Retroperitoneal perforations following endoscopic sphincterotomy; clinical course and management

Sealing the hole: endoscopic management of acute gastrointestinal perforations

Acute perforations are one of the recognised complications of both diagnostic and therapeutic gastrointestinal (GI) endoscopy. The incidence rate varies according to the type of procedure and the anatomical location within the GI tract. For decades, surgical treatment has been the standard of care, but endoscopic closure has become a more popular approach, due to feasibility and the reduction of the burden of surgery. Various devices are available now such as through-the-scope clips, over-the-scope clips, endoscopic suturing devices, stents, bands and omental patch. All have been tested in studies done on humans or animal models, with a reasonable overall technical and clinical success rate, proving efficiency and feasibility of endoscopic closure. The choice of which device to use depends on the site and the size of the perforation. It also depends on availability of thee device and the endoscopist's experience. A number of factors that could predict success of endoscopic closure or favour surgical treatment have been suggested in different studies. After successful endoscopic closure, patients are usually kept nil by mouth and receive antibiotics for a duration that varied between different studies.

Review of duodenal perforations after endoscopic retrograde cholangiopancreatography in Hospital Puerta de Hierro from 1999 to 2014

INTRODUCTION

endoscopic retrograde cholangiopancreatography (ERCP) remains the gold standard in biliary and pancreatic pathology. Although the procedure has a significant morbidity and mortality rate. Algorithms are needed for the management and treatment of the associated complications.

OBJECTIVE

to review the post-ERCP perforations treated in the Department of General Surgery of the Hospital Puerta de Hierro from 1999 to 2014. The results were evaluated according to the types of perforation and treatment.

METHODS AND RESULTS

this is a descriptive and observational study of all post-ERCP perforations reported and treated by the Department of General Surgery of the Hospital Puerta de Hierro from 1999 to 2014. The following data were collected: indication for the test and findings, type of perforation, time and method of diagnosis, time to surgery and the technique used; the subsequent complications as well as the evolution and time of admission were registered. Results were evaluated according to the type of perforation (Stapfer classification) and the treatment performed. Thirty-six perforations were reported (21 type I, eight type II, two type III and five type IV), with an associated incidence of less than 1%. The diagnosis was immediate (in the first 24 hours) in 67% of cases; type I was the most frequent: 28 of 36 patients (77.7%) required surgery. The majority underwent a cholecystectomy followed by suture, intraoperative cholangiography, bile duct exploration and drainage whenever possible. Four patients died with type I perforations; two were intervened and two were managed conservatively. The most frequent complication was a collection/fistula which occurred in 21.42% of patients who underwent surgery.

CONCLUSIONS

periduodenal perforations secondary to ERCP treatment should be oriented according to the clinical and radiological findings. In our experience, type I perforations require immediate surgical intervention, whereas type II and III perforations can be managed conservatively in some cases when there are no complications such as associated abdominal collections, peritoneal irritation and/or sepsis. Type IV perforations respond to conservative management.

Surgery in biliary lithiasis: from the traditional "open" approach to laparoscopy and the "rendezvous" technique

BACKGROUND

According to the current literature, biliary lithiasis is a worldwide-diffused condition that affects almost 20% of the general population. The rate of common bile duct stones (CBDS) in patients with symptomatic cholelithiasis is estimated to be 10% to 33%, depending on patient's age. Compared to stones in the gallbladder, the natural history of secondary CBDS is still not completely understood. It is not clear whether an asymptomatic choledocholithiasis requires treatment or not. For many years, open cholecystectomy with choledochotomy and/or surgical sphincterotomy and cleaning of the bile duct were the gold standard to treat both pathologies. Development of both endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic surgery, together with improvements in diagnostic procedures, influenced new approaches to the management of CBDS in association with gallstones.

DATA SOURCES

We decided to systematically review the literature in order to identify all the current therapeutic options for CBDS. A systematic literature search was performed independently by two authors using PubMed, EMBASE, Scopus and the Cochrane Library Central.

RESULTS

The therapeutic approach nowadays varies greatly according to the availability of experience and expertise in each center, and includes open or laparoscopic common bile duct exploration, various combinations of laparoscopic cholecystectomy and ERCP and combined laparoendoscopic rendezvous.

CONCLUSIONS

Although ERCP followed by laparoscopic cholecystectomy is currently preferred in the majority of hospitals worldwide, the optimal treatment for concomitant gallstones and CBDS is still under debate, and greatly varies among different centers.

Impact of completion of primary biliary procedure on outcome of endoscopic retrograde cholangiopancreatographic related perforation

BACKGROUND AND AIMS

 Perforation is one of the worst complications of therapeutic endoscopic retrograde cholangiopancreatography (ERCP). We aimed to study the epidemiology of ERCP related perforation and the impact of completion of intended procedure on the outcome of this complication.

METHODS

 ERCP records from January 2007 to April 2012 were independently evaluated by two investigators for the occurrence of procedure related perforations. A total of 11 500 patients underwent therapeutic ERCP during the study period. The case records of 171 (1.5 %) patients with ERCP related perforations were reviewed to analyze the epidemiology and risk factors associated with poor outcome.

RESULTS

 Of the 171 patients included in this study, the majority of perforations (n = 129, 75.4 %) were related to use of the needle-knife precut technique. Female gender (1.9 % vs 0.7 %, P  < 0.001), age > 40 years (1.7 % vs 1.1 %, P  < 0.01), and benign disease (1.7 % vs. 1.1 %, P  < 0.01) were risk factors for ERCP related perforation. Most of the perforations (n = 135, 79 %) were detected during the procedure. The majority of patients were managed conservatively (n = 164, 96 %). Although 159 patients recovered, 12 patients (7 %) did not survive. Completion of intended biliary procedure for primary disease was associated with low risk of mortality (2 % vs 15.4 %, P  < 0.001).

CONCLUSIONS

 ERCP related perforation is uncommon. The majority of patients can be managed conservatively. The risk of mortality is low and completion of the intended biliary procedure decreases the risk of mortality.

Results of Medium Seventeen Years' Follow-Up after Laparoscopic Choledochotomy for Ductal Stones

Introduction. In a previously published article the authors reported the long-term follow-up results in 138 consecutive patients with gallstones and common bile duct (CBD) stones who underwent laparoscopic transverse choledochotomy (TC) with T-tube biliary drainage and laparoscopic cholecystectomy (LC). Aim of this study is to evaluate the results at up to 23 years of follow-up in the same series. Methods. One hundred twenty-one patients are the object of the present study. Patients were evaluated by clinical visit, blood assay, and abdominal ultrasound. Symptomatic patients underwent cholangio-MRI, followed by endoscopic retrograde cholangiopancreatography (ERCP) as required. Results. Out of 121 patients, 61 elderly patients died from unrelated causes. Fourteen patients were lost to follow-up. In the 46 remaining patients, ductal stone recurrence occurred in one case (2,1%) successfully managed by ERCP with endoscopic sphincterotomy. At a mean follow-up of 17.1 years no other patients showed signs of bile stasis and no patient showed any imaging evidence of CBD stricture at the site of choledochotomy. Conclusions. Laparoscopic transverse choledochotomy with routine T-tube biliary drainage during LC has proven to be safe and effective at up to 23 years of follow-up, with no evidence of CBD stricture when the procedure is performed with a correct technique.

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.

Diagnosis and management of choledocholithiasis in the golden age of imaging, endoscopy and laparoscopy

Biliary lithiasis is an endemic condition in both Western and Eastern countries, in some studies affecting 20% of the general population. In up to 20% of cases, gallbladder stones are associated with common bile duct stones (CBDS), which are asymptomatic in up to one half of cases. Despite the wide variety of examinations and techniques available nowadays, two main open issues remain without a clear answer: how to cost-effectively diagnose CBDS and, when they are finally found, how to deal with them. CBDS diagnosis and management has radically changed over the last 30 years, following the dramatic diffusion of imaging, including endoscopic ultrasound (EUS) and magnetic resonance cholangiography (MRC), endoscopy and laparoscopy. Since accuracy, invasiveness, potential therapeutic use and cost-effectiveness of imaging techniques used to identify CBDS increase together in a parallel way, the concept of “risk of carrying CBDS” has become pivotal to identifying the most appropriate management of a specific patient in order to avoid the risk of “under-studying” by poor diagnostic work up or “over-studying” by excessively invasive examinations. The risk of carrying CBDS is deduced by symptoms, liver/pancreas serology and ultrasound. “Low risk” patients do not require further examination before laparoscopic cholecystectomy. Two main “philosophical approaches” face each other for patients with an “intermediate to high risk” of carrying CBDS: on one hand, the “laparoscopy-first” approach, which mainly relies on intraoperative cholangiography for diagnosis and laparoscopic common bile duct exploration for treatment, and, on the other hand, the “endoscopy-first” attitude, variously referring to MRC, EUS and/or endoscopic retrograde cholangiography for diagnosis and endoscopic sphincterotomy for management. Concerning CBDS diagnosis, intraoperative cholangiography, EUS and MRC are reported to have similar results. Regarding management, the recent literature seems to show better short and long term outcome of surgery in terms of retained stones and need for further procedures. Nevertheless, open surgery is invasive, whereas the laparoscopic common bile duct clearance is time consuming, technically demanding and involves dedicated instruments. Thus, although no consensus has been achieved and CBDS management seems more conditioned by the availability of instrumentation, personnel and skills than cost-effectiveness, endoscopic treatment is largely preferred worldwide.

Treatment results of gastrointestinal perforation after endoscopic retrograde cholangiopancreatography

INTRODUCTION

Duodenal perforation, damage to common bile duct or ampulla of Vater complicates from 0.7% to 10% of endoscopic retrograde cholangiopancreatography (ERCP) procedures. This complication is associated with high risk of contracting fatal diseases and death. As the endoscopic and minimally invasive treatment methods develop and gain popularity, it becomes increasingly important to determine the correct procedure in the event of gastrointestinal perforation after ERCP.

AIM

To present the results of treatment of gastrointestinal perforation after ERCP and indicate the correct procedure for such cases.

MATERIAL AND METHODS

The material includes 19 patients who underwent ERCP in the years 2008-2011 and were subsequently diagnosed with duodenal perforation (except for duodenal bulb) and common bile duct (CBD). Women accounted for 68% of patients (13/19), while men constituted 32% (6/19). The mean age of patients was 66.6 years old. Indications for ERCP included cholelithiasis in 95% of cases and bile duct strictures in the remaining 5%. Treatment was conditional on the result of X-ray examination of the abdominal cavity, followed by computed tomography with aqueous contrast medium administered orally.

RESULTS

Four patients were diagnosed with intraperitoneal perforation and 15 patients with retroperitoneal perforation. In the patient group with retroperitoneal perforation the contrast media leakage (10 patients) required surgical intervention - the perforation site was located in 5 cases; in the other 5 the site could not be found. With the absence of active contrast media leakage in computed tomography (CT) (5 patients) conservative treatment was applied. Four patients with intraperitoneal perforation were referred for operative treatment. In patients under conservative treatment no complications were observed and the average hospitalization time was 9 days. Among patients with retroperitoneal perforation, who had undergone surgical treatment, complications occurred in 3 cases. The average hospitalization time in the group in which the perforation site was located was 16 days, while in the group with an unidentified perforation site it was 17 days. Patients with intraperitoneal perforation were given operative treatment, with the average hospitalization time of 12 days.

CONCLUSIONS

Each patient with suspected post-ERCP perforation should undergo CT of the abdominal cavity with aqueous contrast medium administered orally. In the event of no contrast leak in patients with retroperitoneal duodenal perforation, conservative treatment should be applied. In the case of retroperitoneal perforation with active contrast media leakage outside the gastrointestinal tract, and in the case of intraperitoneal perforation, an immediate surgical intervention is recommended.

Pseudobowel perforation following endoscopic retrograde cholangiopancreatography

We report two cases of pneumoperitoneum following endoscopic retrograde cholangiopancreatography for retained common bile duct (CBD) stones. These post-cholecystectomy patients underwent sphincterotomy, CBD clearance, and "T" tube removal at the same time. Post-procedure, both of the patients developed pneumoperitoneum. Pneumoperitoneum developed as a result of air traversing from the duodenum to the peritoneum through the ruptured "T" tube tract. "T" tube removal in the same sitting as sphincterotomy and CBD clearance may lead to pneumoperitoneum, which can be managed conservatively.

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.

Proposal of an endoscopic retrograde cholangiopancreatography-related perforation management guideline based on perforation type

Purpose

Consensus for endoscopic retrograde cholangiopancreatography (ERCP) related perforation management is lacking. We aimed to identify candidate patients for conservative management by examining treatment results and to introduce a simple, algorithm-based management guideline.

Methods

A retrospective review of 53 patients with ERCP-related perforation between 2000 and 2010 was conducted. Data on perforation site (duodenum lateral wall or jejunum, type I; para-Vaterian, type II), management method, complication, mortality, hospital stay, and hospital cost were reviewed. Comparative analysis was done according to the injury types and management methods.

Results

The outcome was greater in the conservative group than the operative group with shorter hospital stay (20.6 days vs. 29.8 days, P = 0.092), less cost (10.6 thousand United States Dollars [USD] vs. 19.9 thousand USD, P = 0.095), and lower morbidity rate (22.9% vs. 55.6%, P = 0.017). Eighty-one percent (17/21) of type I injuries were operatively managed and 96.9% (31/32) of type II injuries were conservatively managed. Between the types, type II showed better results over type I with shorter hospital stay (19.3 days vs. 30.6 days, P = 0.010), less cost (9.5 thousand USD vs. 20.1 thousand USD, P = 0.028), and lower complication rate (18.8% vs. 57.1%, P = 0.004). There was no difference in mortality.

Conclusion

Type II injuries were conservatively manageable and demonstrated better outcomes than type I injuries. The management algorithm suggests conservative management in type II injuries without severe peritonitis or unsolved problem requires immediate surgical correction, including operative management in type I injuries unless endoscopic intervention is possible. Conservative management offers socio-medical benefits. Conservative management is recommended in well-selected patients.

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.

Management of endoscopic retrograde cholangiopancreatography: related duodenal perforations

BACKGROUND

As the performance of upper gastrointestinal endoscopy, especially endoscopic retrograde cholangiopancreatography (ERCP), has increased since 1968, so has the incidence of duodenal perforations. The frequency of ERCP use varies among hospitals and depends on the availability of trained endoscopists, equipment, and facilities.

METHODS

A retrospective review of ERCP-related perforations to the duodenum was conducted to identify their incidence, optimal management, and clinical outcome. Charts were reviewed for the following data: ERCP indication, clinical presentation, diagnostic methods, time to diagnosis and treatment, type of injury, management, length of hospital stay, and clinical outcome.

RESULTS

From April 1999 to February 2008, 4,358 ERCP were performed, 15 of which (0.34%) resulted in perforation to the duodenum. Only four of the perforations were discovered during ERCP, with another eight requiring computed tomography or abdominal radiography for diagnosis. Surgery was performed for 13 of the patients (87%), and 2 patients died (15%). One patient was managed conservatively with a successful outcome. Nine patients underwent surgery within 24 h after the ERCP, with only one patient undergoing surgery after 24 h. The overall mortality rate was 20% (3 of 15 patients).

CONCLUSIONS

Clinical and radiographic features can be used to determine the surgical or conservative treatment of ERCP-related duodenal perforations, whereas patient age and intraoperative findings can determine the final outcome and morbidity or mortality. The interval between the perforation and the operation is of great significance. The mortality rate increases dramatically with late surgical management (>24 h). An algorithm for the selective management of ERCP-induced duodenal perforations is proposed.

Operative treatment of periampullary retroperitoneal perforation complicating endoscopic sphincterotomy

BACKGROUND

Evidence-based strategies are lacking regarding the appropriate management of periampullary retroperitoneal perforations complicating endoscopic retrograde cholangiopancreatography (ERCP) combined with endoscopic sphincterotomy (ES). We propose a transduodenal operative repair of periampullary retroperitoneal perforation.

METHODS

Six patients with duodenal periampullary perforation induced by endoscopic sphincterotomy underwent operation after failure of an attempt of conservative management. After mobilization of the second and the third part of the duodenum, a minimal transversal duodenotomy was carried out, the papilla was exposed, periampullary perforation was readily identified, and was sutured easily as a sphincteroplasty or by 2 or 3 Vicryl 3/0 sutures. Patient outcomes were measured.

RESULTS

Periampullary perforation was repaired as sphincteroplasty in 2 cases, and with Vicryl 3/0 sutures in 4 cases. The mean duration of operation was 176 minutes. There were no intraoperative complications. None of the patients required reoperation after transduodenal repair of the perforation. The patients had a normal postoperative course. The median hospital stay was 10.5 days (range, 9 to 20 days) and the mortality rate was nil. There were no delayed complications during a median follow-up of 60 months.

CONCLUSIONS

The transduodenal operative approach to periampullary perforation after ERCP/ES at an early stage in the clinical evolution of the perforation is a safe and effective procedure. We consider this approach a useful option for the treatment of periampullary perforation after ERCP/ES when initial endoscopic and conservative management do not yield good results within 24 hours.

Management of perforation after endoscopic retrograde cholangiopancreatography (ERCP): a population-based review

BACKGROUND

Perforation related to endoscopic retrograde cholangiopancreatography (ERCP) is a rare complication associated with significant morbidity and mortality. This study evaluated the management and outcomes of these perforations.

PATIENTS AND METHODS

Between July 1996 and December 2002, a total of 6620 ERCPs were performed at our regional endoscopy unit serving the 1.5 million population of Southern Alberta. Thirty perforations (0.45%) were identified and retrospectively reviewed. Results. Seven of these 30 patients were found to have guidewire perforations of the bile duct, 11 perforations were peri-ampullary, 3 duodenal, 1 esophageal, and 1 patient had a perforation of an afferent limb of a Billroth II anastomosis. In seven patients the location of the perforation could not be determined (unknown). All patients with guidewire perforations were recognized during ERCP, and all were managed medically. Of the 11 peri-ampullary perforations, 7 of these patients had a pre-cut sphincterotomy, 5 underwent surgery and 4 patients died. Delay in diagnosis occurred in all patients that died. Of the three duodenal perforations, all required operation and one patient died. Of the seven 'unknown' retroperitoneal perforations, two patients required surgery and there was no mortality. The patients with esophageal and afferent limb perforations both recovered uneventfully after surgery. Most patients who required surgery had retroperitoneal fluid seen on CT scanning.

CONCLUSIONS

We found that most guidewire perforations can be managed medically with little morbidity. Pre-cut sphincterotomy is a risk factor for perforation. Peri-ampullary and duodenal perforations have a high morbidity and mortality rate. In particular, retroperitoneal fluid collections on CT scans, delay in diagnosis and failure of medical therapy requiring salvage surgery are associated with poor outcomes. Early aggressive surgery may improve patient care.

Treatment of a duodenal perforation secondary to an endoscopic sphincterotomy with clips

Perforation is one of the most serious complications of endoscopic sphincterotomy (ES) necessitating immediate surgical intervention. We present a case of successful management of such a complication with endoclipping. A 85-year-old woman developed duodenal perforation after ES. The perforation was identified early and its closure was achieved using three metallic clips in a single session. There was no procedure-related morbidity or complications and our patient was discharged from hospital 10 d later. Endoclipping of duodenal perforation induced by ES is a safe, effective and alternative to surgery treatment.

ERCP subsequent to retroperitoneal perforation caused by endoscopic sphincterotomy

BACKGROUND

Perforation occurs after endoscopic sphincterotomy in 0.4% of cases. With recognition of a perforation, the procedure usually is aborted and further attempts at ERCP are thought to be precluded by the complication. The aim of this study was to determine the timing and the outcome of ERCP after retroperitoneal perforation caused by endoscopic sphincterotomy when the initial ERCP was incomplete.

METHODS

A total of 1787 patients underwent endoscopic sphincterotomy during a period of 29 months. A type II duodenal perforation was recognized in 15 patients, whereupon the ERCP, including further intervention, was halted. Eight patients agreed to undergo a second therapeutic ERCP to complete the treatment of the primary disease.

OBSERVATIONS

Therapeutic ERCP was repeated in all patients from 11 to 15 days after the perforation. Treatment was successfully completed in all patients without complication.

CONCLUSIONS

Therapeutic ERCP may be repeated and has a high success rate in patients who sustain a perforation caused by endoscopic sphincterotomy.

Management of duodenal perforation after endoscopic retrograde cholangiopancreatography and sphincterotomy

OBJECTIVE

To evaluate the authors' experience with periduodenal perforations to define a systematic management approach.

SUMMARY BACKGROUND DATA

Traditionally, traumatic and atraumatic duodenal perforations have been managed surgically; however, in the last decade, management has shifted toward a more selective approach. Some authors advocate routine nonsurgical management, but the reported death rate of medical treatment failures is almost 50%. Others advocate mandatory surgical exploration. Those who favor a selective approach have not elaborated distinct management guidelines.

METHODS

A retrospective chart review at the authors' medical center from June 1993 to June 1998 identified 14 instances of periduodenal perforation related to endoscopic retrograde cholangiopancreatography (ERCP), a rate of 1.0%. Charts were reviewed for the following parameters: ERCP findings, clinical presentation of perforation, diagnostic methods, time to diagnosis, radiographic extent and location of duodenal leak, methods of management, surgical procedures, complications, length of stay, and outcome.

RESULTS

Fourteen patients had a periduodenal perforation. Eight patients were initially managed conservatively. Five of the eight patients recovered without incident. Three patients failed nonsurgical management and required extensive procedures with long hospital stays and one death. Six patients were managed initially by surgery, with one death. Each injury was evaluated for location and radiographic extent of leak and classified into types I through IV.

CONCLUSIONS

Clinical and radiographic features of ERCP-related periduodenal perforations can be used to stratify patients into surgical or nonsurgical cohorts. A selective management scheme is proposed based on the features of each type.

Classification and management of perforations complicating endoscopic sphincterotomy

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.

Significance of retroperitoneal air after endoscopic retrograde cholangiopancreatography with sphincterotomy

OBJECTIVE

We designed a prospective study to determine the frequency of retroperitoneal air after endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy. We sought to elucidate the relationship of retroperitoneal air with endoscopic maneuvers, clinical findings, the length of sphincterotomy, and the time spent during the procedure. We also endeavored to determine the importance of retroperitoneal air and its most appropriate clinical management.

METHODS

Twenty-one consecutive patients who had undergone ERCP with sphincterotomy had abdominal computed tomography (CT) examinations within 24 h after completion of the procedure. The CT findings were unknown to the clinicians, and none of the patients received postprocedural antibiotics.

RESULTS

Six (29%) of 21 patients exhibited CT findings of retroperitoneal air. All six patients had uneventful postprocedural courses, and none had abnormal clinical signs or symptoms. The occurrence of retroperitoneal air was not influenced by the presence of hyperamylasemia, the duration of the procedure, or the length of the sphincterotomy.

CONCLUSIONS

Retroperitoneal air is not an uncommon finding after ERCP with sphincterotomy. Moreover, the finding of retroperitoneal air in the absence of physical findings, is not a cause for alarm and does not require surgical intervention.

Papillary injuries and duodenal perforation during endoscopic retrograde sphincterotomy (ERS): radiological findings

OBJECTIVE

To describe the radiological features of duodenal injury during endoscopic retrograde sphincterotomy (ERS) with special reference to limited papillary trauma and minor perforation.

METHODS

The radiological and clinical features of duodenal injuries out of 284 ERS performed in the last 4 years were evaluated retrospectively to document various patterns of trauma and correlation with clinical outcome.

RESULTS

Duodenal injuries occurred in eight patients: mild papillary injuries in five subjects (intrapapillary extravasation of contrast medium in one, peri-Vaterian submucosal diffusion in four) and duodenal perforation in three (peri-choledochal diffusion in one, retroperitoneal leakage in two).

CONCLUSION

The radiological findings in papillary and duodenal injuries are protean and knowledge of their variable appearance is important since their detection may have practical consequences.

Complications of diagnostic and therapeutic ERCP

Complications associated with ERCP have been well defined, clinically recognized, and effectively managed conservatively. Few patients require surgery or prolonged hospitalization. The morbidity and mortality associated with ERCP and sphincterotomy have remained low, and, although the outcome of endoscopy is equivalent or better than surgical or radiologic techniques, the complications are less. Despite the general acceptance of ERCP, its therapeutic applications, its more universal performance, and the morbidity and mortality rates have remained the same or lower since its introduction a quarter of a century ago.

The management of perforation of the duodenum following endoscopic sphincterotomy: a proposal for selective therapy

The successful non-surgical management of retroduodenal perforation following endoscopic sphincterotomy is reported and the literature reviewed. Two patients are described who developed gas in the retroperitoneum following endoscopic sphincterotomy. One patient developed retroperitoneal emphysema and cervical emphysema, while the second patient developed retroperitoneal emphysema and a pneumothorax following endoscopic sphincterotomy. Both patients were treated conservatively and made uneventful recoveries. An algorithm for assessment and treatment is proposed based on the authors' experience and a literature review. Patients with confirmed ongoing duodenal leakage, sepsis or collection should have expeditious surgery.

The successful surgical management of perforation after endoscopic sphincterotomy: report of two cases

Retroperitoneal perforation following endoscopic sphincterotomy (EST) is an infrequent but serious complication with a high mortality rate in patients who do not receive prompt treatment. We report herein two cases of perforation, diagnosed 3 and 7 days after EST, one of whom was treated by choledochojejunostomy (Roux-en-Y) and suturing of the perforation site with jejunal patching, and the other by pancreatoduodenectomy. Both operations were successful as emergency treatments and therefore we consider that radical surgery should be attempted for cases of perforation after endoscopic sphincterotomy with a delayed diagnosis.

Endoscopic sphincterotomy complications and their management: an attempt at consensus

Despite its relative safety (in comparison with surgery), and undoubted role in many clinical circumstances, biliary sphincterotomy is the most dangerous procedure routinely performed by endoscopists. Complications occur in about 10% of patients; 2 to 3% have a prolonged hospital stay, with a risk of dying. This document is an attempt to provide guidelines for prevention and management of complications, based on a workshop of selected experts, and a comprehensive review of the literature. We emphasize particularly the importance of specialist training, disinfection, drainage, and collaboration with surgical colleagues.

Surgical management of complications of endoscopic sphincterotomy with precut papillotomy

We reviewed 574 endoscopic sphincterotomy procedures. Fifty-six precut papillotomies were performed. Presenting conditions included choledocholithiasis, cholangitis, benign and malignant papillary strictures, and stenosing papillitis. Complications were identified in 16 percent: perforation in 9 percent, pancreatitis in 5 percent, bleeding in 2 percent, and pancreatic abscess in 2 percent. One patient died. Six patients required operation for complications. Perforation of the duodenum or common bile duct seen within 8 hours was managed with drainage and closure of the perforation with minimal complications. Duodenal perforations operated on later than 8 hours required more extensive procedures. All these patients had significant post-operative complications. Three patients were managed nonoperatively. Precut papillotomy carries a significantly higher complication rate than conventional sphincterotomy. Our experience suggests that there is no place for conservative management of duodenal perforation.

Perforation of the common bile duct during endoscopic sphincterotomy: recognition on computed tomography and successful percutaneous treatment

Retroperitoneal common bile duct (CBD) perforation is a rare complication of endoscopic retrograde cholangiopancreatography (ERCP). We describe such a case with delayed diagnosis made by computed tomography (CT) and successful percutaneous management of the injury.

Endoscopic sphincterotomy in outpatients

We retrospectively reviewed 137 cases of outpatient endoscopic sphincterotomy (ES) performed over a 4-year period in a single center and compared them with an equal number of inpatient ES. The indications for ES in outpatients as compared with inpatients were, respectively: choledocholithiasis, 60% and 70%; papillary stenosis, 35% and 15% (p less than 0.001); stent insertion, 3.6% and 14% (p less than 0.01); and ampullary tumor, 1.4% and 0.7%. Complications were noted within 2 to 4 hours of ES in 6.6% of outpatients, a rate similar to that of inpatients--7.3%. Outpatients with complications were immediately admitted and stayed in the hospital for a mean of 5 days. No delayed complications were noted and no deaths occurred. Thus, a policy whereby selected individuals undergo ES as outpatients, with hospitalization reserved only for those in whom a complication develops, is reasonable and safe.

Nasobiliary drainage following endoscopic sphincterotomy. A useful method of preventing and treating early complications

The authors analyze a retrospective study of 850 patients who underwent endoscopic sphincterotomy (ES). One group of patients (705) routinely had nasobiliary drainage following ES as a prophylactic measure to prevent complications, while 145 patients were not drained. Complications, mortality and the need for emergency surgery were compared in both groups. In the drained group, the complication rate was 2% vs 10.3% in the nondrained group (P less than 0.001), and mortality was 0.4% vs 2.7% (P = 0.03). Emergency surgery was required in 0.1% in the drained patients versus 3.4% in the nondrained group (P = 0.01). Based on these data within the limits of a retrospective study, the authors strongly support the routine use of nasobiliary drainage to prevent complications, which usually occur within the first 24 h, and also to facilitate the immediate treatment of the complications. This procedure is also highly recommended when ES is performed by inexperienced endoscopists and with a technically demanding ES, which is frequently followed by complications.