perforations, including the definition of procedures that carry a higher risk of this complication. This policy should be shared with the radiologists and surgeons at each center. 2 : ESGE recommends that in the case of an endoscopically identified perforation, the endoscopist reports its size and location, with an image, and statement of the endoscopic treatment that has been applied. 3:  ESGE recommends that symptoms or signs suggestive of iatrogenic perforation after an endoscopic procedure should be rapidly and carefully evaluated and documented with a computed tomography (CT) scan. 4 : ESGE recommends that endoscopic closure should be considered depending on the type of the iatrogenic perforation, its size, and the endoscopist expertise available at the center. Switch to carbon dioxide (CO2) endoscopic insufflation, diversion of digestive luminal content, and decompression of tension pneumoperitoneum or pneumothorax should also be performed. 5 : ESGE recommends that after endoscopic closure of an iatrogenic perforation, further management should be based on the estimated success of the endoscopic closure and on the general clinical condition of the patient. In the case of no or failed endoscopic closure of an iatrogenic perforation, and in patients whose clinical condition is deteriorating, hospitalization and surgical consultation are recommended.

Role of Double-Lumen Irrigation-Suction Tube Drainage in Severe Intra-Abdominal Infection Induced by Endoscopic Sphincterotomy– Related Perforation

This study aimed to assess the efficacy of double-lumen irrigation-suction tube (DLIST) in treating severe intra-abdominal infection (SIAI) induced by endoscopic sphincterotomy–related perforation (EST-rP). We enrolled 34 consecutive patients who had been transferred to our hospital with SIAI induced by EST-rP from January 2000 to June 2018. Then they were assigned into two groups based on whether or not rescue surgery had been performed: failed nonoperative treatment group (n = 9) and failed rescue surgery treatment group (n = 25). All 34 patients received DLIST for positive draining by surgery in our hospital. Data collection included demographics, indication for endoscopic retrograde cholangiopancreatography, time to rescue surgery, surgical procedure, surgical success rate, complications, hospital stay, and postoperative outcome. The research enrolled 34 patients (ages 27–79 years, mean of 57.8 ± 12.1 years). There were no significant differences in age and gender between two groups ( P > 0.05). After being admitted, they were diagnosed with sepsis induced by SIAI (Sequential Organ Failure Assessment score range of 2–6, mean of 3.6 ± 0.95). The time from endoscopic retrograde cholangiopancreatography to rescue surgery was 12 to 336 hours (mean of 73.7 ± 72.2 hours); overall hospital stay was 15 to 405 (mean of 127.5 ± 81.5) days. The hospital stay was significantly longer in the failed rescue surgery group than that of the failed nonoperative treatment group ( P < 0.05). The overall mortality rate was 11.8 per cent (4/34). The mortality rate was 16 per cent (4/25) and 0 per cent (0/9), respectively. As a modified suction technology, DLIST placement can effectively treat SIAI induced by EST-rP and lower the mortality rate of rescue surgery treatment.

Japan Gastroenterological Endoscopy Society guidelines for endoscopic papillary large balloon dilation

The Japan Gastroenterological Endoscopy Society has developed the 'EPLBD Clinical Practice Guidelines' as fundamental guidelines based on new scientific techniques. EPLBD is a treatment method that has recently become widely used for choledocolithiasis. The evidence level in this field is usually low, and in many instances, the recommendation grading has to be determined on the basis of expert consensus. At this point, the guidelines are divided into the following six sections according to the 'EST Clinical Practice Guidelines': (i) Indications, (ii) procedures, (iii) special cases, (iv) procedure-related adverse events, (v) treatment outcomes, and (vi) postoperative follow up observation.

Japan Gastroenterological Endoscopy Society guidelines for endoscopic sphincterotomy

The Japan Gastroenterological Endoscopy Society (JGES) has recently compiled guidelines for endoscopic sphincterotomy (EST) using evidence-based methods. Content regarding actual clinical practice, including detailed endoscopic procedures, instruments, device types and usage, has already been published by the JGES postgraduate education committee in May 2015 and, thus, in these guidelines we avoided duplicating such content as much as possible. The guidelines do not address pancreatic sphincterotomy, endoscopic papillary balloon dilation (EPBD), and endoscopic papillary large balloon dilation (EPLBD). The guidelines for EPLBD are planned to be developed separately. The evidence level in this field is often low and, in many instances, strong recommendation has to be determined on the basis of expert consensus. At this point in time, the guidelines are divided into six items including indications, techniques, specific cases, adverse events, outcomes, and postoperative follow up.

A systematic review of the management and outcome of ERCP related duodenal perforations using a standardized classification system

INTRODUCTION

The incidence of duodenal perforation after ERCP ranges from 0.09% to 1.67% and mortality up to 8%.

METHODS

This systematic review was registered in Prospective Register of Systematic Reviews, PROSPERO. Stapfer classification of ERCP-related duodenal perforations was used.

RESULTS

The systematic search yielded 259 articles. Most frequent post-ERCP perforation was Stapfer type II (58.4%), type I second most frequent perforation (17.8%) followed by Stapfer type III in 13.2% and type IV in 10.6%. Rate of NOM was lowest in Stapfer type I perforations (13%), moderate in type III lesions (58.1%) and high in other types of perforations (84.2% in type II and 84.6% in IV). In patients underwent early surgical treatment (<24 h from ERCP) the most frequent operation was simple duodenal suture with or without omentopexy (93.7%). In patients undergoing late surgical treatment (>24 h from ERCP) interventions performed were more complex. In type I lesions post-operative mortality rate was higher in patients underwent late operation (>24 h). In type I lesions, failure of NOM occurred in 42.8% of patients. In type II failure of NOM occurred in 28.9% of patients and in type III there was failure of NOM in only 11.1%, none in type IV. Postoperative mortality after NOM failure was 75% in type I, 22.5% in type II and none died after surgical treatment for failure of NOM in type III perforations.

CONCLUSIONS

This systematic review showed that in patients with Stapfer type I lesions, early surgical treatment gives better results, however the opposite seems true in Stapfer III and IV lesions.

Endoscopic retrograde cholangiopancreatography-related perforations: Diagnosis and management

Endoscopic retrograde cholangiopancreatography (ERCP) has become an important therapeutic modality for biliary and pancreatic disorders. Perforation is one of the most feared complications of ERCP and endoscopic sphincterotomy. A MEDLINE search was performed from 2000-2014 using the keywords “perforation”, “ERCP” and “endoscopic sphincterotomy”. All articles including more than nine cases were reviewed. The incidence of ERCP-related perforations was low (0.39%, 95%CI: 0.34-0.69) with an associated mortality of 7.8% (95%CI: 3.80-13.07). Endoscopic sphincterotomy was responsible for 41% of perforations, insertion and manipulations of the endoscope for 26%, guidewires for 15%, dilation of strictures for 3%, other instruments for 4%, stent insertion or migration for 2% and in 7% of cases the etiology was unknown. The diagnosis was made during ERCP in 73% of cases. The mechanism, site and extent of injury, suggested by clinical and radiographic findings, should guide towards operative or non-operative management. In type I perforations early surgical repair is indicated, unless endoscopic closure can be achieved. Patients with type II perforations should be treated initially non-operatively. Non-operative treatment includes biliary stenting, fasting, intravenous fluid resuscitation, nasogastric drainage, broad spectrum antibiotics, percutaneous drainage of fluid collections. Non-operative treatment was successful in 79% of patients with type II injuries, with an overall mortality of 9.4%. Non-operative treatment was sufficient in all patients with type III injuries. Surgical technique depends on timing, site and size of defect and clinical condition of the patient. In conclusion, diagnosis is based on clinical suspicion and clinical and radiographic findings. Whilst surgery is usually indicated in patients with type I injuries, patients with type II or III injuries should be treated initially non-operatively. A minority of them will finally require surgical intervention.

Complications following endoscopic retrograde cholangiopancreatography: minimal invasive surgical recommendations

Background

ERCP has a complication rate ranging between 4% and 16% such as post-ERCP pancreatitis, hemorrhage, cholangitis and perforation. Perforation rate was reported as 0.08% to 1% and mortality rate up to 1.5%. Besides, injury related death rate is 16% to 18%. In this study we aimed to present a retrospective review of our experience with post ERCP-related perforations, reveal the type of injuries and management recommendations with the minimally invasive approaches.

Methods

Medical records of 28 patients treated for ERCP-related perforations in Okmeydani Training and Research Hospital between March 2007 and March 2013 were reviewed retrospectively. Patient age, gender, comorbidities, ERCP indication, ERCP findings and details were analyzed. All previous and current clinical history, laboratory and radiological findings were used to assess the evaluation of perforations.

Results

Between March 2007 and March 2013, 2972 ERCPs were performed, 28 (0.94%) of which resulted in ERCP-related perforations. 10 of them were men (35.8%) and 18 women (64.2%). Mean age was 53.36±14.12 years with a range of 28 to 78 years. 14 (50%) patients were managed conservatively, while 14 (50%) were managed surgically. In 6 patients, laparoscopic exploration was performed due to the failure of non-surgical management. In 6 of the patients that ERCP-related perforation was suspected during or within 2 hours after ERCP, underwent to surgery primarily. There were two mortalities. The mean length of hospitalization stay was 10.46±2.83 days. The overall mortality rate was 7.1%.

Conclusion

Successful management of ERCP-related perforation requires immediate diagnosis and early decision to decide whether to manage conservatively or surgically. Although traditionally conventional surgical approaches have been suggested for the treatment of perforations, laparoscopic techniques may be used in well-chosen cases especially in type II, III and IV perforations.

[Retroperitoneal emphysema after endoscopic retrograde cholangiopancreatography]

Retroperitoneal emphysema represents a pathological situation with an abnormal amount of air in the retroperitoneal tissue. The diagnosis is made radiologically.The cause is mostly an iatrogenic complication of different diagnostic or therapeutic procedures. The most common cause is a perforation after endoscopic retrograde cholangiopancreatography (ERCP). In cases of clinically suspected complications after a procedure prompt diagnosis with computed tomography (CT) scan of the abdomen and an interdisciplinary decision on the suitable therapeutic measures is warranted, as immediate therapy reduces morbidity and mortality of patients. For selecting the ideal therapy it is essential to understand the underlying pathophysiological mechanism of retroperitoneal emphysema and to take the clinical situation of the patient into account. Thus periampullary or bile duct lesions facing the retroperitoneum can be treated conservatively in clinically stable patients, whereas in unstable patients with abscess formation, interventional radiological or endoscopic procedures are indicated. In cases of a duodenal lesion an endoscopic closure of the perforation can be performed in stable patients but if the patient shows signs of peritonism or if the clinical situation deteriorates, operative therapy is necessary.

Pneumothorax following ERCP: Report of Two Cases with Different Pathophysiology

In the last thirty years, the widespread use of endoscopic retrograde cholangiopancreatography (ERCP) has radically changed the management of patients with diseases of the extrahepatic biliary tract and pancreas. Pneumothorax is a rare complication of ERCP. We report two cases of pneumothorax following elective ERCP for ductal stone clearance. The first patient was a 45-year-old female, who developed respiratory distress, abdominal pain, and profoundly abdominal distention immediately after the procedure. Imaging studies revealed the presence of a right-side pneumothorax, pneumomediastinum, pneumoperitoneum, and pneumoretroperitoneum. The second patient was a 94-year-old female, who developed tension pneumothorax with clinical signs of shock during the procedure. Imaging studies revealed the presence of a right-side pneumothorax without free air in the mediastinum and retroperitoneal space. The imaging findings suggest that the occurrence of this rare complication in our patients was caused by entirely different pathophysiological mechanisms. Both patients were successfully treated with chest tube insertion, and no further intervention was required. Clinicians should be aware of this serious complication because delayed diagnosis may involve significant morbidity and mortality risks.

Management of duodeno-pancreato-biliary perforations after ERCP: outcomes from an Italian tertiary referral center

BACKGROUND

The management of post-endoscopic retrograde cholangiopancreatography (ERCP) perforation is often unknown by many physicians, and there is a paucity of literature regarding the best surgical management approach.

PATIENTS AND METHODS

A retrospective review of ERCP-related perforations to the duodeno-pancreato-biliary tract observed at the Digestive Surgery Department of the Catholic University of Rome was conducted to identify their optimal management and clinical outcome.

RESULTS

From January 1999 to December 2011, 30 perforations after ERCP were observed. Seven patients underwent ERCP at another institution, and 23 patients underwent an endoscopic procedure at our hospital. Diagnosis of perforation was both clinical and instrumental. Fifteen patients (50 %) were successfully treated conservatively. Fifteen patients (50 %) underwent surgery after a mean time of 8.1 days (range 1-26 days) from ERCP: ten received a retroperitoneal laparostomy approach, three of them both an anterior and posterior laparostomy approach, and two an anterior laparostomy approach. Duodenal leak closure was observed after a mean (± standard deviation, SD) of 12.6 (± 4.6) and 24.6 (± 7.9) days after conservative and surgical treatment, respectively (p < 0.001). The overall and postoperative mortality rates were 13.3 % (4 of 30 patients) and 26.6 % (4 of 15 patients), respectively.

CONCLUSIONS

Post-ERCP perforation is burdened by a high risk of mortality. Early clinical and radiographic features have to be used to determine which type of surgical or conservative treatment is indicated. Half of patients can be treated conservatively, but in case of sepsis or unstable general conditions, early surgical procedure is indicated as the only possible chance of recovery.

Management of duodeno-pancreato-biliary perforations after ERCP: outcomes from an Italian tertiary referral center

BACKGROUND

The management of post-endoscopic retrograde cholangiopancreatography (ERCP) perforation is often unknown by many physicians, and there is a paucity of literature regarding the best surgical management approach.

PATIENTS AND METHODS

A retrospective review of ERCP-related perforations to the duodeno-pancreato-biliary tract observed at the Digestive Surgery Department of the Catholic University of Rome was conducted to identify their optimal management and clinical outcome.

RESULTS

From January 1999 to December 2011, 30 perforations after ERCP were observed. Seven patients underwent ERCP at another institution, and 23 patients underwent an endoscopic procedure at our hospital. Diagnosis of perforation was both clinical and instrumental. Fifteen patients (50 %) were successfully treated conservatively. Fifteen patients (50 %) underwent surgery after a mean time of 8.1 days (range 1-26 days) from ERCP: ten received a retroperitoneal laparostomy approach, three of them both an anterior and posterior laparostomy approach, and two an anterior laparostomy approach. Duodenal leak closure was observed after a mean (± standard deviation, SD) of 12.6 (± 4.6) and 24.6 (± 7.9) days after conservative and surgical treatment, respectively (p < 0.001). The overall and postoperative mortality rates were 13.3 % (4 of 30 patients) and 26.6 % (4 of 15 patients), respectively.

CONCLUSIONS

Post-ERCP perforation is burdened by a high risk of mortality. Early clinical and radiographic features have to be used to determine which type of surgical or conservative treatment is indicated. Half of patients can be treated conservatively, but in case of sepsis or unstable general conditions, early surgical procedure is indicated as the only possible chance of recovery.

Pneumothorax following ERCP: report of four cases and review of the literature

We report four patients with pneumothorax as a complication of ERCP with sphincterotomy. With conservative treatment all patients recovered. Previously, 16 comparable cases have been reported in the literature. The main risk factor for this rare complication seems (pre-cut) sphincterotomy. Pneumothorax is usually right-sided or bilateral and accompanied by pneumomediastinum, pneumoretroperitoneum and subcutaneous emphysema. The prognosis seems favourable with a non-surgical approach including intravenous antibiotics, fasting and when indicated chest tube drainage.

Management of endoscopic retrograde cholangiopancreatography-related perforations

PURPOSE

The purpose of this study is to analyze the treatment strategies of patients with endoscopic retrograde cholangiopancreatography (ERCP)-related perforations. This is a retrospective study.

METHODS

We experienced 13 perforations associated with ERCP. We reviewed the medical recordsand classified ERCP-related perforations according to mechanism of injury in terms of perforating device. Injury by endoscopic tip or insertion tube was classified as type I, injury by cannulation catheter or sphincterotomy knife as type II, and injury by guidewire as type III.

RESULTS

Of four type I injuries, one case was managed by conservative management after primary closure with a hemoclip during ERCP. The other three patients underwent surgical treatments such as primary closure orpancreatico-duodenectomy. Of five type II injuries, two patients underwent conservative management and the other three cases were managed by surgical treatment such as duodenojejunostomy, duodenal diverticulization and pancreatico-duodenectomy. Of four type III injuries, three patients were managed conservatively and the remaining patient was managed by T-tube choledochostomy.

CONCLUSION

Type I injuries require immediate surgical management after EPCP or immediate endoscopic closure during ERCP whenever possible. Type II injuries require surgical or conservative treatment according to intra- and retro-peritoneal dirty fluid collection findings following radiologic evaluation. Type III injuries almost always improve after conservative treatment with endoscopic nasobilliary drainage.

Post-endoscopic retrograde cholangiopancreatography perforation managed by surgery or percutaneous drainage

PURPOSE

Post-endoscopic retrograde cholangiopancreatography (ERCP) perforation usually resolves conservatively; however, intervention is sometimes needed, and there is a paucity of literature regarding the best management approach. We evaluated our experience of managing post-ERCP perforations to help define the role of surgery with percutaneous drainage (PCD).

METHODS

A retrospective chart review revealed 14 cases of post-ERCP perforation with intra-abdominal sepsis referred for intervention. We analyzed data pertaining to clinical details, management, and outcome.

RESULTS

There were 12 patients with duodenal perforation and 2 with biliary perforation. Most (10/14; 72%) had symptom onset within 48 h, but delayed diagnosis or referral resulted in a mean delay until intervention of 6.6 days (range 1-18 days). Computed tomography revealed localized collections in 9 (64%) patients. Seven patients with localized collections and no or minimal contrast leak underwent PCD and rest, and 7 underwent surgery. The indications for surgery were free perforation, generalized peritonitis, and major contrast leak. Overall morbidity was 50% and there was one early postoperative death, caused by severe sepsis.

CONCLUSION

There should be a high index of suspicion of perforation when abdominal signs and symptoms develop after ERCP. Computed tomography is the investigation of choice for diagnosis and guiding therapy. With judicious selection of surgery or PCD based on clinical and imaging features, patients can be managed with acceptable morbidity and low mortality.

Management of ERCP-related perforations: outcomes of single institution in Korea

INTRODUCTION

The aim of this study was to analyze clinicoradiologic findings and treatment outcomes of patients with endoscopic retrograde cholangiopancreatography (ERCP)-related perforations. Between May 2003 and November 2007, 2,247 ERCP procedures with or without sphincterotomy were performed at Ajou University Medical Center, Suwon, Korea, and 20 perforations (0.89%) were identified.

DISCUSSION

We retrospectively reviewed medical and surgical records of each patient. Of 18 patients, 11 patients (61.1%) underwent nonsurgical management, and seven patients (38.9%) received surgical management. There were no significant differences in age, gender, and laboratory findings between two groups (P > 0.05). The hospital stay was significantly longer in the operative group than that of the conservative group (P < 0.05, respectively). The most common cause of perforation was sphincterotomy (n = 8) in the conservative group whereas scope itself (n = 6) in operative group, showing a significant difference between the two groups (P < 0.05). The retroperitoneal air was most common findings in eight patients (72.7%) of the conservative group, while six (85.7%) patients of the operative group presented with intraperitoneal air, displaying a significant difference in location of air between the two groups (P < 0.05). Most of sphincterotomy-related perforations were managed nonsurgically. However, the scope-related perforations were usually large and required immediate surgery. Moreover, the delayed operation resulted in a longer hospital stay and high morbidity. Therefore, the selective early surgical intervention is suggested when scope-related perforations are discovered.

Duodenal perforations after endoscopic retrograde cholangiopancreatography: experience and management

OBJECTIVE

The aim of this study was to summary the experiences and lessons from periduodenal perforations related to endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (EST).

METHODS

A retrospective review from 2004 to 2007 identified 9 patients (0.37%) of periduodenal perforation related to ERCP/EST. Charts were reviewed for the following parameters: clinical presentation of patients, ERCP findings, diagnostic methods, treatment (surgical or conservative procedures), complications, and outcome.

RESULTS

Nine patients who had periampullary perforations received ERCP/EST for common bile duct stones. Cannulation was considered difficult in 7 of 9 patients, and the precut technique was used. The diagnosis was made due to subcutaneous emphysema or peritonitis, and 3 patients received emergent operations (e.g., external biliary or retroperitoneal drainage), and 1 patient had a reoperation for a retroperitoneal sealed abscess. Their median length of hospital stay was 50 days. The other 6 were treated conservatively with nasal-duodenal and nasal-biliary drainage. Their median length of hospital stay was 13 days. There was no mortality.

CONCLUSIONS

The precut technical may be a risk factor of duodenal perforation. Early diagnosis of duodenal perforation is essential for an optimum outcome, and subcutaneous emphysema may be a sensitive sign. Although the management of perforation after ERCP/EST is still controversial, a selective management is proposed, based on the features of classification type. Nevertheless, duodenal and biliary drainage is essential in both surgical and conservative therapy.

Early surgical management for periampullary retroperitoneal perforation caused by endoscopic sphincterotomy: report of a case

A 67-year-old woman was admitted to our hospital for surgical management of cancer of the ascending colon. On admission, she had cholangitis due to choledocholithiasis. Abdominal computed tomography, ultrasonography, and magnetic resonance showed cholelithiasis, choledocholithiasis, and multiple liver tumors. Colonoscope showed advanced cancer of the ascending colon. Because of acute obstructive suppurative cholangitis, endoscopic sphincterotomy was performed. During the procedure, periampullary retroperitoneal perforation was identified on radiologic examination. Because computed tomography had shown extravasation of contrast medium and widespread pneumoretroperitoneum, an emergency operation was performed 2 hours after perforation. After cholecystectomy and choledocholithotomy had been performed and all bile duct stones had been removed, periampullary perforation was readily identified close to the duodenal diverticula and easily repaired. The postoperative course was uneventful. This patient could resume oral feeding soon after the operation, and colonic surgery could be performed immediately thereafter. Therefore, early surgical management is a possible first choice of treatment in patients with remaining biliary disease after periampullary perforation.