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Shimizu T, Yoshioka M, Matsushita A, Kaneko K, Ueda J, Kawashima M, Irie T, Ono T, Furuki H, Kanda T, Mizuguchi Y, Kawano Y, Nakamura Y, Yoshida H. Causes and Management of Endoscopic Retrograde Cholangiopancreatography-Related Perforation: A Retrospective Study. J NIPPON MED SCH 2023; 90:316-325. [PMID: 37271549 DOI: 10.1272/jnms.jnms.2023_90-305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) is essential for diagnosing and treating biliopancreatic disease. Because ERCP-related perforation can result in death, therapeutic decisions are important. The aim of this study was to determine the cause of ERCP-related perforation and suggest appropriate management. METHODS Between January 1999 and August 2022, 7,896 ERCPs were performed in our hospital. We experienced 15 cases (0.18%) of ERCP-related perforation and conducted a retrospective review. RESULTS Of the 15 patients, 6 were female and 9 were male, and the mean age was 77.1 years. According to Stapfer's classification, the 15 cases of ERCP-related perforation comprised 3 type I (duodenum), 3 type II (periampullary), 9 type III (distal bile duct or pancreatic duct), and no type IV cases. Fourteen of 15 (92.6%) were diagnosed during ERCP. The main cause of perforation was scope-induced damage, endoscopic sphincterotomy, and instrumentation penetration in type I, II, and III cases, respectively. Four patients with severe abdominal pain and extraluminal fluid collection underwent emergency surgery for repair and drainage. One type III patient with distal bile duct cancer underwent pancreaticoduodenectomy on day 6. Three type III patients with only retroperitoneal gas on computed tomography (CT) performed immediately after ERCP had no symptoms and needed no additional treatment. Seven of the 15 patents were treated by endoscopic nasobiliary drainage (n=5) or CT-guided drainage (n=2). There were no deaths, and all patients were discharged after treatment. CONCLUSIONS Early diagnosis and appropriate treatment are important in managing ERCP-related perforation.
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Affiliation(s)
- Tetsuya Shimizu
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School
| | - Masato Yoshioka
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School
| | - Akira Matsushita
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School
| | - Keiko Kaneko
- Department of Gastroenterology, Nippon Medical School
| | - Junji Ueda
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School
| | - Mampei Kawashima
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School
| | - Toshiyuki Irie
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School
| | - Takashi Ono
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School
| | - Hiroyasu Furuki
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School
| | - Tomohiro Kanda
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School
| | - Yoshiaki Mizuguchi
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School
| | - Yoichi Kawano
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School
| | - Yoshiharu Nakamura
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School
| | - Hiroshi Yoshida
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School
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Dufera RR, Berake TB, Maliakkal B. Post-endoscopic Retrograde Cholangiopancreatography Complications: A Case of Duodenal Perforation and Literature Review. Cureus 2023; 15:e40303. [PMID: 37313285 PMCID: PMC10259486 DOI: 10.7759/cureus.40303] [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] [Accepted: 06/12/2023] [Indexed: 06/15/2023] Open
Abstract
A duodenal perforation is a serious complication that can occur during endoscopic retrograde cholangiopancreatography (ERCP), particularly if it is associated with therapeutic endoscopic sphincterotomy. Therefore, it is crucial to identify and manage it early to achieve the best possible outcome. Conservative management may be attempted; however, surgical intervention is required if signs of sepsis or peritonitis are present. In this case report, we present the case of post-ERCP duodenal perforation in a 33-year-old female with sickle cell disease who presented on account of abdominal pain. The patient was diagnosed with post-ERCP duodenal perforation, type 4 according to the Stapfer classification. She was subsequently treated conservatively with intravenous antibiotics, bowel rest, and serial abdominal exams. The patient noted significant interval improvement in symptoms and was subsequently discharged home. The early detection and management of suspected complications of ERCP provide a critical prognostic value.
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Affiliation(s)
| | | | - Benedict Maliakkal
- Gastroenterology and Hepatology, Nashville General Hospital, Nashville, USA
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3
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Okuno M, Iwata K, Mukai T, Iwasa Y, Ogiso T, Sasaki Y, Tomita E. Endoscopic nasobiliary drainage tube placement through a periampullary perforation for management of intestinal leak and necrotizing pancreatitis. VIDEOGIE : AN OFFICIAL VIDEO JOURNAL OF THE AMERICAN SOCIETY FOR GASTROINTESTINAL ENDOSCOPY 2022; 8:75-77. [PMID: 36820259 PMCID: PMC9938157 DOI: 10.1016/j.vgie.2022.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
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.
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Affiliation(s)
- Mitsuru Okuno
- Department of Gastroenterology, Gifu Municipal Hospital, Gifu, Japan
| | - Keisuke Iwata
- Department of Gastroenterology, Gifu Municipal Hospital, Gifu, Japan
| | - Tsuyoshi Mukai
- Department of Gastroenterology, Gifu Municipal Hospital, Gifu, Japan,Department of Gastroenterology, Gifu Municipal Hospital, Gifu, Japan
| | - Yuhei Iwasa
- Department of Gastroenterology, Gifu Municipal Hospital, Gifu, Japan
| | - Tomio Ogiso
- Department of Gastroenterology, Gifu Municipal Hospital, Gifu, Japan
| | - Yoshiyuki Sasaki
- Department of Gastroenterological Endoscopy, Kanazawa Medical University, Ishikawa, Japan
| | - Eiichi Tomita
- Department of Gastroenterology, Gifu Municipal Hospital, Gifu, Japan
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4
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Kanaya K, Toyonaga H, Hayashi T, Takahashi K, Katanuma A. Endoscopic clipping to prevent papillary obstruction when closing a duodenal perforation with an over-the-scope clip. VideoGIE 2021; 6:266-268. [PMID: 34141969 PMCID: PMC8186264 DOI: 10.1016/j.vgie.2021.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Kazuya Kanaya
- Center for Gastroenterology, Teine Keijinkai Hospital, Hokkaido, Japan
| | - Haruka Toyonaga
- Center for Gastroenterology, Teine Keijinkai Hospital, Hokkaido, Japan
| | - Tsuyoshi Hayashi
- Center for Gastroenterology, Teine Keijinkai Hospital, Hokkaido, Japan
| | | | - Akio Katanuma
- Center for Gastroenterology, Teine Keijinkai Hospital, Hokkaido, Japan
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Matsuoka M, Kobayashi K, Okura Y, Mochida T, Nozaka T, Sato A, Yauchi M, Matsumoto T, Furumoto Y, Horiuchi T, Asano T. Endoscopic Closure of an Acute Duodenal Perforation Occurring during Endoscopic Ultrasound Using Endoclips and Polyglycolic Acid Sheets with Fibrin Glue. Case Rep Gastroenterol 2021; 15:253-261. [PMID: 33790712 PMCID: PMC7989665 DOI: 10.1159/000512474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 10/16/2020] [Indexed: 11/19/2022] Open
Abstract
Acute duodenal perforation during endoscopic ultrasound (EUS) is a serious complication. The conventional endoscopic treatment for duodenal perforations such as endoscopic clipping is unsatisfactory; recently, the effectiveness of over-the-scope clipping (OTSC) has been reported. A 91-year-old woman was referred to our hospital with the chief complaint of jaundice. Contrast-enhanced computed tomography showed a 2-cm mass in the pancreatic head; we planned EUS-guided fine-needle aspiration. During exploration for a puncture route from the duodenal bulb using a linear echoendoscope under carbon dioxide insufflation, the duodenal lumen was suddenly filled with blood. A perforation <15 mm was identified in the superior duodenal horn. We attempted an endoscopic closure with multiple endoclips but could not completely close the perforation site. Strips of bioabsorbable polyglycolic acid (PGA) sheets were placed over the gaps between the endoclips with biopsy forceps and fixed in place with fibrin glue, completely covering the perforation site. Two days after the procedure, the perforation site had closed. Nine days later, endoscopic biliary stenting was performed. The patient was diagnosed with pancreatic cancer through bile cytology, and the optimal supportive care for her age was selected. Endoscopic tissue shielding with PGA sheets and fibrin glue is increasingly being reported for use during gastrointestinal endoscopic procedures. In this case, surgery was avoided due to successful endoscopic treatment using endoclips and PGA sheets with fibrin glue without OTSC. This method may be useful for repairing acute duodenal perforations during EUS and should therefore be known to pancreatobiliary endoscopists.
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Affiliation(s)
- Mana Matsuoka
- Department of Gastroenterology, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Katsumasa Kobayashi
- Department of Gastroenterology, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Yukito Okura
- Department of Gastroenterology, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Tomohiro Mochida
- Department of Gastroenterology, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Takahito Nozaka
- Department of Gastroenterology, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Ayako Sato
- Department of Gastroenterology, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Masato Yauchi
- Department of Gastroenterology, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Taichi Matsumoto
- Department of Gastroenterology, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Yohei Furumoto
- Department of Gastroenterology, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Takao Horiuchi
- Department of Gastroenterology, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Toru Asano
- Department of Gastroenterology, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
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Kang DH, Ryu DG, Choi CW, Kim HW, Park SB, Kim SJ, Nam HS. Clinical outcomes of iatrogenic upper gastrointestinal endoscopic perforation: a 10-year study. BMC Gastroenterol 2019; 19:218. [PMID: 31842778 PMCID: PMC6916018 DOI: 10.1186/s12876-019-1139-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 12/08/2019] [Indexed: 02/06/2023] Open
Abstract
Background Upper gastrointestinal endoscopic examination is a relatively safe procedure; however, all endoscopic procedures are invasive and are associated with a risk of iatrogenic perforation. To evaluate clinical outcomes of iatrogenic upper gastrointestinal endoscopic perforation. Factors associated with surgical management or mortality were analyzed. Methods Between November 2008 and November 2018, the medical records of 149,792 upper gastrointestinal endoscopic procedures were evaluated. The mechanisms of perforations were categorized as electrocoagulation-induced or blunt trauma-induced injuries. The incidence and clinical outcomes of iatrogenic perforations based on the types of procedures performed were evaluated. Results Iatrogenic endoscopic perforations occurred in 28 cases (0.019%). Iatrogenic perforation-related mortality occurred in 3 patients. The iatrogenic perforation rate based on the types of procedures performed was as follows: diagnostic endoscopy = 0.002%, duodenal endoscopic mucosal resection = 0.9%, esophageal endoscopic submucosal dissection = 10.7%, gastric endoscopic submucosal dissection = 0.2%, endoscopic self-expandable metal stent insertion for malignant esophageal obstruction = 0.1%, duodenoscope-induced injury = 0.02%, endoscopic sphincterotomy = 0.08%, and ampullectomy = 6.8%. All electrocoagulation-induced perforations (n = 21) were managed successfully (15 cases of endoscopic closure, 5 cases treated conservatively, and 1 case treated surgically). Three patients died among those with blunt trauma-induced perforations (n = 7). The factors associated with surgical management or mortality were old age, poor performance status (Eastern Cooperative Oncology Group score ≥ 1), advanced malignancy, and blunt trauma. Conclusions Most cases of electrocoagulation-induced iatrogenic perforations can be treated using endoscopic clips. If endoscopic closure fails for blunt trauma-induced perforations, prompt surgical management is mandatory.
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Affiliation(s)
- Dae Hwan Kang
- Department of Internal Medicine, Medical Research Institute, Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Beomeo-ri Mulgeum-eup, Yangsan-si, Gyeongsangnam-do, 50612, South Korea
| | - Dae Gon Ryu
- Department of Internal Medicine, Medical Research Institute, Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Beomeo-ri Mulgeum-eup, Yangsan-si, Gyeongsangnam-do, 50612, South Korea
| | - Cheol Woong Choi
- Department of Internal Medicine, Medical Research Institute, Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Beomeo-ri Mulgeum-eup, Yangsan-si, Gyeongsangnam-do, 50612, South Korea.
| | - Hyung Wook Kim
- Department of Internal Medicine, Medical Research Institute, Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Beomeo-ri Mulgeum-eup, Yangsan-si, Gyeongsangnam-do, 50612, South Korea
| | - Su Bum Park
- Department of Internal Medicine, Medical Research Institute, Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Beomeo-ri Mulgeum-eup, Yangsan-si, Gyeongsangnam-do, 50612, South Korea
| | - Su Jin Kim
- Department of Internal Medicine, Medical Research Institute, Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Beomeo-ri Mulgeum-eup, Yangsan-si, Gyeongsangnam-do, 50612, South Korea
| | - Hyeong Seok Nam
- Department of Internal Medicine, Medical Research Institute, Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Beomeo-ri Mulgeum-eup, Yangsan-si, Gyeongsangnam-do, 50612, South Korea
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7
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Wu JH, Tsai HM, Chen CY, Wang YS. Computed tomography classification of endoscopic retrograde cholangiopancreatography-related perforation. Kaohsiung J Med Sci 2019; 36:129-134. [PMID: 31633298 DOI: 10.1002/kjm2.12138] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 09/15/2019] [Indexed: 12/25/2022] Open
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP)-related perforation leads to high morbidity and mortality. The Stapfer classification divides patients with different perforation locations and suggests management accordingly. The classification may be unknown if perforation is not detected during endoscopy. We classified patients with ERCP-related perforation (ERP) through computed tomography (CT) and observed the clinical outcomes with varyingly invasive management. Fifty-two cases of ERP between July 2009 and December 2017 were retrospectively reviewed. Of them, 41 who underwent CT for ERCP were included. According to their CT findings, we divided patients into air-alone (n = 16), air-fluid (n = 18), and fluid-alone (n = 7) groups. Perforation severity was graded using the Clavien-Dindo classification for surgical complications. Demographic data and clinical outcomes among different groups were analyzed. Fifteen patients (37%) had an unknown Stapfer classification. More than half of the patients in the air-fluid group had a Clavien-Dindo complication grade of >3. Four patients underwent surgical repair; all of them were from the air-fluid group. All patients in the air- and fluid-alone groups underwent medical treatment without need for subsequent salvage surgery. The air-fluid group had the longest mean hospital stay (25.1 ± 21.9 days) and the exclusive two mortality cases in this study. Patients with ERCP can be divided into groups with different outcomes according to the presence of air or fluid on CT images. Because patients with both air and fluid have the worst clinical outcome, they may require more aggressive treatment than patients with either air or fluid alone.
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Affiliation(s)
- Jhong-Han Wu
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Hong-Ming Tsai
- Department of Radiology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chiung-Yu Chen
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yao-Sheng Wang
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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8
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Endoscopic management of iatrogenic gastrointestinal perforations. LAPAROSCOPIC, ENDOSCOPIC AND ROBOTIC SURGERY 2019. [DOI: 10.1016/j.lers.2019.05.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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9
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ERCP-related perforation: an analysis of operative outcomes in a large series over 12 years. Surg Endosc 2019; 34:77-87. [PMID: 30859489 DOI: 10.1007/s00464-019-06733-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Accepted: 03/06/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Perforation is a rare but serious adverse event of endoscopic retrograde cholangiopancreatography (ERCP). The aim of this study was to determine the predictors of morbidity and mortality after surgical management of ERCP-related perforation (EP). METHODS The records of patients with EP requiring surgical intervention at a tertiary referral center in a 12-year period (2004-2016) were retrospectively analyzed for demography, indications for ERCP, risk factors, timing and type of surgical repair, post-operative course, hospital stay, and outcome. Multiple logistic regression was used to identify the parameters predicting survival. RESULTS Of 25,300 ERCPs, 380 (1.5%) had EP. Non-operative management was successful in 330 (86.8%) patients. 50 (13.2%) patients were operated for EP. Out of 50, the perforation was detected during ERCP (intra-procedure) in 32 patients (64%). In 30 patients (60%), the surgery was performed within 24 h of ERCP. Twenty patients underwent delayed surgery (after 24 h of ERCP) following the failure of initial non-operative management. The delayed surgery after an unsuccessful medical treatment had a detrimental effect on morbidity, mortality and hospital stay. Post-operative duodenal leak was the only independent predictor of 90-day mortality (p = 0.02, OR = 9.1, 95% CI 1.52-54.64). Addition of T-tube duodenostomy (TTD) to the primary repair for either type I or type II perforations increased post-operative duodenal leak (type I, p = 0.048 and type II; p = 0.001) and mortality (type I, p = 0.009 and type II, p = 0.045). CONCLUSION Although EP is a rare event, it has a serious impact on morbidity and mortality. Delaying of surgery following failed non-operative management worsens the prognosis. Addition of TTD to the repair is not helpful in these patients.
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Shi D, Yang JF, Liu YP. Endoscopic Treatment of Endoscopic Retrograde Cholangiopancreatography-Related Duodenal Perforations. J Laparoendosc Adv Surg Tech A 2019; 29:385-391. [PMID: 30676226 DOI: 10.1089/lap.2018.0617] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP)-related duodenal perforation is a rare complication associated with significant morbidity and mortality. This study evaluated endoscopic management experience and outcomes of ERCP-related duodenal perforations. MATERIALS AND METHODS Between March 2005 and March 2017, a total of 19,468 ERCP procedures were performed in three endoscopy units of three hospitals in China. Diagnoses, management, and outcomes were identified and retrospectively reviewed in 58 of these patients. RESULTS According to the classification system, 58 patients included 8 with type I, 44 with type II, 4 with type III, and 2 with type IV perforation. Of type I perforations, 7 patients underwent endoscopic closure with endoclips, and 1 patient was treated with surgical repair. Of type II perforations, 11 patients were actively managed using the fully covered self-expandable metallic stents (SEMS) to seal the perforation, and 33 patients were passively managed using nose-biliary drainage, in which 13 cases had retroperitoneal abscess formation and were successfully treated by abdominal computed tomography (CT)-guided percutaneous external drainage, but 1 patient died due to sepsis. One patient with type III perforation (pancreatic duct perforation) underwent endoscopic pancreatic duct stent placement after surgery failure. The mean hospital stay of 11 cases with type II perforation treated actively by endoscopy (26.5 ± 3.3 days) was lower compared with 33 cases who received passive conservative treatment (34.6 ± 3.9 days). CONCLUSION Many (especially type I and II) ERCP-related duodenal perforations can be successfully treated with endoscopic management. Active endoscopic therapy may be better than passive conservative treatment for type II perforations.
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Affiliation(s)
- Ding Shi
- 1 Department of Gastroenterology, Ningbo No. 2 Hospital, Ningbo, Zhejiang Province, China
| | - Jian Feng Yang
- 2 Department of Gastroenterology, No. 1 People's Hospital of Hangzhou, Hangzhou, Zhejiang Province, China
| | - Yong Pan Liu
- 3 Department of Gastroenterology, The First People's Hospital of Yuhang District, Hangzhou, Zhejiang Province, China
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Bray MS, Borgert AJ, Folkers ME, Kothari SN. Outcome and management of endoscopic retrograde cholangiopancreatography perforations: A community perspective. Am J Surg 2017; 214:69-73. [PMID: 28173939 DOI: 10.1016/j.amjsurg.2017.01.034] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 01/20/2017] [Accepted: 01/29/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) carries a small but significant risk of perforation. Recent data suggest that select patients can be managed non-operatively. We sought to evaluate the management of ERCP perforations at our community medical center. METHODS ERCPs performed from 2004 to 2015 were reviewed. RESULTS Twenty-one of 2423 patients who underwent ERCP had a perforation (0.9%). ERCP procedures included balloon sweep with/without sphincterotomy and pancreatic duct stent (71%), common bile duct brushing (10%), and pancreatic duct stenting (5%). Duodenal diverticula were present in 3 (14%), and altered anatomy was present in 6 (29%). Seventeen patients were treated nonoperatively; 3 (14%) underwent percutaneous drain placement. Two patients failed nonoperative treatment and required surgery. Four patients required ICU stay, and median post-ERCP LOS was 5 days. The 30-day mortality rate was 1/21 (4.8%). CONCLUSIONS Perforations remain a rare, but serious, complication of ERCPs. Nonoperative management is highly successful in carefully selected patients. Early recognition with initiation of antibiotics is paramount. Our community-based practice patterns are similar to those previously published for successful nonoperative management of ERCP perforations.
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Affiliation(s)
- Mallory S Bray
- Department of Medical Education, Gundersen Medical Foundation, La Crosse, WI, USA
| | - Andrew J Borgert
- Department of Medical Research, Gundersen Medical Foundation, La Crosse, WI, USA
| | - Milan E Folkers
- Department of Gastroenterology, Gundersen Health System, La Crosse, WI, USA
| | - Shanu N Kothari
- Department of General Surgery, Gundersen Health System, La Crosse, WI, USA.
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12
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Park SM. Recent Advanced Endoscopic Management of Endoscopic Retrograde Cholangiopancreatography Related Duodenal Perforations. Clin Endosc 2016; 49:376-82. [PMID: 27484814 PMCID: PMC4977750 DOI: 10.5946/ce.2016.088] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2016] [Revised: 07/18/2016] [Accepted: 07/18/2016] [Indexed: 02/06/2023] Open
Abstract
The management strategy for endoscopic retrograde cholangiopancreatography-related duodenal perforation can be determined based on the site and extent of injury, the patient’s condition, and time to diagnosis. Most cases of perivaterian or bile duct perforation can be managed with a biliary stent or nasobiliary drainage. Duodenal wall perforations had been treated with immediate surgical repair. However, with the development of endoscopic devices and techniques, endoscopic closure has been reported to be a safe and effective treatment that uses through-the-scope clips, ligation band, fibrin glue, endoclips and endoloops, an over-the-scope clipping device, suturing devices, covering luminal stents, and open-pore film drainage. Endoscopic therapy could be instituted in selected patients in whom perforation was identified early or during the procedure. Early diagnosis, proper conservative management, and effective endoscopic closure are required for favorable outcomes of non-surgical management. If endoscopic treatment fails, or in the cases of clinical deterioration, prompt surgical management should be considered.
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Affiliation(s)
- Seon Mee Park
- Department of Internal Medicine, Chungbuk National University College of Medicine, Cheongju, Korea
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13
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Kumbhari V, Sinha A, Reddy A, Afghani E, Cotsalas D, Patel YA, Storm AC, Khashab MA, Kalloo AN, Singh VK. Algorithm for the management of ERCP-related perforations. Gastrointest Endosc 2016; 83:934-43. [PMID: 26439541 DOI: 10.1016/j.gie.2015.09.039] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Accepted: 09/28/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Perforation is a rare but serious adverse event of ERCP. There is no consensus to guide the clinician on the management of ERCP-related perforations, with particular controversy surrounding the immediate surgical management of postprocedurally detected duodenal perforation because of overextension of a sphincterotomy. Our aim was to assess patient outcomes using a predetermined algorithm based on managing ERCP-related duodenal perforations according to the mechanism of injury. METHODS A retrospective single-center study of all consecutive patients with Stapfer type I and II perforations between 2000 and 2014 were included. Our institutional algorithm since 2000 dictated that Stapfer type I perforations (duodenal wall perforation, endoscope related) should be managed surgically unless prohibited by underlying comorbidities and Stapfer type II perforations (periampullary, sphincterotomy related) managed nonsurgically unless a deterioration in clinical status necessitated surgery. RESULTS Sixty-one patients (mean age, 51 years; 80% women) were analyzed with Stapfer type I perforations diagnosed in 7 (11%) and type II in 54 (89%). A postprocedural diagnosis of perforation was made in 55 patients (90%). Four patients (7%) had Stapfer type II perforations that failed medical management and required surgery. The mean length of stay (LOS) in the entire cohort was 9.6 days with a low mortality rate of 3%. Systemic inflammatory response syndrome was observed in 18 patients (33%) with Stapfer type II perforations and was not associated with the need for surgery. Concurrent post-ERCP pancreatitis was diagnosed in 26 patients (43%) and was associated with an increased LOS. CONCLUSIONS Stapfer type II perforations have excellent outcomes when managed medically. We validate an algorithm for the management of ERCP-related perforations and propose that it should function as a guide.
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Affiliation(s)
- Vivek Kumbhari
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Amitasha Sinha
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Aditi Reddy
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Elham Afghani
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Deanna Cotsalas
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Yuval A Patel
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Andrew C Storm
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Mouen A Khashab
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Anthony N Kalloo
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Vikesh K Singh
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
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14
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Disibeyaz S, Öztaş E, Kuzu UB, Özdemir M. Closure of echoendoscope-related duodenal free wall perforation by placement of a covered metallic stent. Endosc Ultrasound 2016; 5:399-400. [PMID: 28000634 PMCID: PMC5206831 DOI: 10.4103/2303-9027.195874] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Affiliation(s)
- Selcuk Disibeyaz
- Department of Gastroenterology, Turkiye Yuksek Ihtisas Education and Research Hospital, Ankara, Turkey
| | - Erkin Öztaş
- Department of Gastroenterology, Turkiye Yuksek Ihtisas Education and Research Hospital, Ankara, Turkey
| | - Ufuk Barış Kuzu
- Department of Gastroenterology, Turkiye Yuksek Ihtisas Education and Research Hospital, Ankara, Turkey
| | - Mustafa Özdemir
- Department of Radiology, Turkiye Yuksek Ihtisas Education and Research Hospital, Ankara, Turkey
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15
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Jang JS, Lee S, Lee HS, Yeon MH, Han JH, Yoon SM, Chae HB, Youn SJ, Park SM. Efficacy and Safety of Endoscopic Papillary Balloon Dilation Using Cap-Fitted Forward-Viewing Endoscope in Patients Who Underwent Billroth II Gastrectomy. Clin Endosc 2015; 48:421-7. [PMID: 26473126 PMCID: PMC4604281 DOI: 10.5946/ce.2015.48.5.421] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2014] [Revised: 10/17/2014] [Accepted: 10/21/2014] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND/AIMS Endoscopic exploration of the common bile duct (CBD) is difficult and dangerous in patients with Billroth II gastrectomy (B-II). Endoscopic papillary balloon dilation (EPBD) via a cap-fitted forward-viewing endoscope has been reported to be an effective and safe procedure. We analyzed the technical success and complications of EPBD in patients who underwent B-II. METHODS Thirty-six consecutive patients with B-II were enrolled from among 2,378 patients who had undergone endoscopic retrograde cholangiopancreatography in a single institute in the last 4 years. The EPBD procedure was carried out using a cap-fitted forward-viewing endoscope with 8-mm balloon catheters for 60 seconds. We analyzed the rates of CBD exploration, technical success, and complications. RESULTS Afferent loop intubation was performed in all patients and selective cannulation of the bile duct was performed in 32 patients (88.9%). Complications such as transient hypoxia were observed in two patients (5.6%) and perforation, in three patients (9.7%). The perforation sites were ductal injury in two patients and one patient showed retroperitoneal air alone without symptoms. Three patients manifested different clinical courses of severe acute pancreatitis and peritonitis, transient abdominal pain, and retroperitoneal air alone. The condition of one patient improved with surgery and that of the other two patients, with conservative management. CONCLUSIONS Patients with perforation during EPBD in B-II showed different clinical courses. Tailored treatment strategies are necessary for improving the clinical outcomes.
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Affiliation(s)
- Jong Soon Jang
- Department of Internal Medicine, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Seungho Lee
- Department of Internal Medicine, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Hee Seung Lee
- Department of Internal Medicine, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Myeong Ho Yeon
- Department of Internal Medicine, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Joung-Ho Han
- Department of Internal Medicine, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Soon Man Yoon
- Department of Internal Medicine, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Hee Bok Chae
- Department of Internal Medicine, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Sei Jin Youn
- Department of Internal Medicine, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Seon Mee Park
- Department of Internal Medicine, Chungbuk National University College of Medicine, Cheongju, Korea
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16
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Schröder AS, Heinemann A, Nushida H, Sperhake JP. Fatal pneumoperitoneum following endoscopic retrograde cholangiopancreatography confirmed by post-mortem computed tomography. Forensic Sci Med Pathol 2015; 11:460-3. [PMID: 26044387 DOI: 10.1007/s12024-015-9678-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2015] [Indexed: 02/03/2023]
Affiliation(s)
- Ann Sophie Schröder
- Department of Legal Medicine, University Medical Center Hamburg-Eppendorf, Butenfeld 34, Hamburg, 22529, Germany,
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17
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Chertoff J, Khullar V, Burke L. Duodenal perforation following esophagogastroduodenoscopy (EGD) with cautery and epinephrine injection for peptic ulcer disease: An interesting case of nonoperative management in the medical intensive care unit (MICU). Int J Surg Case Rep 2015; 10:121-5. [PMID: 25837967 PMCID: PMC4429852 DOI: 10.1016/j.ijscr.2015.03.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Revised: 03/04/2015] [Accepted: 03/05/2015] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION The utilization of esophagogastroduodenoscopy (EGD) and related procedures continues to rise. Due to this increase in utilization is an inevitable rise in serious complications such as hemorrhage and perforation. One understudied and dreaded complication of EGD causing significant morbidity and mortality is duodenal perforation. PRESENTATION OF CASE We present the case of a 63-year-old male who presented to our institution's emergency room with dyspepsia, melanic stools, tachycardia, and hypotension. Initial laboratory evaluation was significant for severe anemia, lactic acidosis, and acute kidney injury, while CT scan of the abdomen pelvis did not suggest retroperitoneal hematoma or bowel perforation. An emergent EGD was performed which showed multiple bleeding duodenal ulcers that were cauterized and injected with epinephrine. Post-procedure the patient developed worsening abdominal pain, distension, diaphoresis, and tachypnea, requiring emergent intubation. A CT scan of the abdomen and pelvis with oral contrast confirmed pneumoperitoneum and duodenal perforation. DISCUSSION Due to the patient's hemodynamic instability and multiple comorbidities, he was treated non-operatively with strict bowel rest and intravenous antibiotics. The patient ultimately had a 19-day hospital course complicated by renal failure requiring hemodialysis and an ischemic limb necessitating above knee amputation. CONCLUSION This case describes an unsuccessful attempt at nonoperative management of duodenal perforation following EGD.
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Affiliation(s)
- Jason Chertoff
- University of Florida, College of Medicine, 1600 SW Archer Road, Gainesville, FL 32608, USA.
| | - Vikas Khullar
- University of Florida, College of Medicine, 1600 SW Archer Road, Gainesville, FL 32608, USA
| | - Lucas Burke
- University of Florida, College of Medicine, 1600 SW Archer Road, Gainesville, FL 32608, USA
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18
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Rustagi T, Jamidar PA. Endoscopic retrograde cholangiopancreatography-related adverse events: general overview. Gastrointest Endosc Clin N Am 2015; 25:97-106. [PMID: 25442961 DOI: 10.1016/j.giec.2014.09.005] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) represents a monumental advance in the management of patients with pancreaticobiliary diseases, but is a complex and technically demanding procedure with the highest inherent risk of adverse events of all routine endoscopic procedures. Overall adverse event rates for ERCP are typically reported as 5-10%. The most commonly reported adverse events include post-ERCP pancreatitis, bleeding, perforation, infection (cholangitis), and cardiopulomary or "sedation related" events. This article evaluates patient-related and procedure-related risk factors for ERCP-related adverse events, and discusses strategies for the prevention, diagnosis and management of these events.
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Affiliation(s)
- Tarun Rustagi
- Section of Digestive Diseases, Department of Internal Medicine, Yale University School of Medicine, 333 Cedar Street, 1080 LMP, New Haven, CT 06520, USA
| | - Priya A Jamidar
- Section of Digestive Diseases, Department of Internal Medicine, Yale University School of Medicine, 333 Cedar Street, 1080 LMP, New Haven, CT 06520, USA.
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19
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Lee SM, Cho KB. Value of temporary stents for the management of perivaterian perforation during endoscopic retrograde cholangiopancreatography. World J Clin Cases 2014; 2:689-697. [PMID: 25405193 PMCID: PMC4233427 DOI: 10.12998/wjcc.v2.i11.689] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Revised: 08/25/2014] [Accepted: 09/17/2014] [Indexed: 02/05/2023] Open
Abstract
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.
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20
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Donatelli G, Dumont JL, Vergeau BM, Chiche R, Quioc JJ, Tuszynski T, Meduri B. Colic and gastric over-the-scope clip (Ovesco) for the treatment of a large duodenal perforation during endoscopic retrograde cholangiopancreatography. Therap Adv Gastroenterol 2014; 7:282-4. [PMID: 25364387 PMCID: PMC4212472 DOI: 10.1177/1756283x14551672] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Affiliation(s)
- Gianfranco Donatelli
- Unité d’Endoscopie Interventionnelle, Hôpital Privé des Peupliers, Générale de Santé, 8 Place de l’Abbé G. Hénocque 75013, Paris, France
| | - Jean-Loup Dumont
- Unité d’Endoscopie Interventionnelle, Hôpital Privé des Peupliers, Générale de Santé, Paris, France
| | - Bertrand Marie Vergeau
- Unité d’Endoscopie Interventionnelle, Hôpital Privé des Peupliers, Générale de Santé, Paris, France
| | - Renaud Chiche
- Service de Chirurgie Viscérale et Digestive, Clinique Geoffroy Saint-Hilaire, Générale de Santé, Paris, France
| | - Jean-Jacques Quioc
- Service de Gastro-entérologie, Hôpital Privé de l’Ouest Parisien, Générale de Santé, Trappes, France
| | - Thierry Tuszynski
- Unité d’Endoscopie Interventionnelle, Hôpital Privé des Peupliers, Générale de Santé, Paris, France
| | - Bruno Meduri
- Unité d’Endoscopie Interventionnelle, Hôpital Privé des Peupliers, Générale de Santé, Paris, France
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21
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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.
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Affiliation(s)
- Kwang Bum Cho
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
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22
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Vowinkel T, Senninger N. [Retroperitoneal emphysema after endoscopic retrograde cholangiopancreatography]. Chirurg 2014; 86:462-7. [PMID: 25022517 DOI: 10.1007/s00104-014-2829-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Retroperitoneal emphysema represents a pathological situation with an abnormal amount of air in the retroperitoneal tissue. The diagnosis is made radiologically.The cause is mostly an iatrogenic complication of different diagnostic or therapeutic procedures. The most common cause is a perforation after endoscopic retrograde cholangiopancreatography (ERCP). In cases of clinically suspected complications after a procedure prompt diagnosis with computed tomography (CT) scan of the abdomen and an interdisciplinary decision on the suitable therapeutic measures is warranted, as immediate therapy reduces morbidity and mortality of patients. For selecting the ideal therapy it is essential to understand the underlying pathophysiological mechanism of retroperitoneal emphysema and to take the clinical situation of the patient into account. Thus periampullary or bile duct lesions facing the retroperitoneum can be treated conservatively in clinically stable patients, whereas in unstable patients with abscess formation, interventional radiological or endoscopic procedures are indicated. In cases of a duodenal lesion an endoscopic closure of the perforation can be performed in stable patients but if the patient shows signs of peritonism or if the clinical situation deteriorates, operative therapy is necessary.
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Affiliation(s)
- T Vowinkel
- Klinik für Allgemein- und Viszeralchirurgie, Universitätsklinikum Münster, Waldeyerstr. 1, 48149, Münster, Deutschland,
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23
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Tribonias G, Voudoukis E, Vardas E, Theodoropoulou A, Margarita-Eleni M, Paspatis G. Endoscopic Retrograde Cholangiopancreatography-Related Large Jejunal Perforation: Operate or Apply Over-the-Scope Clip Device? Clin Endosc 2014; 47:281-3. [PMID: 24944996 PMCID: PMC4058550 DOI: 10.5946/ce.2014.47.3.281] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Revised: 01/04/2014] [Accepted: 01/08/2014] [Indexed: 01/11/2023] Open
Affiliation(s)
- George Tribonias
- Department of Gastroenterology, Benizelion General Hospital, Heraklion, Greece
| | - Evangelos Voudoukis
- Department of Gastroenterology, Benizelion General Hospital, Heraklion, Greece
| | - Emmanouil Vardas
- Department of Gastroenterology, Benizelion General Hospital, Heraklion, Greece
| | | | | | - Gregorios Paspatis
- Department of Gastroenterology, Benizelion General Hospital, Heraklion, Greece
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24
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Palomeque Jiménez A, González Puga C, Pérez Cabrera B, Jiménez Ríos JA. [Conservative treatment of duodenal perforation after therapeutic endoscopic retrograde cholangiopancreatography]. GASTROENTEROLOGIA Y HEPATOLOGIA 2014; 38:285-6. [PMID: 24837044 DOI: 10.1016/j.gastrohep.2014.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2014] [Revised: 03/15/2014] [Accepted: 03/18/2014] [Indexed: 10/25/2022]
Affiliation(s)
- Antonio Palomeque Jiménez
- Servicio de Cirugía General y Aparato Digestivo, Hospital Universitario San Cecilio, Granada, España.
| | - Cristina González Puga
- Servicio de Cirugía General y Aparato Digestivo, Hospital Universitario San Cecilio, Granada, España
| | - Beatriz Pérez Cabrera
- Servicio de Cirugía General y Aparato Digestivo, Hospital Universitario San Cecilio, Granada, España
| | - José Antonio Jiménez Ríos
- Servicio de Cirugía General y Aparato Digestivo, Hospital Universitario San Cecilio, Granada, España
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