Operative and non-operative management of endoscopic retrograde cholangiopancreatography-associated duodenal injuries

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.

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

“…(10,12,18,19). Mortality rates between 7% and 25% were reported in several studies, in which the most common types of perforations were type I and II (12,19,20). In our study, the most common type was type II injury (60%); only one patient with type I injury (5%) died of sepsis.…”

“…Although emergency surgical treatment has been advocated in previous studies, conservative treatment was commonly reported with successful outcomes in appropriate cases in recent series. (10,12,18,19). Mortality rates between 7% and 25% were reported in several studies, in which the most common types of perforations were type I and II (12,19,20).…”

Diagnosis and management of duodenal perforations: a narrative review

“…The incidence of endoscopic perforations is higher for therapeutic procedures. The rate of duodenal perforations after ERCP ranges from 0.09 to 1.67% [26,27]. The Stapfer classification has been developed to categorize ERCP-related perforations [28].…”

Endoscopic “rescue” treatment for gastrointestinal perforations, anastomotic dehiscence and fistula

“…In most situations the approach should be individualized to the patient [71]. Multiple case reports of successful clip closure have been reported.…”