Unusual Complications Related to Endoscopic Retrograde Cholangiopancreatography and Its Endoscopic Treatment

Abstract

Endoscopic retrograde cholangiopancreatography (ERCP)-induced complications, once occurred, can lead to significant morbidity. Commonly 5% to 10% of patients experience procedure related complications such as post-ERCP pancreatitis, biliary hemorrhage, and cholangitis, in descending order. However, complications such as perforation, pneumothorax, air embolism, splenic injury, and basket impaction are rare but are associated with high mortality if occurred. Such unexpected unusual complications might extend the length of hospitalization, require urgent surgical intervention, and put the patient in miserable condition leading to permanent disability or mortality. Although these ERCP-induced complications can be minimized by a skilled operator using advanced techniques and devices, the occurrence of unusual complications are hard to expect and induce very difficult management condition. In this review, we will focus on the uncommon complications related to ERCP. This review is also aimed at suggesting optimal endoscopic treatment strategies for several complications based on our institutional experiences.

Emergencies after endoscopic procedures

“…Variceal sclerosis may cause extension of thrombus into the portal and mesenteric venous systems [22] and cyanoacrylate injection has been reported as a cause of systemic emboli to lung, spleen and portal vein [23,24]. ERCP-induced air embolism is extremely rare although severe fatal complications, causing immediate cardiopulmonary collapse have been reported [25].…”

“…The most commonly used classification of ERCP-induced perforation was suggested by Stapfer et al according to that, perforations can be categorized into four types. Bowel perforation is more frequent in patients with Billroth II gastrectomy or Roux-en-Y operation, duodenal stricture, parapapillar diverticulum, while sphincterotomy perforation is more common during needle knife precut [25,73]. It can be prevented by ensuring the correct orientation of the cutting wire during sphincterectomy, following a step-by-step incision, tailoring the size of the papilla and bile ducts, and using balloon dilation of the papilla after a small sphincterotomy in cases of large stones [5].…”

“…ERCP-induced air embolism is a rare but severe complication [25] that possibly occurs due to sphincterotomy or high intra-mural pressure of insufflated air, disrupting the gastrointestinal or hepatobiliary structure and creating connection to the veins in the duodenal walls. Other reported mechanisms include portal vein puncture due to guide-wire cannulation and erroneous placement of nasobiliary drainage tube to the portal vein [75,76].…”

“…Special care should be taken for possible air embolism in relation to the recent wide application of peroral cholangioscopy [77]. Other potential very rare complications are splenic injury, hepatic haematoma, pneumothorax and basket impactation [25].…”

Cholangitis after endoscopic retrograde cholangiopancreatography: a rare complication?

“…Its clinical features, management and outcome are poorly characterized in the literature (2). In a recent study in a low-volume center (200 procedures in 22 months) the reported rate of this complication was less than 5%, with a tendency to reduce with increased experience of the practicioner (3).…”