A Case of Ampullary Perforation Treated with a Temporally Covered Metal Stent

Abstract

Endoscopic retrograde cholangiopancreatography (ERCP)-related perforation is classified into three or four types based on anatomical location and the mechanism of injury. Although ampullary injury, among them, may be managed nonsurgically, surgical management is required in cases of perforation with retroperitoneal fluid collection and severe condition. Here, a patient with ERCP-related severe ampullary perforation with retroperitoneal fluid collection that was treated nonsurgically with a covered stent is presented.

Adverse events associated with ERCP

“…129 The deployment of an FCSEMS to seal the perforation and divert biliary contents is a simple and effective first-line treatment. 138,139 The optimal duration of stent dwell is unknown, but the stent can likely be removed safely after 2 weeks. For large perforations, a nasoduodenal decompression tube may be placed.…”

The Management of Endoscopic Retrograde Cholangiopancreatography-Related Duodenal Perforation

“…Risk factors for perforations include older age, sphincter of Oddi dysfunction, papillary stenosis, anatomical alteration due to surgery (e.g., Billroth II gastrectomy or Roux-en-Y gastric bypass), cases of precut method and prolonged ERCP duration 7,15. Symptoms of perforations range from an initial asymptomatic to severe abdominal pain, subcutaneous emphysema, peritonitis, abdominal distension, fever, cold sweating, and vomiting 10,16. However, even in cases of perforations, the initial stages are often asymptomatic or involve only minor symptoms.…”

Endoscopic Treatments of Endoscopic Retrograde Cholangiopancreatography-Related Duodenal Perforations

“…As a modified method without additional glue injection, endoscopic closure using endoloops with endoclips has provided good clinical results, even though it has been described only in case reports 23-25. Clinical trials have been performed using an endoloop and multiple hemoclips to cover large mucosal defects after endoscopic submucosal dissection or ERCP-induced perforation 23-28. After placement of the endoloop around the perforated area through 1- or 2-channel endoscopy, multiple clips are attached with the endoloop to the perforated area; finally, the endoloop is tightened, and this closes the perforated area (Figs.…”

“…Some patients can be managed by diversion or decompression of contents from the duodenum by placing a nasoduodenal tube alone or with internal pancreaticobiliary drainage. Another option is diversion: a fully covered self-expandable metal stent can be used for the treatment of biliary sphincterotomy-induced perforation 27,28. However, inappropriate biliary drainage may cause bile infiltration or fluid leakage into the perforated site, thus increasing morbidity 1.…”