Recent Advanced Endoscopic Management of Endoscopic Retrograde Cholangiopancreatography Related Duodenal Perforations

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. Clin Endosc 2016;49:376-382

A Case of Unresolved and Worsening Retroperitoneal Abscess

“…Endoscopic repair has been reported successful and can be attempted in stable patients with both Type 1 and Type 2 perforation. Endoscopic clip placement may suffice for a small Type 1 lesion; larger lesions have been successfully closed with adjunctive use of an endoloop, fibrin glue, and over-the-scope stitch system and more recently with use of an over-the-scope clip [2,[7][8][9][10][11]. Endoscopic band ligation has also been used successfully for closure and may be useful for a defect in a difficult location, given the ease of its application [8].…”

“…Endoscopic repair with fibrin glue, clips, and over-thescope clip or stitch with or without biliopancreatic stents has been described for both Type 1 and Type 2 perforations [8][9][10][11]. In majority of the cases, the repair was performed during the same index procedure.…”

Endoscopic retrograde cholangiopancreatography complications: Techniques to reduce risk and management strategies

“…Multiple case series have shown the overall risk of perforation during ERCP to be < 1% with a mortality range of 7.8%-9.9%. 1,14,22,48,[170][171][172] The accepted classification scheme for ERCP-related perforations proposed by Stapfer et al 173 is logically based on location and mechanism of injury. Type 1 perforations are characterized by luminal perforations, which most often occur in the duodenum.…”

“…7), over-the-scope clips, band ligation and endoloops. 172,[187][188][189] Novel endoscopic suturing devices may be applied in this scenario to close large defects. Although the technical application of endoscopic suturing may be challenging and not readily available in most units, the potential to close large defects with multiple sutures through the endoscope is attractive.…”

“…188,192 In patients that do undergo successful endoscopic closure, the chance of clinical successful recovery without surgery is > 90%. 172 Conservative management after endoscopic closure includes IVF, bowel rest, antibiotics and NGT placement. Usually within the next 24-48 hours the patient will declare clinically if they require surgical intervention.…”