Management of endoscopic retrograde cholangiopancreatography-related perforations

Abstract

PurposeThe purpose of this study is to analyze the treatment strategies of patients with endoscopic retrograde cholangiopancreatography (ERCP)-related perforations. This is a retrospective study.MethodsWe experienced 13 perforations associated with ERCP. We reviewed the medical recordsand classified ERCP-related perforations according to mechanism of injury in terms of perforating device. Injury by endoscopic tip or insertion tube was classified as type I, injury by cannulation catheter or sphincterotomy knife as type II, and injury by guidewire as type III.ResultsOf four type I injuries, one case was managed by conservative management after primary closure with a hemoclip during ERCP. The other three patients underwent surgical treatments such as primary closure orpancreatico-duodenectomy. Of five type II injuries, two patients underwent conservative management and the other three cases were managed by surgical treatment such as duodenojejunostomy, duodenal diverticulization and pancreatico-duodenectomy. Of four type III injuries, three patients were managed conservatively and the remaining patient was managed by T-tube choledochostomy.ConclusionType I injuries require immediate surgical management after EPCP or immediate endoscopic closure during ERCP whenever possible. Type II injuries require surgical or conservative treatment according to intra- and retro-peritoneal dirty fluid collection findings following radiologic evaluation. Type III injuries almost always improve after conservative treatment with endoscopic nasobilliary drainage.

Retroperitoneales Emphysem nach endoskopischer retrograder Cholangiopankreatikographie

“…Tab. 1 [7,9,10,11]. Allen 4 Klassifikationen ist gemeinsam, dass sie papillenferne und damit duodenale Lä-sionen von papillennahen, u. a. durch eine Sphinkerotomie hervorgerufene, Lä-sionen sowie von Gallengangsverletzungen, z.…”

“…Operativ kann die Drainage transabdominell oder bei retroperitonealer Flüssigkeitsan-sammlung über einen posterioren Zugang erfolgen [18] [5,12,21]. Eine weitere chirurgische Option besteht bei Versagen der konservativen Therapie im Rahmen periampullärer Verletzungen (Typ II nach Kim et al [9], Stapfer et al [10] und Howard et al [11]). Hier favorisieren einige Autoren den transduodenalen Zugang über eine transverse Duodenotomie mit Direktnaht der Perforationsstelle mit oder ohne Sphinkteroplastik [22].…”

“…Abb. 6 vorgeschlagen, der die obigen Abschnitte und die in der Literatur verfügbare Evidenz zusammenfasst [1,9,10,12,21,23]. Bei klinisch stabilen Patienten können zum Retroperitoneum gelegene periampulläre oder Gallengangsverletzungen zumeist konservativ behandelt werden.…”

The Management of Perforation after Endoscopic retrograde cholangiopancreatography (ERCP).

“…In addition, they stated that surgical treatment should be considered in type 2 injuries with dirty fluid collection in the intra-and retroperitoneal area on CT; if there is no fluid collection, conservative treatment is possible. [17] Husain et al reported that 33% (7/21) of patients showed extraluminal retroperitoneal air following ERCP; they concluded that it was not clinically significant. [20] Stapfer et al suggested that retroperitoneal air alone requires no additional treatment or further work-up if abdominal examinations are normal and there is no evidence or suspicion of contrast extravasation.…”

“…[14,[16][17][18] It has been reported that peritoneal perforations can be sutured under endoscope. [17,19] Successful closure with endoscopy in conservatively managed patients can reduce the fasting period, duration of intravenous antibiotic administration, and hospital stay. Moreover, it can improve patient quality of life and reduce medical costs.…”