Computed tomography classification of endoscopic retrograde cholangiopancreatography‐related perforation

Abstract

Endoscopic retrograde cholangiopancreatography (ERCP)-related perforation leads to high morbidity and mortality. The Stapfer classification divides patients with different perforation locations and suggests management accordingly. The classification may be unknown if perforation is not detected during endoscopy. We classified patients with ERCP-related perforation (ERP) through computed tomography (CT) and observed the clinical outcomes with varyingly invasive management. Fifty-two cases of ERP between July 2009 and December 2017 were retrospectively reviewed. Of them, 41 who underwent CT for ERCP were included. According to their CT findings, we divided patients into air-alone (n = 16), air-fluid (n = 18), and fluid-alone (n = 7) groups. Perforation severity was graded using the Clavien-Dindo classification for surgical complications. Demographic data and clinical outcomes among different groups were analyzed. Fifteen patients (37%) had an unknown Stapfer classification. More than half of the patients in the air-fluid group had a Clavien-Dindo complication grade of >3. Four patients underwent surgical repair; all of them were from the airfluid group. All patients in the air-and fluid-alone groups underwent medical treatment without need for subsequent salvage surgery. The air-fluid group had the longest mean hospital stay (25.1 ± 21.9 days) and the exclusive two mortality cases in this study. Patients with ERCP can be divided into groups with different outcomes according to the presence of air or fluid on CT images. Because patients with both air and fluid have the worst clinical outcome, they may require more aggressive treatment than patients with either air or fluid alone. K E Y W O R D S air, computed tomography, endoscopic retrograde cholangiopancreatography, fluid, perforation 1 | INTRODUCTION Complications from endoscopic retrograde cholangiopancreatography (ERCP) include cholangitis, pancreatitis, bleeding, and perforation. The likelihood of these complications is 5%-12% in all cases, and they can increase morbidity and mortality. 1 Among these complications, endoscopic retrograde cholangiopancreatography-related perforation (ERP)remains a clinical challenge to endoscopists because it may be overlooked during these procedures and there is no consensus on its management. Overall, the incidence of ERP is approximately 0.1%-1.6% 2,3 with a mortality rate of 3%-35.7%. 4,5 Surgical debridement and repair is the mainstay of treatment options for ERP. It is, however, associated with high morbidity and mortality; recent studies have suggested more conservative treatment for certain

A Novel Cause of Biliary Peritonitis after Endoscopic Retrograde Cholangiopancreatography: Case Report and Literature Review

“…Early diagnosis and prompt treatment is essential in the management of post-ERCP duodenal perforation [ 12 ]. Computed tomography has proven to be the most useful imaging method [ 13 ]. There are several classifications being used for this condition, but the most frequently used is the Stapfer classification [ 14 ], which besides the anatomical localization also includes the mechanism and severity of injury.…”

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

“…Compared to other classifications, Stapfer classification is detailed and reasonable, but it was difficult to use in clinical practice. The Wu et al [23] method is a good supplement, especially when the Stapfer classification cannot be used after ERCP, and it can also distinguish the severity of perforation. It may become an important classification method to distinguish non-surgical patients in the future.…”

“…The location and severity of the perforation were clarified and treatment methods were proposed, but it is difficult to distinguish these four types of perforation in clinical practice. Subsequently, Howard et al [20], Enns et al [21], and Kim et al [22] classified perforations in a variety of ways according to the location of the perforation and the device that 23.3%, and because of bleeding and infection after ERCP, it is more difficult to distinguish the location and type of perforation, which limits the clinical usefulness of these classifications; thus, a better classification is required [16]. In recent years, three new classifications have emerged (Table IV).…”

“…Miłek et al [18] preferred a classification treatment based on intraperitoneal and extraperitoneal perforation, while Bray et al [12] and Wu et al [23] proposed a classification based on computed tomography (CT) scan. The Wu et al [23] classification divides patients into air-alone, air-fluid, and fluid-alone groups. This method is a good supplement, especially when the Stapfer classification cannot be used after ERCP, and it can also distinguish the severity of perforation.…”

“…If the perforation is small, or if it is only retroperitoneal air, the patient can be treated with medication alone. If retroperitoneal or peritoneal effusion is present, percutaneous drainage is performed under CT guidance [23]. In specific drug treatment, research by Bray et al [12] showed that early antibiotic use is beneficial for prognosis.…”