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Nadeem A, Husnain A, Zia MT, Ahmed A. Concurrent acute pancreatitis, pneumoperitoneum, pneumoretroperitoneum, and pneumomediastinum following ERCP-related perforation: A rare and insightful case study. Radiol Case Rep 2024; 19:1419-1423. [PMID: 38292793 PMCID: PMC10827534 DOI: 10.1016/j.radcr.2023.12.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Accepted: 12/27/2023] [Indexed: 02/01/2024] Open
Abstract
This case report details an extraordinary occurrence following endoscopic retrograde cholangiopancreatography (ERCP) in a 42-year-old woman. Despite ERCP being a commonly performed procedure, this case presented an unusual combination of acute pancreatitis, pneumoperitoneum, pneumoretroperitoneum, and pneumomediastinum resulting from a Stapfer type III perforation. The patient managed conservatively with nil per os, nasogastric tube, intravenous fluids, pain relief, and antibiotics, exhibited clinical improvement. Remarkably, resolution of complications occurred without surgical intervention. This case underscores the significance of vigilance in diagnosing and appropriately managing ERCP-related complications, contributing to the broader understanding of these rare events and fostering improved patient outcomes.
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Affiliation(s)
- Arsalan Nadeem
- Department of Medicine, Allama Iqbal Medical College, Lahore, Punjab, Pakistan
| | - Ali Husnain
- Department of Interventional Radiology, Northwestern Medicine, Chicago, IL, USA
| | - Muhammad Tayyab Zia
- Department of Radiology, Pakistan Kidney & Liver Institute and Research Centre, Lahore, Punjab, Pakistan
| | - Abdullah Ahmed
- Department of Medicine, Allama Iqbal Medical College, Lahore, Punjab, Pakistan
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2
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Akshintala VS, Singh A, Singh VK. Prevention and Management of Complications of Biliary Endoscopy. Gastrointest Endosc Clin N Am 2022; 32:397-409. [PMID: 35691688 DOI: 10.1016/j.giec.2022.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is an essential procedure for the management of pancreaticobiliary disorders. ERCP is, however, associated with the risk of complications including pancreatitis, bleeding, perforation, infection, and instrument failure, which can often be fatal. It is, therefore, necessary to recognize the risk of ERCP-associated complications and understand the methods to prevent and treat such complications.
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Affiliation(s)
- Venkata S Akshintala
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Johns Hopkins University School of Medicine, 1830 East Monument Street, Suite 428, Baltimore, MD 21205, USA
| | - Anmol Singh
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Johns Hopkins University School of Medicine, 1830 East Monument Street, Suite 428, Baltimore, MD 21205, USA
| | - Vikesh K Singh
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Johns Hopkins University School of Medicine, 1830 East Monument Street, Suite 428, Baltimore, MD 21205, USA.
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3
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Wu X, Li G, Liu Z. A rare case of duodenum perforation after biliary stenting under endoscopic retrograde cholangiopancreatography: a case report. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1690. [PMID: 33490202 PMCID: PMC7812185 DOI: 10.21037/atm-20-7595] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Duodenal injury under endoscopic retrograde cholangiopancreatography (ERCP) is extremely rare. This study describes a case of duodenum perforation after biliary stenting under ERCP for the first time. A 67-year-old female patient was transferred to the emergency department of First Hospital of China Medical University after experiencing whole abdominal pain for 6 hours. The patient had received a biliary stent placement under ERCP at an outer hospital 6 days previously due to duodenal papillary occupy. During the operation, a small perforation caused by a biliary stent was found at the lateral side of the duodenum, but no biliary stent was found. Duodenal juice was flowing out from the perforation, Then, the perforation was opened obliquely, and an 8-cm portion of the biliary stent was removed. Gastrostomy, jejunostomy, and choledochotomy T-tube drainage procedures were subsequently performed. The patient recovered well and was discharged with the T-tube and the jejunal nutrition tube after 20 days. Four types of perforation under ERCP have been reported in previous literature, and this case report documents a rare complication from biliary stenting under ERCP. This case is different from the previous four types and can be called type V, which give general endoscopic doctors a serious warning.
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Affiliation(s)
- Xingda Wu
- Department of Pancreatic-Billary Surgery, First Hospital of China Medical University, Shenyang, China
| | - Guichen Li
- Department of Pancreatic-Billary Surgery, First Hospital of China Medical University, Shenyang, China
| | - Zhe Liu
- Department of Pancreatic-Billary Surgery, First Hospital of China Medical University, Shenyang, China
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4
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Bostancı Ö, Battal M, Yazıcı P, Demir U, Alkım C. Management of iatrogenic injuries due to endoscopic sphincterotomy: Surgical or conservative approaches. Turk J Surg 2018; 34:24-27. [PMID: 29756102 PMCID: PMC5937654 DOI: 10.5152/turkjsurg.2017.3820] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 04/20/2017] [Indexed: 01/19/2023]
Abstract
OBJECTIVE The best therapeutic approach for endoscopic retrograde cholangiopancreatography-related perforations remains controversial; while some authors suggest routine conservative management, others advocate mandatory surgical exploration. We aimed to evaluate our clinical experience of perforations during endoscopic sphincterotomy. MATERIAL AND METHODS A retrospective chart review from January 2010 to October 2015 identified 20 patients with endoscopic retrograde cholangiopancreatography-related perforations. Data collection included demographics, time to diagnosis, type of perforation, treatment strategy, surgical procedure, complications, hospital stay, and outcome. All patients were classified into two groups on the basis of radiological and operative findings. RESULTS Only five patients underwent surgical treatment, whereas 15 patients were managed conservatively. The mean time to diagnosis was 7.8 hrs (range: 1 to 36 hrs). In patients who underwent surgical treatment, the types of perforations included type I and III in one patient each and type II in three patients. Surgical procedures included laparoscopic and open cholecystectomy with t-tube drainage in two patients each and primary repair of duodenal injury with hepaticojejunostomy in one patient. Among conservatively managed patients, eight, four, and three had type II, type III, and type IV injuries, respectively. Of these 15 patients, 60% (n=9) underwent percutaneous procedures. The mean length of hospital stay was similar for conservatively and surgically treated patients (12 vs. 12.4 days, respectively, p=0.790). One patient (5%) with type I injury died of multiorgan deficiency. CONCLUSION With close close clinical follow-up, medical treatment can be beneficial for most patients, and surgical procedures should be reserved for patients with type I (definite) and type II/III injuries; in patients with these clinical parameters, conservative management will likely be unsuccessful.
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Affiliation(s)
- Özgür Bostancı
- Department of General Surgery, Şişli Etfal Training and Research Hospital, İstanbul, Turkey
| | - Muharrem Battal
- Department of General Surgery, Şişli Etfal Training and Research Hospital, İstanbul, Turkey
| | - Pınar Yazıcı
- Department of General Surgery, Şişli Etfal Training and Research Hospital, İstanbul, Turkey
| | - Uygar Demir
- Department of General Surgery, Şişli Etfal Training and Research Hospital, İstanbul, Turkey
| | - Canan Alkım
- Department of Gastroenterology, Şişli Etfal Training and Research Hospital, İstanbul, Turkey
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Park SM. Recent Advanced Endoscopic Management of Endoscopic Retrograde Cholangiopancreatography Related Duodenal Perforations. Clin Endosc 2016; 49:376-82. [PMID: 27484814 PMCID: PMC4977750 DOI: 10.5946/ce.2016.088] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2016] [Revised: 07/18/2016] [Accepted: 07/18/2016] [Indexed: 02/06/2023] Open
Abstract
The management strategy for endoscopic retrograde cholangiopancreatography-related duodenal perforation can be determined based on the site and extent of injury, the patient’s condition, and time to diagnosis. Most cases of perivaterian or bile duct perforation can be managed with a biliary stent or nasobiliary drainage. Duodenal wall perforations had been treated with immediate surgical repair. However, with the development of endoscopic devices and techniques, endoscopic closure has been reported to be a safe and effective treatment that uses through-the-scope clips, ligation band, fibrin glue, endoclips and endoloops, an over-the-scope clipping device, suturing devices, covering luminal stents, and open-pore film drainage. Endoscopic therapy could be instituted in selected patients in whom perforation was identified early or during the procedure. Early diagnosis, proper conservative management, and effective endoscopic closure are required for favorable outcomes of non-surgical management. If endoscopic treatment fails, or in the cases of clinical deterioration, prompt surgical management should be considered.
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Affiliation(s)
- Seon Mee Park
- Department of Internal Medicine, Chungbuk National University College of Medicine, Cheongju, Korea
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6
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Kumbhari V, Sinha A, Reddy A, Afghani E, Cotsalas D, Patel YA, Storm AC, Khashab MA, Kalloo AN, Singh VK. Algorithm for the management of ERCP-related perforations. Gastrointest Endosc 2016; 83:934-43. [PMID: 26439541 DOI: 10.1016/j.gie.2015.09.039] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Accepted: 09/28/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Perforation is a rare but serious adverse event of ERCP. There is no consensus to guide the clinician on the management of ERCP-related perforations, with particular controversy surrounding the immediate surgical management of postprocedurally detected duodenal perforation because of overextension of a sphincterotomy. Our aim was to assess patient outcomes using a predetermined algorithm based on managing ERCP-related duodenal perforations according to the mechanism of injury. METHODS A retrospective single-center study of all consecutive patients with Stapfer type I and II perforations between 2000 and 2014 were included. Our institutional algorithm since 2000 dictated that Stapfer type I perforations (duodenal wall perforation, endoscope related) should be managed surgically unless prohibited by underlying comorbidities and Stapfer type II perforations (periampullary, sphincterotomy related) managed nonsurgically unless a deterioration in clinical status necessitated surgery. RESULTS Sixty-one patients (mean age, 51 years; 80% women) were analyzed with Stapfer type I perforations diagnosed in 7 (11%) and type II in 54 (89%). A postprocedural diagnosis of perforation was made in 55 patients (90%). Four patients (7%) had Stapfer type II perforations that failed medical management and required surgery. The mean length of stay (LOS) in the entire cohort was 9.6 days with a low mortality rate of 3%. Systemic inflammatory response syndrome was observed in 18 patients (33%) with Stapfer type II perforations and was not associated with the need for surgery. Concurrent post-ERCP pancreatitis was diagnosed in 26 patients (43%) and was associated with an increased LOS. CONCLUSIONS Stapfer type II perforations have excellent outcomes when managed medically. We validate an algorithm for the management of ERCP-related perforations and propose that it should function as a guide.
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Affiliation(s)
- Vivek Kumbhari
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Amitasha Sinha
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Aditi Reddy
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Elham Afghani
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Deanna Cotsalas
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Yuval A Patel
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Andrew C Storm
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Mouen A Khashab
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Anthony N Kalloo
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Vikesh K Singh
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
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7
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Dabizzi E, De Ceglie A, Kyanam Kabir Baig KR, Baron TH, Conio M, Wallace MB. Endoscopic "rescue" treatment for gastrointestinal perforations, anastomotic dehiscence and fistula. Clin Res Hepatol Gastroenterol 2016. [PMID: 26209869 DOI: 10.1016/j.clinre.2015.04.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Luminal perforations and anastomotic leaks of the gastrointestinal tract are life-threatening events with high morbidity and mortality. Early recognition and prompt therapy is essential for a favourable outcome. Surgery has long been considered the "gold standard" approach for these conditions; however it is associated with high re-intervention morbidity and mortality. The recent development of endoscopic techniques and devices to manage perforations, leaks and fistulae has made non-surgical treatment an attractive and reasonable alternative approach. Although endoscopic therapy is widely accepted, comparative data of the different techniques are still lacking. In this review we describe, benefits and limitations of the current options in the management of patients with perforations and leaks, in order to improve outcomes.
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Affiliation(s)
- Emanuele Dabizzi
- Gastroenterology and Digestive Endoscopy Division, Vita-Salute San Raffaele Univeristy, San Raffaele Scientific Institute, Milan, Italy.
| | - Antonella De Ceglie
- Gastroenterology and Digestive Endoscopy Unit, "G. Borea" Hospital, San Remo, Italy
| | | | - Todd H Baron
- Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Massimo Conio
- Gastroenterology and Digestive Endoscopy Unit, "G. Borea" Hospital, San Remo, Italy
| | - Michael B Wallace
- Division of Gastroenterology and Hepatology, Mayo Clinic Jacksonville, Florida, USA
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Vezakis A, Fragulidis G, Polydorou A. Endoscopic retrograde cholangiopancreatography-related perforations: Diagnosis and management. World J Gastrointest Endosc 2015; 7:1135-1141. [PMID: 26468337 PMCID: PMC4600179 DOI: 10.4253/wjge.v7.i14.1135] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Revised: 07/31/2015] [Accepted: 09/08/2015] [Indexed: 02/05/2023] Open
Abstract
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.
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9
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Endoscopic treatment of iatrogenic gastrointestinal perforations: an overview. Dig Liver Dis 2014; 46:195-203. [PMID: 24210991 DOI: 10.1016/j.dld.2013.09.024] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2013] [Revised: 08/28/2013] [Accepted: 09/10/2013] [Indexed: 02/06/2023]
Abstract
In the past, the treatment of iatrogenic gastrointestinal perforations was limited to surgical management or to medical observation. Natural Orifice Transluminal Endoscopic Surgery (NOTES) has paved the way towards the development of reliable endoscopic closure techniques, which can be applicable in accidental perforations of the gastrointestinal tract. When endoscopic treatment is feasible, hemoclips are preferred in smaller perforations, while over-the-scope-clips or a combination of hemoclips, endoloops, and glue are used in larger ones. Endoscopic stitching is rarely utilized, and endoscopic stapling has been practically abandoned. The use of self-expandable covered stents can be considered in the esophagus and duodenum. Broad spectrum antibiotics are recommended in most cases. Clinical follow-up in a medico-surgical unit is mandatory and surgical intervention should not be delayed more than 24h if clinical or biological worsening occurs. Imaging with oral contrast medium is advisable before resumption of oral feeding in the case of large perforations.
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10
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Völgyi Z, Szenes M, Gasztonyi B. Types and management of perforations occurring during endoscopic retrograde cholangiopancreatography. Orv Hetil 2014; 155:248-54. [DOI: 10.1556/oh.2014.29829] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The authors discuss the incidence of perforation related to endoscopic retrograde cholangio-pancreatography, which is relatively uncommon (0.3–1%) among other types of complications. Perforations can be classified into three types based on their forms and locations. Having reviewed the literature the authors conclude that the most common type is periampullary perforation and the less frequent one is peritoneal perforation. The former usually heals after conservative treatment, while the latter needs an operation. The authors emphasize the important prognostic role of timely diagnosis and surgical treatment if alarming signs (peritoneal, septic) are present. Known predisposing factors, when the procedure needs more careful attention, are also summarized (postoperative status, needle knife papillectomy, intramural contrast media, long lasting examination). After reviewing their own cases, the authors establish that the incidence of perforation in their own centre was four per thousand (10/2400), out of which nine were periampullar and one peritoneal type. In 6 cases operation was necessary, and there was no mortality. The authors conclude that individually tailored therapy can largely reduce the 30–40% mortality rate reported in earlier studies. Orv. Hetil., 2014, 155(7), 248–254.
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Affiliation(s)
- Zoltán Völgyi
- Zala Megyei Kórház Belgyógyászati Osztály Zalaegerszeg Zrínyi M. u. 1. 8900
| | - Mária Szenes
- Zala Megyei Kórház Belgyógyászati Osztály Zalaegerszeg Zrínyi M. u. 1. 8900
| | - Beáta Gasztonyi
- Zala Megyei Kórház Belgyógyászati Osztály Zalaegerszeg Zrínyi M. u. 1. 8900
- Pécsi Tudományegyetem Egészségtudományi Kar Pécs
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Perforations following endoscopic retrograde cholangiopancreatography: a single institution experience and surgical recommendations. Am J Surg 2013; 206:180-6. [PMID: 23870391 DOI: 10.1016/j.amjsurg.2012.07.050] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2012] [Revised: 07/18/2012] [Accepted: 07/24/2012] [Indexed: 12/13/2022]
Abstract
BACKGROUND Perforation after endoscopic retrograde cholangiopancreatography (ERCP) is uncommon, and its management is dependent on the mechanism and the graded classification of injury. METHODS Records of patients undergoing ERCP were analyzed over a 16-year period, patterning the types of injuries, diagnosis, management, and patient outcome. Type I injuries damage the medial or lateral duodenal wall before sphincter cannulation. Type II injuries are periampullary and occur as a result of a precut or a papillotomy. Type III injuries occur secondary to guidewire insertion or stone extraction from the common bile duct. Type IV injuries are probably microperforations that are noted on excessive insufflation during and after ERCP withdrawal. RESULTS Between 1995 and 2011, 27 perforations were identified from 1,638 ERCP procedures (1.6%). Nearly half of the procedures were regarded as difficult by the endoscopist, with 70% of the ERCPs (19 of 27) being for therapeutic indications. There were 5 type I, 12 type II, 5 type III, and 5 type IV perforations, of which 18 cases were diagnosed at the time of ERCP. Delayed diagnosis of type I perforations that were associated with free intraperitoneal air and contrast leakage proved fatal. Most type II perforations required immediate surgery with pyloric exclusion; delayed surgery with simple drainage had a high mortality rate. Most type III and type IV injuries can successfully be managed conservatively without delayed sepsis. CONCLUSIONS In perforation, the mechanism of injury during ERCP predicts the need for surgical management. Type I and type II injuries require early diagnosis and aggressive surgery, whereas type III and type IV injuries may be managed conservatively.
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12
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Schepers NJ, van Buuren HR. Pneumothorax following ERCP: report of four cases and review of the literature. Dig Dis Sci 2012; 57:1990-5. [PMID: 22466080 PMCID: PMC3405237 DOI: 10.1007/s10620-012-2150-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2011] [Accepted: 03/16/2012] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Nicolien J. Schepers
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Room Ha-203, PO Box 2040, 3000 CA Rotterdam, The Netherlands
| | - Henk R. van Buuren
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Room Ha-203, PO Box 2040, 3000 CA Rotterdam, The Netherlands
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13
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A tailored approach to the management of perforations following endoscopic retrograde cholangiopancreatography and sphincterotomy. J Gastrointest Surg 2011; 15:2211-7. [PMID: 22005896 DOI: 10.1007/s11605-011-1723-3] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2011] [Accepted: 09/30/2011] [Indexed: 02/07/2023]
Abstract
BACKGROUND The management of endoscopic retrograde cholangiopancreatography (ERCP)-related perforations remains controversial. Τhe aim of the study was to determine the incidence of perforations following ERCP, their characteristics, operative and non-operative management options and clinical outcome. METHODS A retrospective review of ERCP-related perforations, during a 21-year period, was performed. Each perforation was categorized into types I to IV according to the location, mechanism and radiographic evaluation of the injury. Comparisons were made between patients treated operatively and non-operatively. RESULTS Forty-four perforations (0.4%) occurred in 9,880 procedures. They were mainly caused by the passage of the endoscope (type I) in 7 (16%) and sphincterotomy (type II) in 30 (68%) patients. The management was non-operative in 32 (72%) and operative in 12 patients. In multivariate analysis, only the type of perforation (type I: endoscope-related) was found significant for predicting operative treatment. The hospital stay was longer for patients requiring an operation (median, 24 vs 9 days). The overall mortality was 2/44 (4.5%). There was no death in the non-operative group. CONCLUSIONS The need for immediate operative intervention should be based on the type of injury and clinical findings. Patients with type I perforations should be treated surgically and primary repair should be tried. Patients with type II injuries may be treated initially non-operatively. Delayed operative intervention will be required in a minority of these patients.
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14
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Ter Horst M, Boer MCHD, Raber MH, Klaase JM. Giant Diverticulum of the Duodenum. Gastroenterology Res 2011; 4:289-293. [PMID: 27957031 PMCID: PMC5139869 DOI: 10.4021/gr359w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/29/2011] [Indexed: 11/03/2022] Open
Abstract
A 50-year old female presented herself with abdominal bloating and pain in the Emergengy Department. The symptoms persisted and a clinical evaluation was made. A lesion suspect for a giant duodenal diverticulum was seen on the CT-scan, which was confirmed by enteroclysis. Surgical resection was performed. The diagnosis was histological confirmed after surgery. Small bowel diverticula are relatively common, with an estimated 5 - 22% incidence in the healthy population. They are usually asymptomatic, but can present with abdominal pain and weight loss. Complications such as bleeding and perforation can occur. Surgical resection is the treatment of choice in symptomatic patients.
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Affiliation(s)
- Matthijs Ter Horst
- Department of General Surgery, Medisch Spectrum Twente, Enschede, the Netherlands
| | | | - Menno H Raber
- Department of General Surgery, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Joost M Klaase
- Department of General Surgery, Medisch Spectrum Twente, Enschede, the Netherlands
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15
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Successful Nonsurgical Treatment of Pneumomediastinum, Pneumothorax, Pneumoperitoneum, Pneumoretroperitoneum, and Subcutaneous Emphysema following ERCP. Gastroenterol Res Pract 2010; 2010:289135. [PMID: 20631834 PMCID: PMC2901617 DOI: 10.1155/2010/289135] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2010] [Revised: 04/16/2010] [Accepted: 04/19/2010] [Indexed: 12/29/2022] Open
Abstract
Complications related to endoscopic retrograde cholangiopancreatography (ERCP) include pancreatitis, hemorrhage, cholangitis, and perforation. ERCP-related perforation is uncommon, but mortality rates are high. Diagnosis requires a high clinical suspicion for early detection to allow optimal management of the perforation and a better prognosis. Treatment depends on the location and mechanism and increasingly involves nonoperative management. We report a case of successful nonsurgical treatment of a patient with extensive air involving the peritoneum, retroperitoneum, thorax, mediastinum, and subcutaneous tissues following an ERCP perforation.
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Morgan KA, Fontenot BB, Ruddy JM, Mickey S, Adams DB. Endoscopic Retrograde Cholangiopancreatography Gut Perforations: When to Wait! When to Operate! Am Surg 2009. [DOI: 10.1177/000313480907500605] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Most perforations of the gastrointestinal tract during endoscopic retrograde cholangiopancreatography (ERCP) can be managed nonoperatively. Identifying patients who require operative management is problematic. A clinical endoscopy database was queried for patients who sustained ERCP perforation over a 13-year period. Records were reviewed and analyzed with approval of the Institutional Review Board. During the study period, 12,817 patients underwent ERCP; 24 (0.2%) had an endoscopic perforation. Twelve patients had a retroperitoneal perforation during sphincterotomy and all were successfully managed nonoperatively. Nine of these were undergoing treatment for sphincter of Oddi dysfunction. Twelve patients had perforation remote from the papilla. Of these, 10 required surgical intervention. Six patients had surgically altered anatomy (three postpancreaticoduodenectomy, three post-Billroth II gastrectomy) and one had situs inversus. Six of these seven required surgical intervention. Median length of stay of all patients was 7.5 days, morbidity was 25 per cent, and one patient died 16 days after surgery. Gut perforation after ERCP requires prompt surgical evaluation. Patients with sphincterotomy-related retroperitoneal perforation can be managed safely with nonoperative therapy in most instances. Patients with remote perforation usually need surgical intervention. Altered foregut anatomy leads to injuries that usually require operative management.
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Affiliation(s)
- Katherine A. Morgan
- Section of Gastrointestinal and Laparoscopic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Bennett B. Fontenot
- Section of Gastrointestinal and Laparoscopic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Jean M. Ruddy
- Section of Gastrointestinal and Laparoscopic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Suzanne Mickey
- Section of Gastrointestinal and Laparoscopic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - David B. Adams
- Section of Gastrointestinal and Laparoscopic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, South Carolina
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Knudson K, Raeburn CD, McIntyre RC, Shah RJ, Shaw RJ, Chen YK, Brown WR, Stiegmann G. Management of duodenal and pancreaticobiliary perforations associated with periampullary endoscopic procedures. Am J Surg 2009; 196:975-81; discussion 981-2. [PMID: 19095118 DOI: 10.1016/j.amjsurg.2008.07.045] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2008] [Revised: 07/08/2008] [Accepted: 07/08/2008] [Indexed: 12/18/2022]
Abstract
BACKGROUND The purpose of this study was to determine the incidence and outcome of pancreaticobiliary and duodenal (PB/D) perforations from periampullary endoscopic procedures and to examine whether clinical indexes are predictive of the need for operative management. METHODS A retrospective review compared patients who had operative intervention for PB/D perforation with those managed nonoperatively. RESULTS Thirty-two PB/D perforations occurred in 4,919 procedures (.6%). Twelve (37%) required operation; 20 (63%) were successfully managed nonoperatively. Radiographic imaging was not helpful in predicting the need for operation. A clinical scoring system was predictive of the need for operative management. The length of stay and morbidity rates were higher in the operatively managed patients. CONCLUSIONS Most endoscopic PB/D perforations can be successfully managed without operation and, clinical indices are most predictive in determining the need for surgery. Further prospective evaluation of this scoring system may help guide the need for and timing of operative intervention for PB/D perforations.
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Affiliation(s)
- Kelly Knudson
- Department of Surgery, University of Colorado, Denver Health Sciences Center, 12631 E 17th Avenue, C-313, PO Box 6511, Aurora, CO 80045, USA
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Ringold DA, Jonnalagadda S. Complications of Therapeutic Endoscopy: A Review of the Incidence, Risk Factors, Prevention, and Endoscopic Management. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2007. [DOI: 10.1016/j.tgie.2007.02.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Pantanowitz L, Goldar-Najafi A, Nasser I. Xanthogranulomatous choledochitis mimicking cholangiocarcinoma. Pathol Int 2004; 54:213-5. [PMID: 14989746 DOI: 10.1111/j.1440-1827.2004.01610.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
Iatrogenic perforation of the gastrointestinal tract is a medical emergency and is inevitable. An endoscopist must maintain a high index of suspicion despite minimal or atypical symptoms and negative radiologic studies, because perforation is a complication with tremendous morbidity and mortality. The endoscopist must know how to manage this complication appropriately and to seek immediate surgical consultation. There is ongoing controversy about when a patient should undergo nonoperative or surgical therapy. An evidence-based approach to manage iatrogenic perforation is not possible. The trend in the modern era is to less invasive, nonoperative therapy, given advancements in ICU care and antibiotics. Laparoscopy or laparoscopic-assisted (minilaparotomy) surgery is also being increasingly used with outcomes comparable with conventional laparotomy. Experience and advancements in accessories have enabled endoscopic repair of iatrogenic perforation in many situations [84]. The management algorithms provided synthesize the pertinent literature into reasonable guidelines to follow. Ultimately, an individualized approach must be taken to manage the patient with an iatrogenic perforation.
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Affiliation(s)
- Rajesh V Putcha
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center at Dallas, Room F.4.310, 5323 Harry Hines Boulevard, Dallas, TX 75390-8887, USA
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Pannu HK, Fishman EK. Complications of endoscopic retrograde cholangiopancreatography: spectrum of abnormalities demonstrated with CT. Radiographics 2001; 21:1441-53. [PMID: 11706215 DOI: 10.1148/radiographics.21.6.g01nv101441] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is an invasive procedure that is performed to diagnose and treat pancreatic and biliary disease. In approximately 5%-10% of cases, the procedure itself causes adverse events. Diagnosis and management of ERCP-induced complications are performed with clinical, laboratory, and radiologic procedures. Evaluation of the type and severity of the complication is necessary and is successfully performed with computed tomography (CT). The most common causes of post-ERCP pain are acute pancreatitis and duodenal perforation. In severe pancreatitis, the pancreas is enlarged and enhances heterogeneously at CT. Pancreatic enhancement is diminished in areas of glandular necrosis. In duodenal perforation, CT may reveal extraluminal air or fluid. CT findings of acute duodenal hemorrhage are duodenal wall thickening and a high-attenuation mass in the duodenal wall. In infection, the bile ducts can be dilated and the attenuation of the bile can be increased at CT. Abscesses appear as hypoattenuating masses with enhancing capsules. CT findings of stent migration are an atypical location of the stent and bowel impaction. Other complications of ERCP are those related to endoscopy and include esophageal, liver, and splenic injury.
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Affiliation(s)
- H K Pannu
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University, Baltimore, MD, USA.
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Howard TJ. Re: Stapfer M et al. Management of duodenal perforation after endoscopic retrograde cholangiopancreatography and sphincterotomy. Ann Surg 2000; 232:191-8. Ann Surg 2001; 234:132-3. [PMID: 11420495 PMCID: PMC1421958 DOI: 10.1097/00000658-200107000-00027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Yarze JC. Asymptomatic retroperitoneal air after endoscopic sphincterotomy. Am J Gastroenterol 2000; 95:553. [PMID: 10685772 DOI: 10.1111/j.1572-0241.2000.t01-1-01802.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Howard TJ, Tan T, Lehman GA, Sherman S, Madura JA, Fogel E, Swack ML, Kopecky KK. Classification and management of perforations complicating endoscopic sphincterotomy. Surgery 1999. [PMID: 10520912 DOI: 10.1016/s0039-6060(99)70119-4] [Citation(s) in RCA: 108] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The management of perforations after endoscopic sphincterotomy (ES) is controversial. The purpose of this study was to analyze the treatments and outcome of patients with ES perforations. METHODS Between January 1994 and July 1998, in a series of 6040 endoscopic retrograde cholangiopancreatographies, 2874 (48%) ESs were performed: 40 patients (0.6%) with perforation were identified and retrospectively reviewed. RESULTS All patients (n = 14) with guidewire perforation (group I) were recognized early, managed medically, and discharged after a mean hospital stay of 3.5 days. Twenty of 22 patients with periampullary perforation (group II) were identified early; 18 patients (90%) had aggressive endoscopic drainage, and none required operation. Of the 2 patients identified late, 1 patient required operation and subsequently died. Mean hospital stay for this group was 8.5 days. Only 1 of 4 patients with duodenal perforations (group III) was identified early; all required operation; 1 patient died, and the mean hospital stay was 19.5 days. CONCLUSIONS ES perforation has 3 distinct types: guidewire, periampullary, and duodenal. Guidewire perforations are recognized early and resolve with medical treatment. Periampullary perforations diagnosed early respond to aggressive endoscopic drainage and medical treatment. Postsphincterotomy perforations diagnosed late (particularly duodenal) require surgical drainage, which carries a high morbidity and mortality rate.
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Affiliation(s)
- T J Howard
- Department of Surgery, Indiana University School of Medicine, Indianapolis, USA
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