Endoscopic sphincterotomy-related perforation in the common bile duct successfully treated by placement of a covered metal stent

Management of iatrogenic perforations during endoscopic interventions in the hepato-pancreatico-biliary tract

Endoscopic retrograde cholangiopancreaticography (ERCP) and endoscopic ultrasound (EUS) guided interventions are among the most challenging procedures performed by interventional endoscopists and are associated with a significant risk of complications. Early recognition and classification of perforations allows immediate therapy which improves clinical outcomes. In this article we review the different aspects of iatrogenic perforations associated with pancreatico-biliary interventions, elucidating risk factors, diagnostic challenges and the latest therapeutic interventions.

Endoscopic nasobiliary drainage tube placement through a periampullary perforation for management of intestinal leak and necrotizing pancreatitis

Video 1Management of ampullary perforation by endoscopic nasobiliary drainage tube placement through the perforation for suctioning out leaked intestinal juice and indicating the presence of the hepatic portal vein.

Fully covered self-expandable metal stent for intraprocedural or late-diagnosed Type-II endoscopic retrograde cholangiopancreatography-related perforations

Background

Perforations related to endoscopic retrograde cholangiopancreatography (ERCP) are rare but life-threatening complications. The treatment of Type-II-periampullary perforations that develop during endoscopic sphincterotomy remains a topic of discussion. This study aimed to evaluate the usefulness of fully covered self-expanding metal stenting (FCSEMS) for treating Type-II perforations.

Methods

The files of all patients who underwent the ERCP procedures between January 2015 and October 2021 were retrospectively reviewed; patients with Stapher Type-II perforation were included in the current study. Patients with FCSEMS were classified into two groups: those who underwent FCSEMS and those who were conventionally followed up. Moreover, patients with FCSEMS were classified into two subgroups: those who underwent simultaneous stenting and those who underwent late stenting. Mortality, surgical intervention, percutaneous drainage, length of hospital stay, and inflammatory markers were all compared between the groups.

Results

Of the 9253 patients undergoing ERCP during the study period, 28 patients (0.3%) were found to have Type-II perforation. The mean age of these patients was 67.7 ± 3.9 years, and 15 patients were female. FCSEMS was performed on 19 patients, whereas 9 patients were on conventional follow-up. None of the patients developed mortality. In the conventional follow-up group, one patient required percutaneous drainage and one required surgical intervention. In contrast, none of the patients in the FCSEMS group required additional intervention. At a statistically significant level, the length of hospital stay was found to be shorter in the FCSEMS group. There was no difference in inflammatory markers between the two groups. In nine patients, FCSEMS was performed simultaneously, whereas, in ten patients, FCSEMS was performed later because they required a second intervention. These two subgroups did not differ in terms of outcomes.

Conclusions

FCSEMS is a safe and effective treatment modality for patients with Type-II perforation. Moreover, it can be safely used in patients whose perforations are diagnosed during the ERCP procedure and in patients whose diagnoses are made after the procedure.

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.

Endoscopic Retrograde Cholangiopancreatography-Related Complications and Their Management Strategies: A "Scoping" Literature Review

Endoscopic retrograde cholangiopancreatography (ERCP) is a well-known procedure with both diagnostic and therapeutic utilities in managing pancreaticobiliary conditions. With the advancements of endoscopic techniques, ERCP has become a relatively safe and effective procedure. However, as ERCP is increasingly being utilized for different advanced techniques, newer complications have been noticed. Post-ERCP complications are known, and mostly include pancreatitis, infection, hemorrhage, and perforation. The risks of these complications vary depending on several factors, such as patient selection, endoscopist's skills, and the difficulties involved during the procedure. This review discusses post-ERCP complications and management strategies with new and evolving concepts.

Biliary endoscopic sphincterotomy: Techniques and complications

Biliary endoscopic sphincterotomy (EST) refers to the cutting of the biliary sphincter and intraduodenal segment of the common bile duct following selective cannulation, using a high frequency current applied with a special knife, sphincterotome, inserted into the papilla. EST is either used solely for the treatment of diseases of the papilla of Vater, such as sphincter of Oddi dysfunction or to facilitate subsequent therapeutic biliary interventions, such as stone extraction, stenting, etc. It is a prerequisite for biliary interventions, thus every practitioner who performs endoscopic retrograde cholangiopancreatography needs to know different techniques and the clinical and anatomic parameters related to the efficacy and safety of the procedure. In this manuscript, we will review the indications, contraindications and techniques of biliary EST and the management of its complications.

Temporary FC-SEMS for type II ERCP-related perforations: a case series from two referral centers and review of the literature<sup/>

BACKGROUND AND AIM

Some case reports have shown that fully covered self-expandable metal stents (FC-SEMS) are effective in cases of Stapfer Type II perforation as rescue treatment. The aim of the study was to assess the efficacy and safety of temporary placement of FC-SEMS as primary treatment for Type II perforations and review the literature regarding the use of FC-SEMS in this setting.

PATIENTS AND METHOD

Retrospective analysis of consecutive patients with Type II perforation treated with immediate placement of FC-SEMS. Primary outcomes were need for surgery and mortality rate. Secondary outcomes were complications, technical and clinical success, time to post-operative feeding, length of the hospitalization and time to stent removal.

RESULTS

Overall, 18 consecutive patients were enrolled (median age 71.5). All patients were treated with FC-SEMS (6-10 mm, 4-8 cm long). In all patients, there were no need for surgery, and no patient died. Technical and clinical success were achieved both in 100% of cases. The median time to stent removal was 43 (2-105) days. The median hospital stay was of 10 (4-21) days. Median time to post-operative feeding was 4 days (2-15).

CONCLUSION

FC-SEMS placement could be a safe and effective treatment in Type II perforations and represent a valuable development and innovation of conservative treatment.

Can a Fully Covered Self-Expandable Metallic Stent be Used Temporarily for the Management of Duodenal Retroperitoneal Perforation During ERCP as a Part of Conservative Therapy?

PURPOSE

There are no reports comparing the results of conservative/nonsurgical management with the addition of fully covered self-expandable metallic stents (FCSEMS) with the conservative approach in endoscopic retrograde cholangiopancreatography (ERCP)-related duodenal retroperitoneal (type II) perforations. The aim of this study was to evaluate whether the addition of FCSEMS to conventional treatment provides further benefits in the course of type II perforations.

METHODS

A total of 7471 ERCP with sphincterotomy performed between 2007 and 2014 were evaluated, and a total of 25 type II perforations (0.33%) were identified. About 20 patients who were detected during ERCP and biliary cannulation was accomplished were included in the study. Patients were divided into 2 groups: the conservative treatment group (10 patients) and the FCSEMS group (10 patients). Groups were compared for clinical findings, results of serial white blood cell (WBC) counts, the length of hospital stay, the need for surgery, and death, retrospectively.

RESULTS

Five patients in the conservative treatment group and none of the patients in the FCSEMS group had pain requiring narcotic and/or nonsteroidal anti-inflammatory analgesics during the follow-up period (P=0.005). On post-ERCP day 1, in the conservative and the FCSEMS groups, mean WBC counts were 13,218±4410×10 and 8714±3270×10, respectively (P=0.029). The perforation-related length of hospital stay was 15.77±5.21 days in the conservative group and 11.7±3.19 days in the FCSEMS group (P=0.053). Excluding the patient with severe pancreatitis in the conservative group, there were no deaths or need for surgery.

CONCLUSIONS

Compared with conservative treatment alone, the addition of FCSEMS provides further benefits in terms of a painless course, lower WBC counts, and a short hospital stay. FCSEMS can be used as an additional treatment modality in type II perforation.

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.

Closing perforations and postperforation management in endoscopy: duodenal, biliary, and colorectal

Early recognition of adverse events arising from endoscopy is essential. In some cases the injury can be viewed clearly during the procedure, and immediate action should be taken to repair the defect endoscopically if feasible. If perforation is unclear, imaging can be used to confirm the diagnosis. Surgical intervention is not always necessary; however, a surgical consultation for backup is essential. Selective cases can be managed conservatively or endoscopically with successful outcomes. Early recognition and intervention, input from specialist colleagues, and communication with the patient and family are keys to successfully managing the event.

Value of temporary stents for the management of perivaterian perforation during endoscopic retrograde cholangiopancreatography

Endoscopic retrograde cholangiopancreatography (ERCP) has become the mainstay of treatment in hepato-pancreato-biliary disease. However, ERCP requires a high level of technical skills and experience in therapeutic endoscopy, there is always a risk of complications. Especially, the perforation per se affects the patient adversely, and the clinical course may lead to a poor prognosis, even with appropriate management. The treatments for ERCP-related perforation are diverse, depending on the location and mechanism of the bowel perforation and the time of diagnosis. Thus, we reviewed the appropriate surgical and non-surgical management options for therapeutic ERCP-related perforations, especially, evaluating metallic stenting as a treatment modality in perivaterian perforation.