Splenic Laceration After Endoscopic Retrograde Cholangiopancreatography

Abstract

The advent of endoscopic retrograde cholangio-pancreatography (ERCP) has enabled physicians and surgeons to carry out a range of diagnostic and therapeutic procedures pertaining to various pathologies found within the hepato-biliary system. Despite being relatively less invasive when compared to traditional methods of surgery, ERCP still carries recognized complications that are a cause for morbidity amongst patients. Furthermore, rarer complications can occur in difficult circumstances that are potentially fatal. We report two cases whereby the patients sustained serious splenic injuries as a consequence of the procedure. Splenic lacerations were diagnosed on computer tomography scanning in both patients who subsequently underwent emergency splenectomy. The patients made an uneventful recovery and returned home after surgery.To date twelve cases have been reported in current medical literature regarding injury to the spleen following ERCP. These aforementioned injuries have arisen particularly when the endoscopist has encountered difficult or variations in anatomy whilst performing ERCP. In addition to presenting two cases, we review the literature and discuss the implications of these complications and how this may affect the way in which clinicians take informed consent from patients before conducting ERCP.

Endoscopic retrograde cholangiopancreatography induced splenic injury: comprehensive analysis and new perspectives based on a case report

“… 21 In CT scans, findings include free abdominal fluid, splenic rupture and/or laceration, subcapsular hematoma, and capsular avulsion. In two cases, 7 , 22 CT scan was not diagnostic for splenic injury. In the first case, one more CT scan was needed 24 h after the first to reveal the free fluid and the splenic rupture and in the second case CT scan was suggestive of post-procedure pancreatitis.…”

“…From all reviewed cases, many predisposing factors are referred to play an important role in post-ERCP splenic injury. These factors include altered anatomy from previous major surgeries such as left hepatectomy, 28 sleeve gastrectomy, 24 liver transplant, 26 Billroth I gastrectomy, 10 or other anatomic reasons such as cascade stomach 17 and small intra-abdominal cavity, 15 pancreatic head masses 8 , 13 and duodenal masses narrowing the duodenum lumen, pyloric stenosis, 8 , 22 , 29 and requirement of prolonged loop position to achieve cannulation. 25 The referred factors act by reducing the available space for endoscopic movements, increasing the duration of ERCP, multiplying the number of maneuvers needed for the proper cannulation, and increasing the direct forces transmitted to the surrounding tissues resulting in increased chances of a splenic injury.…”

Etiologies and risks of splenic decapsulation after endoscopic retrograde cholangiopancreatography: case report and literature review

“…This maneuver translates into direct forces in surrounding organs including the spleen causing capsular tears or vascular avulsion. In addition, increased manipulation of the endoscope resulting from prolonged procedure transmits excessive torque to the patient and increases risk of excessive ligamentous tension and may cause splenic injury 6 8 9 . Although many causes have been proposed, the true mechanism of post-ERCP splenic injuries remains an enigma 6 .…”

“…Onset of symptoms in patients with post-ERCP injury can vary widely. While some patients complain of symptoms immediately after the procedure 6 8 , it is possible for a patient to report symptoms more than 5 days after the procedure 6 . Based on previous case reports, the most common signs and symptoms include abdominal pain, hemodynamic instability, and a drop in hemoglobin.…”

“…There are many accounts of splenic injury after colonoscopy and are well described in the literature, but splenic injury after ERCP is much less frequent. Splenic injury can include subcapsular hematoma 5 6 , peri-splenic hematoma 6 , laceration 6 7 , rupture 6 8 , avulsion of splenic vessels 6 9 , avulsion of spleen from the capsule 6 10 , and direct tearing of the splenic capsule 6 8 . The main factors influencing complication rate were the difficulty of the examination, patient comorbidity, and the operator’s level of experience 1 6 .…”