Management of endoscopic retrograde cholangiopancreatography–related perforations: Experience of a tertiary center

Weiser, Roi; Pencovich, Niv; Mlynarsky, Liat; Senderey, Adi Berliner; Lahat, Guy; Santo, Erwin; Klausner, Joseph M.; Nachmany, Ido

doi:10.1016/j.surg.2016.10.029

Cited by 26 publications

(26 citation statements)

References 22 publications

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“…ERCP may cause perforation in different locations, as recognized in the Stapfer classification which includes four categories of decreasing severity ( [133]. The presence of a papillary lesion necessitating endoscopic papillectomy (OR 18.0, P < 0.01) and the performance of a precut (OR 3.0, P = 0.04) were independent risk factors in another study (37 perforations) [134].…”

Section: Periampullary and Biliopancreatic Ductal Perforationmentioning

confidence: 97%

“…General indications that warrant surgery include major contrast medium leak, unsolved problems (e. g. perforation during endoscopic treatment of an ampullary tumor) [134], severe peritonitis, severe sepsis despite nonsurgical management, or retroperitoneal fluid collections not amenable to percutaneous or EUS-guided drainage [1, 48,153 -156]. Clinical signs such as fever, tachycardia, guarding, or leukocytosis are suggestive that conservative measures are failing and emergency surgery is indicated [47 -49].…”

Section: Treatment Measuresmentioning

confidence: 99%

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Diagnosis and management of iatrogenic endoscopic perforations: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement – Update 2020

et al. 2020

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Summary of Recommendations 1 ESGE recommends that each center implements a written policy regarding the management of iatrogenic perforations, including the definition of procedures that carry a higher risk of this complication. This policy should be shared with the radiologists and surgeons at each center. 2 ESGE recommends that in the case of an endoscopically identified perforation, the endoscopist reports its size and location, with an image, and statement of the endoscopic treatment that has been applied. 3 ESGE recommends that symptoms or signs suggestive of iatrogenic perforation after an endoscopic procedure should be rapidly and carefully evaluated and documented with a computed tomography (CT) scan. 4 ESGE recommends that endoscopic closure should be considered depending on the type of the iatrogenic perforation, its size, and the endoscopist expertise available at the center. Switch to carbon dioxide (CO2) endoscopic insufflation, diversion of digestive luminal content, and decompression of tension pneumoperitoneum or pneumothorax should also be performed. 5 ESGE recommends that after endoscopic closure of an iatrogenic perforation, further management should be based on the estimated success of the endoscopic closure and on the general clinical condition of the patient. In the case of no or failed endoscopic closure of an iatrogenic perforation, and in patients whose clinical condition is deteriorating, hospitalization and surgical consultation are recommended.

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Section: Periampullary and Biliopancreatic Ductal Perforationmentioning

confidence: 97%

Section: Treatment Measuresmentioning

confidence: 99%

Diagnosis and management of iatrogenic endoscopic perforations: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement – Update 2020

et al. 2020

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“…Mit zunehmender Invasivität steigt das Risiko weiter an und erreicht bei einer kolorektalen ESD eine Inzidenz von 5 % bis zu 16 % [42][43][44]. Auch bei der ERCP besteht ein relativ hohes Perforationsrisiko in der Größenordnung von etwa 1 %, vor allem bei Ausführung einer Papillotomie [21,22,45]. Dagegen ist das Risiko bei einer ÖGD anscheinend etwas niedriger als bei einer diagnostischen Koloskopie und wird angegeben mit etwa 0,03 % [46].…”

Section: Introductionunclassified

“…Wir verzeichneten dabei eine Quote von 0,59 %. Dies deckt sich aber mit den Ergebnissen von Weiser et al, die von 0,53 % bei knapp 7000 ERCPs berichten [45]. Die Spannbreite in der Literatur ist groß; es werden Perforationsraten von 0,09 % bis 1,69 % berichtet [22].…”

Section: Introductionunclassified

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APP – Das Amberger Perforationsprojekt als Grundlage für die Etablierung eines Komplikationserfassungs- und Managementsystems (KEMS) in der Endoskopie

Decassian

Dauer

2019

Z Gastroenterol

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Zusammenfassung Hintergrund Zurzeit ist ein Paradigmenwechsel bei der Therapie der iatrogenen gastrointestinalen Perforation hin zu einer primär endoskopischen Versorgung festzustellen. Material und Methoden Alle Perforationen im Rahmen aller konsekutiven gastrointestinalen Endoskopien von 01.01.2014 bis 31.12.2017 im Klinikum St. Marien Amberg wurden erfasst, dokumentiert und evaluiert. Hausinterne SOPs zum Prozedere wurden erstellt und kommuniziert. Grundsätzlich wurde der primäre interventionell-endoskopische Perforationsverschluss angestrebt, stets im interdisziplinären Konsens mit der Viszeralchirurgie. Ergebnisse Es kam im Beobachtungszeitraum zu 24 Perforationen bei 18 627 konsekutiven Endoskopien (0,13 %). Fälle mit bildgebendem Nachweis freier Luft ohne erkennbare Perforation waren gleich häufig wie Perforationen (12 Post-Polypektomiesyndrome und 12 Ereignisse nach ERCP mit EPT). Die Diagnose der Perforation erfolgte zu 95,8 % (23/24) innerhalb 12 h (davon 20 bereits bei der Endoskopie). Die initiale Therapiemodalität war in jeweils 3 Fällen primär operativ bzw. primär konservativ und in 17 Fällen primär endoskopisch (4 × Clips, 10 × OTSC, 3 × SEMS). In 1 Fall wurde keine Therapie durchgeführt. Es war eine Letalität von 4,2 % (1/24) zu verzeichnen. In 3 Fällen war sekundär ein operatives Vorgehen erforderlich, sodass insgesamt in 25 % (6/24) eine chirurgische Therapie erfolgte. Die interventionell-endoskopische Therapie war technisch erfolgreich zu 94,1 % (16/17) bei einem klinischen Erfolg nach Perforationsverschluss von 87,5 % (14/16). Diskussion Das Konzept der interventionell-endoskopischen Therapie iatrogener Perforationen ist im klinischen Alltag sicher und erfolgreich umsetzbar. Entscheidende Erfolgsfaktoren sind die kurze Zeitspanne bis zum Verschluss der Perforation und der stets anzustrebende interdisziplinäre Konsens im Vorfeld der Therapie. Auf der Basis der Ergebnisse wurde ein umfassendes Komplikationserfassungs- und Managementsystem (KEMS) für die Endoskopie ab 2016 in unserer Klinik etabliert (integriert in das Befunderstellungssystem und das Klinikinformationssystem).

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Computed tomography classification of endoscopic retrograde cholangiopancreatography‐related perforation

Tsai

Chen

et al. 2019

The Kaohsiung J of Med Scie

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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

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Management of endoscopic retrograde cholangiopancreatography–related perforations: Experience of a tertiary center

Cited by 26 publications

References 22 publications

Diagnosis and management of iatrogenic endoscopic perforations: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement – Update 2020

Diagnosis and management of iatrogenic endoscopic perforations: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement – Update 2020

APP – Das Amberger Perforationsprojekt als Grundlage für die Etablierung eines Komplikationserfassungs- und Managementsystems (KEMS) in der Endoskopie

Computed tomography classification of endoscopic retrograde cholangiopancreatography‐related perforation

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