Advertisement

Algorithm for the management of ERCP-related perforations

Published:October 03, 2015DOI:https://doi.org/10.1016/j.gie.2015.09.039

      Background and Aims

      Perforation is a rare but serious adverse event of ERCP. There is no consensus to guide the clinician on the management of ERCP-related perforations, with particular controversy surrounding the immediate surgical management of postprocedurally detected duodenal perforation because of overextension of a sphincterotomy. Our aim was to assess patient outcomes using a predetermined algorithm based on managing ERCP-related duodenal perforations according to the mechanism of injury.

      Methods

      A retrospective single-center study of all consecutive patients with Stapfer type I and II perforations between 2000 and 2014 were included. Our institutional algorithm since 2000 dictated that Stapfer type I perforations (duodenal wall perforation, endoscope related) should be managed surgically unless prohibited by underlying comorbidities and Stapfer type II perforations (periampullary, sphincterotomy related) managed nonsurgically unless a deterioration in clinical status necessitated surgery.

      Results

      Sixty-one patients (mean age, 51 years; 80% women) were analyzed with Stapfer type I perforations diagnosed in 7 (11%) and type II in 54 (89%). A postprocedural diagnosis of perforation was made in 55 patients (90%). Four patients (7%) had Stapfer type II perforations that failed medical management and required surgery. The mean length of stay (LOS) in the entire cohort was 9.6 days with a low mortality rate of 3%. Systemic inflammatory response syndrome was observed in 18 patients (33%) with Stapfer type II perforations and was not associated with the need for surgery. Concurrent post-ERCP pancreatitis was diagnosed in 26 patients (43%) and was associated with an increased LOS.

      Conclusions

      Stapfer type II perforations have excellent outcomes when managed medically. We validate an algorithm for the management of ERCP-related perforations and propose that it should function as a guide.

      Abbreviations:

      CCI (Charlson Comorbidity Index), LOS (length of stay), SIRS (systemic inflammatory response syndrome), PEP (post-ERCP pancreatitis)
      To read this article in full you will need to make a payment

      Subscribe:

      Subscribe to Gastrointestinal Endoscopy
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Kodali S.
        • Monkemuller K.
        • Kim H.
        • et al.
        ERCP-related perforations in the new millennium: a large tertiary referral center 10-year experience.
        United Eur Gastroenterol J. 2015; 3: 25-30
        • Masci E.
        • Toti G.
        • Mariani A.
        • et al.
        Complications of diagnostic and therapeutic ERCP: a prospective multicenter study.
        Am J Gastroenterol. 2001; 96: 417-423
        • Cotton P.B.
        • Garrow D.A.
        • Gallagher J.
        • et al.
        Risk factors for complications after ERCP: a multivariate analysis of 11,497 procedures over 12 years.
        Gastrointest Endosc. 2009; 70: 80-88
        • Silviera M.L.
        • Seamon M.J.
        • Porshinsky B.
        • et al.
        Complications related to endoscopic retrograde cholangiopancreatography: a comprehensive clinical review.
        J Gastrointestin Liver Dis. 2009; 18: 73-82
        • Miller R.
        • Zbar A.
        • Klein Y.
        • et al.
        Perforations following endoscopic retrograde cholangiopancreatography: a single institution experience and surgical recommendations.
        Am J Surg. 2013; 206: 180-186
        • Jin Y.J.
        • Jeong S.
        • Kim J.H.
        • et al.
        Clinical course and proposed treatment strategy for ERCP-related duodenal perforation: a multicenter analysis.
        Endoscopy. 2013; 45: 806-812
        • Freeman M.L.
        Complications of endoscopic retrograde cholangiopancreatography.
        Gastrointest Endosc Clin N Am. 2012; 14: 148-155
        • Dubecz A.
        • Ottmann J.
        • Schweigert M.
        • et al.
        Management of ERCP-related small bowel perforations: the pivotal role of physical investigation.
        Can J Surg. 2012; 55: 99-104
        • Enns R.
        • Eloubeidi M.A.
        • Mergener K.
        • et al.
        ERCP-related perforations: risk factors and management.
        Endoscopy. 2002; 34: 293-298
        • Howard T.J.
        • Tan T.
        • Lehman G.A.
        • et al.
        Classification and management of perforations complicating endoscopic sphincterotomy.
        Surgery. 1999; 126 (discussion 664-5): 658-663
        • Stapfer M.
        • Selby R.R.
        • Stain S.C.
        • et al.
        Management of duodenal perforation after endoscopic retrograde cholangiopancreatography and sphincterotomy.
        Ann Surg. 2000; 232: 191-198
        • Polydorou A.
        • Vezakis A.
        • Fragulidis G.
        • et al.
        A tailored approach to the management of perforations following endoscopic retrograde cholangiopancreatography and sphincterotomy.
        J Gastrointest Surg. 2011; 15: 2211-2217
        • Morgan K.A.
        • Fontenot B.B.
        • Ruddy J.M.
        • et al.
        Endoscopic retrograde cholangiopancreatography gut perforations: when to wait! When to operate!.
        Am Surg. 2009; 75 (discussion 483-4): 477-483
        • Assalia A.
        • Suissa A.
        • Ilivitzki A.
        • et al.
        Validity of clinical criteria in the management of endoscopic retrograde cholangiopancreatography related duodenal perforations.
        Arch Surg. 2007; 142: 1059-1064
        • Alfieri S.
        • Rosa F.
        • Cina C.
        • et al.
        Management of duodeno-pancreato-biliary perforations after ERCP: outcomes from an Italian tertiary referral center.
        Surg Endosc. 2013; 27: 2005-2012
        • Avgerinos D.V.
        • Llaguna O.H.
        • Lo A.Y.
        • et al.
        Management of endoscopic retrograde cholangiopancreatography: related duodenal perforations.
        Surg Endosc. 2009; 23: 833-838
        • Baron T.H.
        • Wong Kee Song L.M.
        • Zielinski M.D.
        • et al.
        A comprehensive approach to the management of acute endoscopic perforations (with videos).
        Gastrointest Endosc. 2012; 76: 838-859
        • Christensen M.
        • Matzen P.
        • Schulze S.
        • et al.
        Complications of ERCP: a prospective study.
        Gastrointest Endosc. 2004; 60: 721-731
        • de Vries J.H.
        • Duijm L.E.
        • Dekker W.
        • et al.
        CT before and after ERCP: detection of pancreatic pseudotumor, asymptomatic retroperitoneal perforation, and duodenal diverticulum.
        Gastrointest Endosc. 1997; 45: 231-235
        • Genzlinger J.L.
        • McPhee M.S.
        • Fisher J.K.
        • et al.
        Significance of retroperitoneal air after endoscopic retrograde cholangiopancreatography with sphincterotomy.
        Am J Gastroenterol. 1999; 94: 1267-1270
        • Charlson M.
        • Szatrowski T.P.
        • Peterson J.
        • et al.
        Validation of a combined comorbidity index.
        J Clin Epidemiol. 1994; 47: 1245-1251
        • Charlson M.E.
        • Pompei P.
        • Ales K.L.
        • et al.
        A new method of classifying prognostic comorbidity in longitudinal studies: development and validation.
        J Chronic Dis. 1987; 40: 373-383
        • Huang L.
        • Yu Q.S.
        • Zhang Q.
        • et al.
        Comparison between double-guidewire technique and transpancreatic sphincterotomy technique for difficult biliary cannulation.
        Dig Endosc. 2015; 27: 381-387
        • Bone R.C.
        • Balk R.A.
        • Cerra F.B.
        • et al.
        Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of Critical Care Medicine.
        Chest. 1992; 101: 1644-1655
        • Cotton P.B.
        • Lehman G.
        • Vennes J.
        • et al.
        Endoscopic sphincterotomy complications and their management: an attempt at consensus.
        Gastrointest Endosc. 1991; 37: 383-393
        • Fluss R.
        • Reiser B.
        • Faraggi D.
        • et al.
        Estimation of the ROC curve under verification bias.
        Biom J. 2009; 51: 475-490
        • Petersen B.T.
        Sphincter of Oddi dysfunction, part 2: evidence-based review of the presentations, with “objective” pancreatic findings (types I and II) and of presumptive type III.
        Gastrointest Endosc. 2004; 59: 670-687
        • Petersen B.T.
        An evidence-based review of sphincter of Oddi dysfunction, part I: presentations with “objective” biliary findings (types I and II).
        Gastrointest Endosc. 2004; 59: 525-534
        • Rehman A.
        • Affronti J.
        • Rao S.
        Sphincter of Oddi dysfunction: an evidence-based review.
        Expert Rev Gastroenterol Hepatol. 2013; 7: 713-722
        • Teoh A.Y.
        • Cheung F.K.
        • Hu B.
        • et al.
        Randomized trial of endoscopic sphincterotomy with balloon dilation versus endoscopic sphincterotomy alone for removal of bile duct stones.
        Gastroenterology. 2013; 144: 341-345
        • Feng Y.
        • Zhu H.
        • Chen X.
        • et al.
        Comparison of endoscopic papillary large balloon dilation and endoscopic sphincterotomy for retrieval of choledocholithiasis: a meta-analysis of randomized controlled trials.
        J Gastroenterol. 2012; 47: 655-663
        • Seo Y.R.
        • Moon J.H.
        • Choi H.J.
        • et al.
        Comparison of endoscopic papillary balloon dilation and sphincterotomy in young patients with CBD stones and gallstones.
        Dig Dis Sci. 2014; 59: 1042-1047
        • Park W.Y.
        • Cho K.B.
        • Kim E.S.
        • et al.
        A case of ampullary perforation treated with a temporally covered metal stent.
        Clin Endosc. 2012; 45: 177-180
        • Vezakis A.
        • Fragulidis G.
        • Nastos C.
        • et al.
        Closure of a persistent sphincterotomy-related duodenal perforation by placement of a covered self-expandable metallic biliary stent.
        World J Gastroenterol. 2011; 17: 4539-4541
      1. Kirtane T, Singhal S. Endoscopic closure of iatrogenic duodenal perforation when using dual over-the-scope clips. Gastrointest Endosc. Epub 2015 Aug 15.

        • Lee T.H.
        • Han J.H.
        • Park S.H.
        Endoscopic treatments of endoscopic retrograde cholangiopancreatography-related duodenal perforations.
        Clin Endosc. 2013; 46: 522-528
        • Kumar N.
        • Thompson C.C.
        A novel method for endoscopic perforation management by using abdominal exploration and full-thickness sutured closure.
        Gastrointest Endosc. 2014; 80: 156-161
        • Fatima J.
        • Baron T.H.
        • Topazian M.D.
        • et al.
        Pancreaticobiliary and duodenal perforations after periampullary endoscopic procedures: diagnosis and management.
        Arch Surg. 2007; 142 (discussion 454-5): 448-454
        • Lai C.H.
        • Lau W.Y.
        Management of endoscopic retrograde cholangiopancreatography-related perforation.
        Surgeon. 2008; 6: 45-48
        • Zissin R.
        • Shapiro-Feinberg M.
        • Oscadchy A.
        • et al.
        Retroperitoneal perforation during endoscopic sphincterotomy: imaging findings.
        Abdom Imag. 2000; 25: 279-282
        • Wu H.M.
        • Dixon E.
        • May G.R.
        • et al.
        Management of perforation after endoscopic retrograde cholangiopancreatography (ERCP): a population-based review.
        HPB Surg. 2006; 8: 393-399
        • Bove V.
        • Tringali A.
        • Familiari P.
        • et al.
        ERCP in patients with prior Billroth II gastrectomy: report of 30 years' experience.
        Endoscopy. 2015; 47: 611-616
        • Cicek B.
        • Parlak E.
        • Disibeyaz S.
        • et al.
        Endoscopic retrograde cholangiopancreatography in patients with Billroth II gastroenterostomy.
        J Gastroenterol Hepatol. 2007; 22: 1210-1213
        • Kim M.H.
        • Lee S.K.
        • Lee M.H.
        • et al.
        Endoscopic retrograde cholangiopancreatography and needle-knife sphincterotomy in patients with Billroth II gastrectomy: a comparative study of the forward-viewing endoscope and the side-viewing duodenoscope.
        Endoscopy. 1997; 29: 82-85

      Linked Article