Management of iatrogenic injuries due to endoscopic sphincterotomy: Surgical or conservative approaches

Abstract

Based on a single center experience with the management of ERCP-rP, we aimed to analyze the types of injuries, surgical options, and outcomes of patients with ERCP-rP. MATERIAL AND METHODSOver a five-year period between January 2010 and October 2015, all ERCP procedures (n=3432) that were performed at the Gastroenterology and General Surgery Clinic at Şişli Hamidiye Etfal Training and Research Objective: The best therapeutic approach for endoscopic retrograde cholangiopancreatography-related perforations remains controversial; while some authors suggest routine conservative management, others advocate mandatory surgical exploration. We aimed to evaluate our clinical experience of perforations during endoscopic sphincterotomy. Material and Methods:A retrospective chart review from January 2010 to October 2015 identified 20 patients with endoscopic retrograde cholangiopancreatography-related perforations. Data collection included demographics, time to diagnosis, type of perforation, treatment strategy, surgical procedure, complications, hospital stay, and outcome. All patients were classified into two groups on the basis of radiological and operative findings. Results:Only five patients underwent surgical treatment, whereas 15 patients were managed conservatively. The mean time to diagnosis was 7.8 hrs (range: 1 to 36 hrs). In patients who underwent surgical treatment, the types of perforations included type I and III in one patient each and type II in three patients. Surgical procedures included laparoscopic and open cholecystectomy with t-tube drainage in two patients each and primary repair of duodenal injury with hepaticojejunostomy in one patient. Among conservatively managed patients, eight, four, and three had type II, type III, and type IV injuries, respectively. Of these 15 patients, 60% (n=9) underwent percutaneous procedures. The mean length of hospital stay was similar for conservatively and surgically treated patients (12 vs. 12.4 days, respectively, p=0.790). One patient (5%) with type I injury died of multiorgan deficiency. Conclusion:With close close clinical follow-up, medical treatment can be beneficial for most patients, and surgical procedures should be reserved for patients with type I (definite) and type II/III injuries; in patients with these clinical parameters, conservative management will likely be unsuccessful.

Surgical management of duodenal perforation after endoscopic retrograde cholangiopancreatography: case series

“…An abdominal ultrasound can identify intraperitoneal or retroperitoneal free air, and the formation of abscesses. The CT is the most sensitive method for patients with suspected intestinal perforation, with a specificity of 82-90%, as it allow to observe if there is an extravasation of the contrast medium, collections, or neumoretroperitoneum 5,13,14 . In our study, all patients had a contrasted abdominal CT scan as a diagnostic method, and the most common finding was the pneuroretroperitoneum.…”

Manejo quirúrgico de perforaciones duodenales tras colangiopancreatografía retrógrada endoscópica: serie de casos

“…La ecografía de abdomen puede identificar aire libre intraperitoneal o retroperitoneal, y la formación de abscesos. La TC es el método más sensible para los pacientes con sospecha de perforación intestinal, con una especificidad del 82-90%, ya que permite observar si hay extravasación del medio de contraste, colecciones o neumorretroperitoneo 5,13,14 . En nuestro estudio, a todos los pacientes se les realizó una TC abdominal contrastada como método diagnóstico, y el hallazgo más común fue neumorretroperitoneo.…”

Recent advances in prevention and management of endoscopic retrograde cholangiopancreatography-related duodenal perforation.

“…Indeed, this is the best time to treat; even if the endoscopic treatment fails, early surgery can be performed and the prognosis is better [ 5 , 7 , 14 ]. Finally, some studies have shown that the mortality rate within 12 h of diagnosis and treatment was within 10%, and the difference between surgery and endoscopic treatment was small [ 10 , 11 , 15 , 17 , 24 ]. The mortality rate increased after 24 h, and the surgical mortality rate could be as high as 50% [ 4 , 5 , 13 , 16 , 18 ].…”

“…Iatrogenic ERCP-related duodenal perforation is a rare and fatal complication of ERCP, and the incidence ranges from 0.29% to 3.5% [4][5][6][7][8][9][10][11][12][13][14][15][16], but the highest reported mortality rate is 34.4% [13]. Due to the low incidence and high mortality, there are few large multi-centre cases.…”