1
|
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.
Collapse
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
| |
Collapse
|
2
|
Miao YS, Li YY, Cheng BW, Zhan YF, Zeng S, Zhou XJ, Chen YX, Lv NH, Li GH. Clinical analysis of 45 cases of perforation were identified during endoscopic retrograde cholangiopancreatography procedure. Front Med (Lausanne) 2022; 9:1039954. [PMID: 36507518 PMCID: PMC9729696 DOI: 10.3389/fmed.2022.1039954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 11/02/2022] [Indexed: 11/25/2022] Open
Abstract
Background Endoscopic retrograde cholangiopancreatography (ERCP) has become an important method to diagnose and treat biliary-pancreatic diseases. Perforations are infrequent but serious complications can occur during ERCPs. However, it is unclear which patients are suitable for surgery and when these patients should receive surgery. Aim To analyze the outcome of 45 patients with endoscopic retrograde cholangiopancreatography (ERCP) related perforation. Materials and methods We retrospectively reviewed all 45 patients with ERCP-related perforation between January 2003 and December 2017, and observed the location and causes of perforation, treatment strategies, and mortality. Results Twenty thousand four hundred and seventy-nine patients received ERCP procedures from January 2003 to December 2017 in our digestive endoscopy center. Forty-five patients suffered from ERCP-related perforations. The incidence rate of ERCP-related perforations was 0.22%. Twenty-six patients suffered from periampullary perforations, 15 patients suffered from duodenal wall perforations, 1 patient suffered from a fundus perforation, 1 patient suffered from a residual gallbladder duct perforation, 1 patient suffered from a papillary diverticulum perforation, and 1 patient suffered from an intrahepatic bile duct perforation. Six patients with duodenal perforations underwent surgery, and the other patients received conservative treatment. One patient with a duodenal perforation and ERCP-related pancreatitis died of heart failure, and all the other patients recovered. The mortality rate was 2.2%. Conclusion Endoscopic closure is seen as the first method for treating Stapfer type I perforations in the early phase, and surgery is seen as a remedial method when local treatment was failed. The Stapfer type II to type IV perforations can recover by conservative treatment.
Collapse
Affiliation(s)
- Yin-Shui Miao
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China,School of Medicine, Nanchang University, Nanchang, Jiangxi, China
| | - Yuan-Yuan Li
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Bo-Wen Cheng
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China,School of Medicine, Nanchang University, Nanchang, Jiangxi, China
| | - Yan-Fang Zhan
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China,School of Medicine, Nanchang University, Nanchang, Jiangxi, China
| | - Sheng Zeng
- Department of Record Room, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Xiao-Jiang Zhou
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - You-Xiang Chen
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Nong-Hua Lv
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Guo-Hua Li
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China,*Correspondence: Guo-Hua Li,
| |
Collapse
|
3
|
Mousa HM, Hefny AF, Abu-Zidan FM. Life-threatening duodenal perforation complicating endoscopic retrograde cholangiopanceatography: A case series. Int J Surg Case Rep 2020; 66:404-407. [PMID: 31978721 PMCID: PMC6976903 DOI: 10.1016/j.ijscr.2020.01.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 01/04/2020] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Endoscopic retrograde cholangiopancreatography (ERCP) is a diagnostic and therapeutic procedure for biliary and pancreatic diseases. It is associated with low rate of complications. However, some complications as duodenal perforation can be fatal. PRESENTATION OF CASES 852 patients underwent ERCP at our hospital, six patients had a duodenal perforation (0.7 %). All patients were admitted with clinical and biochemical findings of obstructive jaundice without acute cholangitis. All patients had biliary tree dilatation confirmed on abdominal ultrasound scan and/or magnetic resonance cholangiopanceatography. Two patients were initially managed surgically, one of them died due to multi-organ failure. The other four patients were initially treated conservatively; two of them failed conservative management with one death due to sepsis, other two patients recovered without complications. The overall mortality rate was (33.3 %). DISCUSSION Multiple attempts of CBD cannulation and pre-cut sphincterotomy may increase the possibility of duodenal perforation. In the presence of clinical suspicion of perforation, an early radiological imaging is helpful for an early intervention. CONCLUSION A high index of suspicion is essential for early diagnosis and intervention to improve the clinical outcome. In difficult ERCP, performing a post-procedural fluoroscopy study with contrast injection is essential.
Collapse
Affiliation(s)
- Hussam M Mousa
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Ashraf F Hefny
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates.
| | - Fikri M Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| |
Collapse
|
4
|
Evans N, Buxbaum JL. Endoscopic treatment of ERCP-related duodenal perforation. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2019. [DOI: 10.1016/j.tgie.2019.04.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
|
5
|
Tringali A, Pizzicannella M, Andrisani G, Cintolo M, Hassan C, Adler D, Dioscoridi L, Pandolfi M, Mutignani M, Di Matteo F. Temporary FC-SEMS for type II ERCP-related perforations: a case series from two referral centers and review of the literature<sup/>. Scand J Gastroenterol 2018; 53:760-767. [PMID: 29688094 DOI: 10.1080/00365521.2018.1458894] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
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.
Collapse
Affiliation(s)
- Alberto Tringali
- a Endoscopy Unit , Azienda Socio Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda , Milan , Italy
| | | | | | - Marcello Cintolo
- a Endoscopy Unit , Azienda Socio Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda , Milan , Italy
| | - Cesare Hassan
- c Endoscopy Unit , Nuovo Regina Margherita Hospital , Rome , Italy
| | - Douglas Adler
- d Division of Gastroenterology and Hepatology , University of Utah Hospital , Salt Lake City , UT , USA
| | - Lorenzo Dioscoridi
- a Endoscopy Unit , Azienda Socio Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda , Milan , Italy
| | - Monica Pandolfi
- b Endoscopy Unit , Universita' Campus Bio-Medico di Roma , Roma , Italy
| | - Massimiliano Mutignani
- a Endoscopy Unit , Azienda Socio Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda , Milan , Italy
| | | |
Collapse
|
6
|
Cirocchi R, Kelly MD, Griffiths EA, Tabola R, Sartelli M, Carlini L, Ghersi S, Di Saverio S. A systematic review of the management and outcome of ERCP related duodenal perforations using a standardized classification system. Surgeon 2017; 15:379-387. [PMID: 28619547 DOI: 10.1016/j.surge.2017.05.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 05/16/2017] [Indexed: 02/06/2023]
Abstract
INTRODUCTION The incidence of duodenal perforation after ERCP ranges from 0.09% to 1.67% and mortality up to 8%. METHODS This systematic review was registered in Prospective Register of Systematic Reviews, PROSPERO. Stapfer classification of ERCP-related duodenal perforations was used. RESULTS The systematic search yielded 259 articles. Most frequent post-ERCP perforation was Stapfer type II (58.4%), type I second most frequent perforation (17.8%) followed by Stapfer type III in 13.2% and type IV in 10.6%. Rate of NOM was lowest in Stapfer type I perforations (13%), moderate in type III lesions (58.1%) and high in other types of perforations (84.2% in type II and 84.6% in IV). In patients underwent early surgical treatment (<24 h from ERCP) the most frequent operation was simple duodenal suture with or without omentopexy (93.7%). In patients undergoing late surgical treatment (>24 h from ERCP) interventions performed were more complex. In type I lesions post-operative mortality rate was higher in patients underwent late operation (>24 h). In type I lesions, failure of NOM occurred in 42.8% of patients. In type II failure of NOM occurred in 28.9% of patients and in type III there was failure of NOM in only 11.1%, none in type IV. Postoperative mortality after NOM failure was 75% in type I, 22.5% in type II and none died after surgical treatment for failure of NOM in type III perforations. CONCLUSIONS This systematic review showed that in patients with Stapfer type I lesions, early surgical treatment gives better results, however the opposite seems true in Stapfer III and IV lesions.
Collapse
Affiliation(s)
- Roberto Cirocchi
- Department of General and Oncologic Surgery, University of Perugia, Terni, Italy.
| | | | - Ewen A Griffiths
- Department of Gastrointestinal and General Surgery, Medical University of Wrocław, Wrocław, Poland.
| | - Renata Tabola
- Department of Upper Gastrointestinal Surgery, University Hospitals Birmingham NHS Foundation Trust, Edgbaston, Birmingham B15 2WB, United Kingdom.
| | | | - Luigi Carlini
- Section of Legal Medicine, University of Perugia, Terni, Italy.
| | - Stefania Ghersi
- Unit of Gastroenterology and Digestive Endoscopy, AUSL Bologna, Bellaria-Maggiore Hospital, Bologna, Italy.
| | - Salomone Di Saverio
- Emergency Surgery and Trauma Surgery Unit, Maggiore Hospital Trauma Center, Bologna, Italy.
| |
Collapse
|
7
|
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.
Collapse
|
8
|
Kodali S, Mönkemüller K, Kim H, Ramesh J, Trevino J, Varadarajulu S, Wilcox CM. ERCP-related perforations in the new millennium: A large tertiary referral center 10-year experience. United European Gastroenterol J 2015; 3:25-30. [PMID: 25653856 DOI: 10.1177/2050640614560784] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2014] [Accepted: 10/01/2014] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION Endoscopic retrograde cholangiopancreatography (ERCP) is an important diagnostic and therapeutic modality for pancreatic and biliary disorders. Perforation is one of the most dreaded complications of ERCP. Since it is uncommon, there has been little study of incidence, risk factors, and outcomes of management. OBJECTIVES We aim to assess the incidence of ERCP-related perforations and outcomes at a large tertiary referral center. METHODS We undertook a review of an ERCP database for all perforations from 2002 to December 2012. RESULTS The cumulative incidence of ERCP-related perforations was 0.14% (12 out of 8264), and sphincterotomy-related perforations constituted the most common cause. The mean age of these 12 patients was 58.6 years and majority were female (83.3%). The most common indications for ERCP were: suspected sphincter of Oddi dysfunction (SOD) 41%, and common bile duct stones (CBD stones) 41%. Nine of the 12 patients (75%) had a leak and were managed medically, and four who had a perforation had surgical repair (25%). CONCLUSIONS In our study, leaks were much more common than perforations and the majority of patients were successfully managed with conservative therapy alone. We report a very low perforation rate and most perforations can be managed conservatively with a good outcome.
Collapse
Affiliation(s)
- Sudha Kodali
- Division of Gastroenterology and Hepatology, Basil I. Hirschowitz Endoscopic Center of Excellence, University of Alabama at Birmingham, Alabama, USA
| | - Klaus Mönkemüller
- Division of Gastroenterology and Hepatology, Basil I. Hirschowitz Endoscopic Center of Excellence, University of Alabama at Birmingham, Alabama, USA
| | - Hwasoon Kim
- Division of Gastroenterology and Hepatology, Basil I. Hirschowitz Endoscopic Center of Excellence, University of Alabama at Birmingham, Alabama, USA
| | - Jayapal Ramesh
- Division of Gastroenterology and Hepatology, Basil I. Hirschowitz Endoscopic Center of Excellence, University of Alabama at Birmingham, Alabama, USA
| | - Jessica Trevino
- Division of Gastroenterology and Hepatology, Basil I. Hirschowitz Endoscopic Center of Excellence, University of Alabama at Birmingham, Alabama, USA
| | - Shyam Varadarajulu
- Division of Gastroenterology and Hepatology, Basil I. Hirschowitz Endoscopic Center of Excellence, University of Alabama at Birmingham, Alabama, USA
| | - C Mel Wilcox
- Division of Gastroenterology and Hepatology, Basil I. Hirschowitz Endoscopic Center of Excellence, University of Alabama at Birmingham, Alabama, USA
| |
Collapse
|
9
|
Koc B, Bircan HY, Adas G, Kemik O, Akcakaya A, Yavuz A, Karahan S. Complications following endoscopic retrograde cholangiopancreatography: minimal invasive surgical recommendations. PLoS One 2014; 9:e113073. [PMID: 25426633 PMCID: PMC4245110 DOI: 10.1371/journal.pone.0113073] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2014] [Accepted: 10/23/2014] [Indexed: 12/28/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Bora Koc
- Department of Surgery, Okmeydani Training and Research Hospital, Istanbul, Turkey
| | - Huseyin Yuce Bircan
- Department of Surgery, Baskent University Faculty of Medicine, Istanbul Research Hospital, Istanbul, Turkey
| | - Gokhan Adas
- Department of Surgery, Okmeydani Training and Research Hospital, Istanbul, Turkey
| | - Ozgur Kemik
- Department of Surgery, Yuzuncu Yil University Faculty of Medicine, Van, Turkey
- * E-mail:
| | - Adem Akcakaya
- Department of Surgery, Okmeydani Training and Research Hospital, Istanbul, Turkey
| | - Alpaslan Yavuz
- Department of Radiology, Yuzuncu Yil University Faculty of Medicine, Van, Turkey
| | - Servet Karahan
- Department of Surgery, Okmeydani Training and Research Hospital, Istanbul, Turkey
| |
Collapse
|
10
|
Prachayakul V, Aswakul P. Endoscopic retrograde cholangiopancreatography-related perforation: Management and prevention. World J Clin Cases 2014; 2:522-527. [PMID: 25325062 PMCID: PMC4198404 DOI: 10.12998/wjcc.v2.i10.522] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Revised: 07/07/2014] [Accepted: 07/29/2014] [Indexed: 02/05/2023] Open
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is a procedure that can result in serious complications, and thus should be handled by a skilled endoscopist to minimize the risk of complications and to enhance the success rate. The incidence of ERCP-related complications is 5%-10%, most commonly involving post-ERCP pancreatitis and clinically significant post-endoscopic sphincterotomy bleeding. Although ERCP-related perforation has a relatively lower incidence of 0.14%-1.6%, this complication is associated with a high mortality rate of 4.2%-29.6%. A classification of perforation type based on the instrument that caused the perforation was recently described that we postulated could affect the implementation of perforation management. In the present article, an algorithm for management and prevention of ERCP-related perforations is proposed that is based on the perforation type and delay of diagnosis. Available evidence demonstrates that a delayed diagnosis and/or treatment of perforation results in a poorer prognosis, and thus should be at the forefront of procedural consideration. Furthermore, this review provides steps and recommendations from the pre-procedural stage through the post-procedural evaluation with consideration of contributing factors in order to minimize ERCP-related complication risk and improve patient outcome. To avoid perforation, endoscopists must evaluate the risks related to the individual patient and the procedure and perform the procedure gently. Once a perforation occurs, immediate diagnosis and early management are key factors to minimize mortality.
Collapse
|
11
|
Diagnosis and treatment of perforated or bleeding peptic ulcers: 2013 WSES position paper. World J Emerg Surg 2014; 9:45. [PMID: 25114715 PMCID: PMC4127969 DOI: 10.1186/1749-7922-9-45] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Accepted: 06/26/2014] [Indexed: 12/11/2022] Open
|
12
|
Di Saverio S, Bassi M, Smerieri N, Masetti M, Ferrara F, Fabbri C, Ansaloni L, Ghersi S, Serenari M, Coccolini F, Naidoo N, Sartelli M, Tugnoli G, Catena F, Cennamo V, Jovine E. Diagnosis and treatment of perforated or bleeding peptic ulcers: 2013 WSES position paper. World J Emerg Surg 2014. [PMID: 25114715 DOI: 10.1186/1749-7922-9-451749] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Affiliation(s)
- Salomone Di Saverio
- Emergency and General Surgery Dept, Maggiore Hospital- Bologna Local Health District, Bologna, Italy
| | - Marco Bassi
- Department of Gastroenterology and Operative Endoscopy, Maggiore Hospital- Bologna Local Health District, Bologna, Italy
| | - Nazareno Smerieri
- Emergency and General Surgery Dept, Maggiore Hospital- Bologna Local Health District, Bologna, Italy.,Liver and Multivisceral Transplantation Unit, University of Modena&Reggio Emilia - Policlinico Hospital, Modena, Italy
| | - Michele Masetti
- Emergency and General Surgery Dept, Maggiore Hospital- Bologna Local Health District, Bologna, Italy
| | - Francesco Ferrara
- Department of Gastroenterology and Operative Endoscopy, Maggiore Hospital- Bologna Local Health District, Bologna, Italy
| | - Carlo Fabbri
- Department of Gastroenterology and Operative Endoscopy, Maggiore Hospital- Bologna Local Health District, Bologna, Italy
| | - Luca Ansaloni
- General and Emergency and Trauma Surgery, I unit, Ospedali Riuniti, Bergamo, Italy
| | - Stefania Ghersi
- Department of Gastroenterology and Operative Endoscopy, Maggiore Hospital- Bologna Local Health District, Bologna, Italy
| | - Matteo Serenari
- Emergency and General Surgery Dept, Maggiore Hospital- Bologna Local Health District, Bologna, Italy
| | - Federico Coccolini
- General and Emergency and Trauma Surgery, I unit, Ospedali Riuniti, Bergamo, Italy
| | - Noel Naidoo
- Port Shepstone Regional Hospital, Port Shepstone, South Africa - Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | | | - Gregorio Tugnoli
- Emergency and General Surgery Dept, Maggiore Hospital- Bologna Local Health District, Bologna, Italy
| | - Fausto Catena
- Emergency and Trauma Surgery Dept., Maggiore Hospital of Parma, Parma, Italy
| | - Vincenzo Cennamo
- Department of Gastroenterology and Operative Endoscopy, Maggiore Hospital- Bologna Local Health District, Bologna, Italy
| | - Elio Jovine
- Emergency and General Surgery Dept, Maggiore Hospital- Bologna Local Health District, Bologna, Italy
| |
Collapse
|
13
|
Cho KB. The management of endoscopic retrograde cholangiopancreatography-related duodenal perforation. Clin Endosc 2014; 47:341-5. [PMID: 25133122 PMCID: PMC4130890 DOI: 10.5946/ce.2014.47.4.341] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Revised: 07/04/2014] [Accepted: 07/08/2014] [Indexed: 02/06/2023] Open
Abstract
Uneventful duodenal perforation during endoscopic retrograde cholangiopancreatography (ERCP) is an uncommon but occasionally fatal complication. ERCP-related perforations may occur during sphincterotomy and improper manipulation of the equipment and scope. Traditionally, duodenal perforation has been treated with early surgical repair. Recently, nonoperative early endoscopic management techniques including clips or fibrin glue have been reported. In the present paper we review the literature pertaining to the treatment of perforations.
Collapse
Affiliation(s)
- Kwang Bum Cho
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| |
Collapse
|
14
|
Turner RC, Steffen CM, Boyd P. Endoscopic duodenal perforation: surgical strategies in a regional centre. World J Emerg Surg 2014; 9:11. [PMID: 24461069 PMCID: PMC3902478 DOI: 10.1186/1749-7922-9-11] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2013] [Accepted: 01/19/2014] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Duodenal perforation is an uncommon complication of endoscopic retrograde cholangio-pancreatography (ERCP) and a rare complication of upper gastrointestinal endoscopy. Most are minor perforations that settle with conservative management. A few perforations however result in life-threatening retroperitoneal necrosis and require surgical intervention. There is a relative paucity of references specifically describing the surgical interventions required for this eventuality. METHODS Five cases of iatrogenic duodenal perforation were ascertained between 2002 and 2007 at Cairns Base Hospital. Clinical features were analyzed and compared, with reference to a review of ERCP at that institution for the years 2005/2006. RESULTS One patient recovered with conservative management. Of the other four, one died after initial laparotomy. The other three survived, undergoing multiple procedures and long inpatient stays. CONCLUSIONS Iatrogenic duodenal perforation with retroperitoneal necrosis is an uncommon complication of endoscopy, but when it does occur it is potentially life-threatening. Early recognition may lead to a better outcome through earlier intervention, although a protracted course with multiple procedures should be anticipated. A number of surgical techniques may need to be employed according to the individual circumstances of the case.
Collapse
Affiliation(s)
- Richard C Turner
- Department of Surgery, Hobart Clinical School, University of Tasmania, Hobart, Australia.
| | | | | |
Collapse
|
15
|
Rabie ME, Mir NH, Al Skaini MS, El Hakeem I, Hadad A, Ageely H, Shaban AN, Obaid M, Hummadi AM. Operative and non-operative management of endoscopic retrograde cholangiopancreatography-associated duodenal injuries. Ann R Coll Surg Engl 2013; 95:285-90. [PMID: 23676815 DOI: 10.1308/003588413x13511609958578] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Endoscopic retrograde cholangiopancreatography (ERCP) is indispensable in everyday surgical practice. Despite this, as an invasive procedure, it has its own mortality and morbidity, the most feared of which is periduodenal perforations. Our experience with ERCP related periduodenal perforations and its treatment strategies are presented. Additionally, a rarely encountered subtype is highlighted. METHODS Patients who underwent ERCP and sustained a periduodenal perforation between August 2008 and October 2011 were reviewed. RESULTS During the period from August 2008 to October 2011, 597 ERCP procedures were performed in our hospital. Ten of these patients (3 male, 7 female) had a perforation. The mean patient age was 56.6 years. During the procedure, injury was suspected in four patients; it passed unnoticed in the remaining six. The decision to operate or follow a conservative policy was based on a combination of clinical and radiological findings. Operative intervention was required in three patients, with one mortality, while conservative treatment was followed in the remaining seven. A laparotomy was performed early in two patients whereas it was performed after an initial period of conservative treatment in one. The presence of periduodenal fluid collection, contrast extravasation or free intraperitoneal air were decisive factors for performing laparotomy. CONCLUSIONS ERCP-related periduodenal perforations include different categories. Certain types require operative repair while others should be treated conservatively. The choice of the management approach should be individualised, depending on the clinical picture and radiological findings. Although rare, these are potentially serious complications that may end fatally. Early recognition and appropriate intervention is the only way to avert a fatal outcome.
Collapse
|
16
|
Abstract
Injuries to the duodenum pose a diagnostic and therapeutic challenge to the surgeon. Due to the intra- and extra-peritoneal location of the duodenum, the presentation can be overt or occult, and delay in diagnosis is associated with an increased mortality rate. A range of interventions have been described and this article reviews the relevant literature, highlights the salient points and suggests a treatment algorithm.
Collapse
Affiliation(s)
- Mansoor A Khan
- Specialist Registrar, General Surgery, Doncaster Royal Infirmary, Doncaster, UK
| | - Jeff Garner
- Consultant Colorectal Surgeon, Rotherham NHS Foundation Trust, Rotherham, UK
| | - Clive Kelty
- Consultant General and Upper GI Surgeon, Doncaster Royal Infirmary, Doncaster, UK
| |
Collapse
|
17
|
Katsinelos P, Paroutoglou G, Kountouras J, Chatzimavroudis G, Zavos C, Terzoudis S, Katsinelos T, Fasoulas K, Gelas G, Tzovaras G, Pilpilidis I. Partially covered vs uncovered sphincterotome and post-endoscopic sphincterotomy bleeding. World J Gastroenterol 2010; 16:5077-83. [PMID: 20976845 PMCID: PMC2965285 DOI: 10.3748/wjg.v16.i40.5077] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
AIM: To prospectively compare partially covered vs uncovered sphincterotome use on post-endoscopic biliary sphincterotomy (ES) hemorrhage and other complications.
METHODS: All patients referred for therapeutic endoscopic retrograde cholangiopancreatography (ERCP) were randomly assigned to undergo ES either with a partially covered or an uncovered sphincterotome. Both patient and technical risk factors contributing to the development of post-ES bleeding were recorded and analyzed. The characteristics of bleeding was recorded during and after ES. Other complications were also compared.
RESULTS: Three-hundred and eighty-seven patients were recruited in this study; 194 patients underwent ES with a partially covered sphincterotome and 193 with conventional uncovered sphincterotome. No statistical difference was noted in the baseline characteristics and risk factors for post-ES induced hemorrhage between the 2 groups. No significant difference in the incidence and pattern of visible bleeding rates was found between the 2 groups (immediate bleeding in 24 patients with the partially covered sphincterotome vs 19 patients with the uncovered sphincterotome, P = 0.418). Delayed bleeding was observed in 2 patients with a partially covered sphincterotome and in 1 patient with an uncovered sphincterotome (P = 0.62). No statistical difference was noted in the rate of other complications.
CONCLUSION: The partially covered sphincterotome was not associated with a lower frequency of bleeding. Also, there was no difference in the incidence of other significant complications between the 2 types of sphincterotome.
Collapse
|
18
|
Affiliation(s)
- F Y Lui
- Section of Trauma, Surgical Critical Care and Surgical Emergencies, Yale University Department of Surgery, New Haven, CT 06520-8062, USA
| | | |
Collapse
|
19
|
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.
Collapse
|
20
|
Woods KE, Willingham FF. Endoscopic retrograde cholangiopancreatography associated pancreatitis: A 15-year review. World J Gastrointest Endosc 2010; 2:165-78. [PMID: 21160744 PMCID: PMC2998911 DOI: 10.4253/wjge.v2.i5.165] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2010] [Revised: 04/29/2010] [Accepted: 05/06/2010] [Indexed: 02/06/2023] Open
Abstract
The aim of this article is to review the literature regarding post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. We searched for and evaluated all articles describing the diagnosis, epidemiology, pathophysiology, morbidity, mortality and prevention of post-ERCP pancreatitis (PEP) in adult patients using the PubMed database. Search terms included endoscopic retrograde cholangiopancreatography, pancreatitis, ampulla of vater, endoscopic sphincterotomy, balloon dilatation, cholangiography, adverse events, standards and utilization. We limited our review of articles to those published between January 1, 1994 and August 15, 2009 regarding human adults and written in the English language. Publications from the reference sections were reviewed and included if they were salient and fell into the time period of interest. Between the dates queried, seventeen large (> 500 patients) prospective and four large retrospective trials were conducted. PEP occurred in 1%-15% in the prospective trials and in 1%-4% in the retrospective trials. PEP was also reduced with pancreatic duct stent placement and outcomes were improved with endoscopic sphincterotomy compared to balloon sphincter dilation in the setting of choledocholithiasis. Approximately 34 pharmacologic agents have been evaluated for the prevention of PEP over the last fifteen years in 63 trials. Although 22 of 63 trials published during our period of review suggested a reduction in PEP, no pharmacologic therapy has been widely accepted in clinical use in decreasing the development of PEP. In conclusion, PEP is a well-recognized complication of ERCP. Medical treatment for prevention has been disappointing. Proper patient selection and pancreatic duct stenting have been shown to reduce the complication rate in randomized clinical trials.
Collapse
Affiliation(s)
- Kevin E Woods
- Kevin E Woods, Department of Medicine, Gastrointestinal Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, United States
| | | |
Collapse
|
21
|
Hajdú N, Zsoldos P, Neuberger G. [Rectum tumor diagnosed by subcutaneous emphysema of the chest]. Magy Seb 2009; 62:308-11. [PMID: 19828421 DOI: 10.1556/maseb.62.2009.5.4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Various benign and malignant thoracic or abdominal diseases can cause subcutaneous emphysema on the chest, pneumomediastinum or pneumopericardium. To date only 7 cases have been reported on perforation of the sigmoid colon or the rectum presenting with these rare symptoms. METHODS We report a case of a 72-year-old woman who presented with thoracic and cervical subcutaneous emphysema, pneumomediastinum and pneumopericardium. Further examination revealed that this was caused by a rectal tumor causing large bowel obstruction and a consequent perforation of the transverse colon. Due to the patient's old age, poor health and the special anatomic situation after previous laparotomies, she presented with atypical symptoms. CONCLUSIONS Subcutaneous emphysema of the chest, pneumomediastinum and pneumopericardium are uncommon symptoms and can be a real challenge in diagnosis. Especially in old patients with significant past medical history, life-threatening conditions present misleadingly with vague clinical symptoms. In case of these patients it is important to remember that even cardiopulmonary symptoms such as pneumomediastinum, pneumopericardium or subcutaneous emphysema of the chest can be signs of severe diseases in the abdomen.
Collapse
Affiliation(s)
- Nóra Hajdú
- Petz Aladár Megyei Oktató Kórház, Sebészeti Centrum, 9024 Gyor, Vasvári u. 2.
| | | | | |
Collapse
|