Endoscopic Perforation Research Articles

Management of colonoscopic perforation: a systematic review and treatment algorithm.

The aim of this review is to evaluate and summarize the current strategies used in the management of colonoscopic perforations as well as propose a modern treatment algorithm. Articles published between January 2004 and January 2019 were screened. A total of 167 reports were identified in combined literature search, of which 61 articles were selected after exclusion of duplicate and unrelated articles. Only studies that reported on the management of endoscopic perforation in an adult population were retrieved for review. Case reports and case series of 8 patients or less were not considered. Ultimately, 19 articles were considered eligible for review. A total of 744 cases of colonoscopic perforations were reported in 19 major articles. The cause of perforation was mentioned in 16 articles. Colonoscopic perforations were reported as a consequence of diagnostic colonoscopies in 222 cases and therapeutic colonoscopies in 248 cases. The site of perforation was mentioned in 486 cases. Sigmoid colon was the predominant site followed by the cecum. The management of colonoscopic perforations was reported in a total of 741 patients. Surgical intervention was employed in 75% of the patients, of these 15% were laparoscopic and 85% required laparotomy. The predominant surgical intervention was primary repair. Management strategies of colon perforations depend upon the etiology, size, severity, location, available expertise, and general health status. Usually, peritonitis, sepsis, or hemodynamic compromise requires immediate surgical management. Endoscopic techniques are under continuous evolution. Newer developments have offered high success rate with least amount of post-procedure complications. However, there is a need for further studies to compare the newer endoscopic techniques in terms of success rate, cost, complications, and the affected part of colon.

173 THE POTENTIAL ROLE OF NON-TECHNICAL SKILLS IN RISK MANAGEMENT OF ENDOSCOPIC PERFORATIONS

Perforation is an expected, sometimes unavoidable endoscopic complication resulting in major morbidity and (rarely) death. Identifying whether the endoscopist in question falls below accepted standards of competence is often based on collected data of performance indicators that emphasize technical or endoscopic skills. On the other hand, non-technical skills such as clinical and interpersonal skills can be overlooked, or not readily identifiable. Our aim was to perform a root cause analysis of malpractice lawsuits for endoscopic perforations, looking at both technical and non-technical skills.

Closure of Lateral Duodenal Wall Perforation using Over-the-Scope Clip

AbstractLateral duodenal wall perforation occurring during endoscopic retrograde cholangiopancreatography (ERCP) due to scope trauma is large and usually treated by surgery. With advances in endoscopic instrumentation, interest in treating these complications using endoscopic devices has increased. Over-the-scope clip (OTSC) which has higher compression force and can approximate large perforations is being increasingly used for the closure of gastrointestinal fistulae and perforations. We recently used OTSC for treating duodenal perforations which occurred during ERCP in two elderly patients. Both these patients had comorbid conditions and were high risk for surgery. Perforations were immediately identified during endoscopy and were closed with OTSC. Both patients had uneventful further course and were discharged successfully. These cases highlight the usefulness of OTSC for the management of endoscopic duodenal perforations.

Role of Double-Lumen Irrigation-Suction Tube Drainage in Severe Intra-Abdominal Infection Induced by Endoscopic Sphincterotomy– Related Perforation

This study aimed to assess the efficacy of double-lumen irrigation-suction tube (DLIST) in treating severe intra-abdominal infection (SIAI) induced by endoscopic sphincterotomy-related perforation (EST-rP). We enrolled 34 consecutive patients who had been transferred to our hospital with SIAI induced by EST-rP from January 2000 to June 2018. Then they were assigned into two groups based on whether or not rescue surgery had been performed: failed nonoperative treatment group (n = 9) and failed rescue surgery treatment group (n = 25). All 34 patients received DLIST for positive draining by surgery in our hospital. Data collection included demographics, indication for endoscopic retrograde cholangiopancreatography, time to rescue surgery, surgical procedure, surgical success rate, complications, hospital stay, and postoperative outcome. The research enrolled 34 patients (ages 27-79 years, mean of 57.8 ± 12.1 years). There were no significant differences in age and gender between two groups (P > 0.05). After being admitted, they were diagnosed with sepsis induced by SIAI (Sequential Organ Failure Assessment score range of 2-6, mean of 3.6 ± 0.95). The time from endoscopic retrograde cholangiopancreatography to rescue surgery was 12 to 336 hours (mean of 73.7 ± 72.2 hours); overall hospital stay was 15 to 405 (mean of 127.5 ± 81.5) days. The hospital stay was significantly longer in the failed rescue surgery group than that of the failed nonoperative treatment group (P < 0.05). The overall mortality rate was 11.8 per cent (4/34). The mortality rate was 16 per cent (4/25) and 0 per cent (0/9), respectively. As a modified suction technology, DLIST placement can effectively treat SIAI induced by EST-rP and lower the mortality rate of rescue surgery treatment.

Endoscopic Treatment of Endoscopic Retrograde Cholangiopancreatography-Related Duodenal Perforations.

Endoscopic retrograde cholangiopancreatography (ERCP)-related duodenal perforation is a rare complication associated with significant morbidity and mortality. This study evaluated endoscopic management experience and outcomes of ERCP-related duodenal perforations. Between March 2005 and March 2017, a total of 19,468 ERCP procedures were performed in three endoscopy units of three hospitals in China. Diagnoses, management, and outcomes were identified and retrospectively reviewed in 58 of these patients. According to the classification system, 58 patients included 8 with type I, 44 with type II, 4 with type III, and 2 with type IV perforation. Of type I perforations, 7 patients underwent endoscopic closure with endoclips, and 1 patient was treated with surgical repair. Of type II perforations, 11 patients were actively managed using the fully covered self-expandable metallic stents (SEMS) to seal the perforation, and 33 patients were passively managed using nose-biliary drainage, in which 13 cases had retroperitoneal abscess formation and were successfully treated by abdominal computed tomography (CT)-guided percutaneous external drainage, but 1 patient died due to sepsis. One patient with type III perforation (pancreatic duct perforation) underwent endoscopic pancreatic duct stent placement after surgery failure. The mean hospital stay of 11 cases with type II perforation treated actively by endoscopy (26.5 ± 3.3 days) was lower compared with 33 cases who received passive conservative treatment (34.6 ± 3.9 days). Many (especially type I and II) ERCP-related duodenal perforations can be successfully treated with endoscopic management. Active endoscopic therapy may be better than passive conservative treatment for type II perforations.

Propofol administration by anesthesiologists versus endoscopists during colonoscopy: Does it make a difference?

Background: Propofol anesthesia for endoscopic procedures has gained wide acceptance among physicians and patients. Much debate remains though whether propofol can be safely administered by non-anesthesiologists. Objective: To compare the procedural outcome of patients undergoing colonoscopy with Propofol target-controlled infusion administered by anesthesiologists vs. non-anesthesiologists. Design: A retrospective review. Setting: A private community hospital in Dubai, United Arab Emirates. Patients and Methods: All consecutive patients (age > 13 years, with American Society of Anesthesiologists class I-II and no other contraindications to administration of sedation by non-anesthesiologists) who underwent colonoscopy between January 1, 2017 and September 30, 2017. In the initial part of the study, propofol was administered by an anesthesiologist until the endoscopists were trained to provide propofol anesthesia via targeted-controlled infusion [TCI] by syringe pump. Intraprocedural data was collected in a prospective registry. Statistical analysis was performed using Chi square and student t test. Main Outcome Measures: Cecal intubation rate, procedural time, procedural-related complications, and polypectomy/biopsy rate. Sample Size: 347 patients. Results: Group 1 [anesthesiologists] 84 patients, Group 2 [endoscopists] 263 patients. Mean age was 44.8 and 46.9 years in Group 1 and 2, respectively (P = 0.17). There was no difference in gender distribution. The mean procedural time was 21 minutes in both groups (P = 0.93). The cecal intubation rate was similar [92.9% in Group 1 vs. 94.3% in Group 2, P = 0.40). No difference in procedural-related complications was noted between groups, with 1 patient in Group 2 sustaining endoscopic perforation during balloon dilation of a near obstructing anastomotic stricture. Except for the patient with endoscopic perforation, no patient required advanced airway management. Conclusions: Propofol can be safely administered by endoscopists using target-controlled infusion. Similar total procedural time and cecal intubation rate can be achieved without increased risk of procedural-related complications. Limitations: Retrospective review, community-based hospital, elective cases, small cohort size. Conflict of Interest: None.

Management laparo endoscopic perforation post ERCP

Background: Presentation as a case report of a post-ERCP perforation and its conservative surgical management by laparoendoscopic "Rendez Vous" technique (RVLE) in a patient with a history of cholecystectomy. Methods: Post-ERCP perforation is a rare complication but with high morbidity and mortality in cases with late diagnosis. This is why some authors suggest an urgent surgical procedure due to the deterioration of the patient's clinical status, since its natural course is towards septic shock. Results: Therapeutic behavior, whether conservative or surgical, depends, in addition to the clinical status of the patient, the site of perforation and the diagnostic moment (intra or postoperative). RVLE is a tool used to access the main biliary tract in cases of cholecystocytocholithiasis, which consists of cannulation of the biliary tract or endoscopic sphincterotomy through a transcystic-transpapillary guide, thus avoiding the need for instrumentation of the Bile duct decreasing the likelihood of adverse effects. Conclusion: In our case, the re-dissection of the cystic duct with the subsequent RVLE technique allowed the successful cannulation of the biliary tract with the consequent removal of the colejicillar lithiasis and subsequent placement of biliary stents.

Management laparo endoscopic perforation post ERCP

Background: Presentation as a case report of a post-ERCP perforation and its conservative surgical management by laparoendoscopic "Rendez Vous" technique (RVLE) in a patient with a history of cholecystectomy. Methods: Post-ERCP perforation is a rare complication but with high morbidity and mortality in cases with late diagnosis. This is why some authors suggest an urgent surgical procedure due to the deterioration of the patient's clinical status, since its natural course is towards septic shock. Results: Therapeutic behavior, whether conservative or surgical, depends, in addition to the clinical status of the patient, the site of perforation and the diagnostic moment (intra or postoperative). RVLE is a tool used to access the main biliary tract in cases of cholecystocytocholithiasis, which consists of cannulation of the biliary tract or endoscopic sphincterotomy through a transcystic-transpapillary guide, thus avoiding the need for instrumentation of the Bile duct decreasing the likelihood of adverse effects. Conclusion: In our case, the re-dissection of the cystic duct with the subsequent RVLE technique allowed the successful cannulation of the biliary tract with the consequent removal of the colejicillar lithiasis and subsequent placement of biliary stents.

Trends in Post-Therapeutic Endoscopic Retrograde Cholangiopancreatography Gastrointestinal Hemorrhage, Perforation and Mortality from 2000 to 2012: A Nationwide Study

Background/Aims: Recent trends in complications following inpatient therapeutic Endoscopic Retrograde Cholangiopancreatography (ERCP) remain poorly defined. We studied trends of gastrointestinal (GI) hemorrhage, perforation, and mortality following inpatient therapeutic ERCPs from 2000 to 2012 with the hypothesis that ERCPs would have down trending complication rates. Methods: First, we isolated therapeutic ERCPs in patients 18 years or older using the International Classification of Diseases, Ninth Edition in the 2000 to 2012 National Inpatient Sample databases. Procedures complicated by hemorrhage, perforation, and mortality were identified. Multivariate logistic regressions were used to calculate trends in complication rates and secondary variables, including hospital and patient demographics. Time series regressions were then built for each complication to assess for trends from 2000 to 2012. Results: The mortality rate decreased from 1.77 to 1.24%, a trend that was confirmed by time series regression. Perforation rates increased from 0.07 to 0.10% for therapeutic ERCPs. However, time series regression did not show a significant trend. GI hemorrhage rates increased from 1.36 to 1.57% and this uptrend was confirmed by our time series regression. Conclusion: Therapeutic ERCPs have become safer, as demonstrated by a down trending mortality rate. Over the same time, GI hemorrhage rates trended upwards, while no change was noted in perforation rates.

Management of iatrogenic injuries due to endoscopic sphincterotomy: Surgical or conservative approaches.

The best therapeutic approach for endoscopic retrograde cholangiopancreatography-related perforations remains controversial; while some authors suggest routine conservative management, others advocate mandatory surgical exploration. We aimed to evaluate our clinical experience of perforations during endoscopic sphincterotomy. A retrospective chart review from January 2010 to October 2015 identified 20 patients with endoscopic retrograde cholangiopancreatography-related perforations. Data collection included demographics, time to diagnosis, type of perforation, treatment strategy, surgical procedure, complications, hospital stay, and outcome. All patients were classified into two groups on the basis of radiological and operative findings. Only five patients underwent surgical treatment, whereas 15 patients were managed conservatively. The mean time to diagnosis was 7.8 hrs (range: 1 to 36 hrs). In patients who underwent surgical treatment, the types of perforations included type I and III in one patient each and type II in three patients. Surgical procedures included laparoscopic and open cholecystectomy with t-tube drainage in two patients each and primary repair of duodenal injury with hepaticojejunostomy in one patient. Among conservatively managed patients, eight, four, and three had type II, type III, and type IV injuries, respectively. Of these 15 patients, 60% (n=9) underwent percutaneous procedures. The mean length of hospital stay was similar for conservatively and surgically treated patients (12 vs. 12.4 days, respectively, p=0.790). One patient (5%) with type I injury died of multiorgan deficiency. With close close clinical follow-up, medical treatment can be beneficial for most patients, and surgical procedures should be reserved for patients with type I (definite) and type II/III injuries; in patients with these clinical parameters, conservative management will likely be unsuccessful.

Correction: Endoscopic perforation during EMR or ESD: who should take care of the patient?

[This corrects the article DOI: 10.1055/s-0044-101348.].

Endoscopic perforations: what are the indications for surgery?

Despite their low occurrence, endoscopic perforations (EPs) are concerning. Some predictive factors have been identified, and EP management is debated, whether non-surgical (medical and/or endoscopic) or surgical. The objective was to elaborate a predictive score for surgical management of EP. All the patients addressed for upper and lower EP, except oesophageal EP, were retrospectively included (2004-2015). Demographic data, endoscopic features (indication, location, type), clinical, biological and radiological presentations of EP were reviewed. Management of EP and outcomes were recorded. A predictive score was constructed by multiple linear regression and a cut-off value for surgical management was identified. Additional subgroup analysis was performed according to the location of EP (upper and lower). Among 41150 endoscopic procedures, 44 patients (22 males, median age = 65years [22-87]) presenting with EP were included (0.09%). Lower gastrointestinal (GI) endoscopy was mostly performed (66%). EP diagnosis was immediate in 73% of the cases (n = 32). Non-surgical management was efficient in 2/3 cases treated medically alone, and 18/20 cases treated by endoscopy. Surgical management was always successful (n = 24/24). In case of peritonitis, surgery was systematically required, whereas easily required in case of delayed diagnostic of EP. The EP score was based on the presence of previous abdominal surgery, lower GI endoscopy and diagnostic endoscopy. A cut-off EP score of 22.8% for surgery was chosen; it was associated with a specificity and sensitivity of 40 and 100%, respectively. When subgroups were analysed according to EP location, the EP score was still based on the presence of previous abdominal surgery and diagnostic endoscopy. The cut-off was 6.3 and 73.3% for upper (specificity: 73%, sensitivity: 100%) and lower (89 and 45%) locations, respectively. The predictive EP score may avoid inappropriate surgical management, as well as delayed surgery after non-surgical management failure. Forthcoming study should prospectively validate this score.

Esophageal perforation in children: etiology and management, with special reference to endoscopic esophageal perforation.

Perforation of the esophagus is an uncommon problem with significant morbidity and mortality. In children undergoing endoscopy, the risk of perforation is higher when interventional endoscopy is performed. The clinical features depend upon the site of esophageal perforation. Opinions vary regarding the optimal treatment protocol, and the role of conservative management in this context is not well established. Esophageal perforation that occurs as a consequence of endoscopy in children requires careful evaluation and management, as outlined in this article.

An Alternative Method of Endoscopic Intrasphenoidal Vidian Neurectomy.

ObjectiveTo develop an easy surgical approach to facilitate clinical management.Study DesignA novel transnasal endoscopic 3-step surgical method for vidian neurectomy was designed and tried in 91 cases with a mild-to-severe degree of allergic and nonallergic rhinitis refractory to routine medical therapy.SettingEndoscopic vidian neurectomy requires accurate localization of the vidian canal. However, it is not easy to localize during surgery because of its deep location and the complex anatomy of the pterygopalatine fossa.Subjects and MethodsThis technique consists of 3 steps, including transnasal endoscopic perforation of the anterior wall of the sphenoidal sinus as the first step and removal of the anterior wall until the exposure of the vidian canal in the junction between the anterior wall and the floor of the sphenoid sinus as the second step. The last step is the accurate resection and cauterization of the vidian nerve. In some cases in which the sphenoid sinus developed well with a big lateral space, an extended procedure of posterior ethmoidectomy was included to allow good exposure of the vidian canal.ResultsUsing this technique, successful endoscopic vidian neurectomy in this series of patients was confirmed by both histology and Schirmer test, showing its distinct advantages of easy localization of the vidian canal and less risk of injury to the nerve and vessel bundles within the pterygopalatine fossa.ConclusionTaken together, this novel 3-step procedure of endoscopic vidian neurectomy plus an extended procedure guarantees good exposure of the vidian canal and therefore accurate vidian neurectomy.

Endoscopic Suturing: Closing Perforations of the Upper Gastrointestinal Tract in Various Settings

Abstract Background: Perforation can occur in the midst of a diagnostic or therapeutic procedure.1–3 Urgent surgical repair has been the most common response to treat iatrogenic perforation during endoscopy. As more endoscopic procedures develop, the risk of endoscopic perforations has increased, but so has our experience in managing them endoscopically.4 The purpose of this video is to demonstrate the adaptability and effectiveness of endoscopic suturing in the treatment of a wide range of complicated iatrogenic perforations along the upper gastrointestinal tract. Materials/Methods: Three patients undergoing different endoscopic procedures were complicated by acute perforation. We present this series of cases to highlight the utility and efficacy of managing patients with acute iatrogenic perforations using endoscopic suturing. Results: Case 1: An 85-year-old woman began to experience jaundice and weight loss. A 2.8 cm mass was found in the head of the pancreas on a CT scan. During an endoscopic ultrasou...

THECALOSCOPY: A NOVEL METHOD IN SPINE SURGERY

ABSTRACT Objetive: Thecaloscopy is a less invasive method of exploration of the spinal subarachnoid space, using an ultra-thin, flexible endoscope and endoscopic fenestration of scars and adhesions. Thecalopscopy was used in Russian neurosurgery for the first time. Methods: Since 2009, we have operated on 32 patients with the following diagnoses: 17 - spinal adhesive arachnoiditis (8 - local forms, 9 - diffuse forms), 12 - spinal arachnoid cysts (7 - post-traumatic cysts, 5 - idiopathic cysts), and 3 - extramedullary tumors (thecaloscopic videoassistance and biopsy). In all cases, we performed exploration of subarachnoid space and pathologic lesion with endoscopic perforation of the cyst or dissection of adhesions using special instrumentation. The mean follow-up time in our group was 11.4 months. Results: Neurological improvement (mean 1.4 by the modified Frankel scale, 1.8 by the Ashworth spasticity scale) was seen in 87% of patients operated for spinal arachnopathies. Temporary neurological deterioration (mild disturbances of deep sensitivity) was seen in 9% of patients and managed successfully with conservative treatment. One patient (3.1%) was operated three times due to relapse of adhesions. There were no serious intraoperative complications (e.g. severe bleeding or dura perforation). Postoperative complications included one CSF leakage and one case of postoperative neuralgic pain. The mean hospitalization time was 7.6 days. Conclusion: According to our data, we conclude that thecaloscopy is efficient and safe method, and should be widely used for spinal arachnopathies, adhesive arachnoiditis and arachnoid cysts. Taking into account that adhesive spinal arachnoiditis is a systemic process, and that spinal arachnoid cysts may also be extended, thecaloscopy may be regarded as the most radical and less-invasive form of surgical treatment that currently exists in neurosurgery.

Impact of completion of primary biliary procedure on outcome of endoscopic retrograde cholangiopancreatographic related perforation.

Background and aims Perforation is one of the worst complications of therapeutic endoscopic retrograde cholangiopancreatography (ERCP). We aimed to study the epidemiology of ERCP related perforation and the impact of completion of intended procedure on the outcome of this complication. Methods ERCP records from January 2007 to April 2012 were independently evaluated by two investigators for the occurrence of procedure related perforations. A total of 11 500 patients underwent therapeutic ERCP during the study period. The case records of 171 (1.5 %) patients with ERCP related perforations were reviewed to analyze the epidemiology and risk factors associated with poor outcome. Results Of the 171 patients included in this study, the majority of perforations (n = 129, 75.4 %) were related to use of the needle-knife precut technique. Female gender (1.9 % vs 0.7 %, P < 0.001), age > 40 years (1.7 % vs 1.1 %, P < 0.01), and benign disease (1.7 % vs. 1.1 %, P < 0.01) were risk factors for ERCP related perforation. Most of the perforations (n = 135, 79 %) were detected during the procedure. The majority of patients were managed conservatively (n = 164, 96 %). Although 159 patients recovered, 12 patients (7 %) did not survive. Completion of intended biliary procedure for primary disease was associated with low risk of mortality (2 % vs 15.4 %, P < 0.001). Conclusions ERCP related perforation is uncommon. The majority of patients can be managed conservatively. The risk of mortality is low and completion of the intended biliary procedure decreases the risk of mortality.

MEDIASTINAL EMPHYSEMA AS A COMPLICATION OF COLONOSCOPY

Cases of mediastinal emphysema (pneumomediastinum), as a complication of endoscopic colonoscopy perforation of the colon, according to the publications and given its own experience in the treatment of this rare complication were analyzed. There are few publications on the perforation of the colon during colonoscopy, with the development of pneumomediastinum, pnevmoretroperitoneuma, pneumothorax in a scientific literature. Air supply into the retroperitoneal space and the mediastinum from perforation of the intestine through the place connected with the lifting him through the natural anatomical connection. Some authors provide proven X-ray of the chest clinical cases pneumomediastinum and subcutaneous emphysema in a patient suspected of having ulcerative colitis after outpatient colonoscopy with biopsies, as well as pneumomediastinum with emphysema of soft tissues of the neck after endoscopic polypectomy. The diagnosis was established clinically (dyspnea, subcutaneous emphysema of the neck), but also the data of X-ray studies. The most life-threatening complication of colonoscopy a combination of pneumothorax, pneumomediastinum, and pneumoperitoneum retropnevmoperitoneuma that requires immediate diagnosis and surgical intervention. In these cases, it may be a tension pneumothorax, in which is shown an emergency thoracostomy. During the stress pneumomediastinum an adequate drainage of the mediastinum and (if indicated) pleural cavities is performed. Clinical terms of self-resolution of mediastinal emphysema account for an average of 6.2 days in the majority of patients. During colonoscopy balloon dilation of strictures of the colon may also be complications: subcutaneous emphysema and bilateral pneumothorax. In our practice, there were two clinical cases of mediastinal emphysema at colonoscopy due to perforation of the sigmoid colon in one case, and perforation of the sigmoid colon diverticulum in another. The patients were operated on with a favorable outcome, laparotomy and bowel resection with anastomosis device SEEA-29 were performed. The perforation of the gut during endoscopy requires emergency surgery. Mediastinal emphysema may be as a complication of colonoscopy and is associated with the air intake from the intestine through the perforation into the retroperitoneal space, and then in the mediastinum. During unstressed pnemomediastinume resorption occurs independent of emphysema in the next day after a bowel injury.

Surgical Management of Iatrogenic Perforation of the Gastrointestinal Tract: 15 Years of Experience in a Single Center

Gastrointestinal (GI) tract perforation during endoscopy is a rare but severe complication. The aim of this study was to determine predictors of morbidity and mortality after iatrogenic endoscopic perforation. All cases with iatrogenic endoscopic perforation receiving surgery at a tertiary referral center in a 15-year period (2000-2015) were retrospectively analyzed. Demographics, type of endoscopy, site of perforation, operative procedure, morbidity and mortality were analyzed. Multiple logistic regression was used to identify parameters predicting survival. A total of 106.492 endoscopies were performed, and 82 (0.08%) patients were diagnosed with GI perforation. Most perforations (63.4%) occurred in the lower GI tract, compared to 36.6% in the upper GI tract. In 21 cases (25%), perforation was noticed during endoscopy, whereas 61 perforations (75%) were diagnosed during the further clinical course. Operative care was applied within 24h in 61%. Surgery of perforations was almost completely performed maintaining the intestinal continuity (68%), whereas diversion was performed in 32%. Mortality was associated with age above 70 (OR 4.89, p=0.027), ASA class>3 (OR 4.08, p=0.018), delayed surgery later than 24h after perforation (OR 5.9, p=0.015), peritonitis/mediastinitis intraoperatively (OR 4.68, p=0.031) and severe postoperative complications with a Clavien-Dindo grade ≥III (OR 5.12, p=0.023). The prevalence of iatrogenic endoscopic perforation is low, although it is associated with a serious impact on morbidity and mortality. Delayed management worsens prognosis. To achieve successful management of endoscopic perforations, early diagnosis is essential in cases of deviation from the normal post-interventional course, especially in elderly.

Outcome and management of endoscopic retrograde cholangiopancreatography perforations: A community perspective

BackgroundEndoscopic retrograde cholangiopancreatography (ERCP) carries a small but significant risk of perforation. Recent data suggest that select patients can be managed non-operatively. We sought to evaluate the management of ERCP perforations at our community medical center. MethodsERCPs performed from 2004 to 2015 were reviewed. ResultsTwenty-one of 2423 patients who underwent ERCP had a perforation (0.9%). ERCP procedures included balloon sweep with/without sphincterotomy and pancreatic duct stent (71%), common bile duct brushing (10%), and pancreatic duct stenting (5%). Duodenal diverticula were present in 3 (14%), and altered anatomy was present in 6 (29%). Seventeen patients were treated nonoperatively; 3 (14%) underwent percutaneous drain placement. Two patients failed nonoperative treatment and required surgery. Four patients required ICU stay, and median post-ERCP LOS was 5 days. The 30-day mortality rate was 1/21 (4.8%). ConclusionsPerforations remain a rare, but serious, complication of ERCPs. Nonoperative management is highly successful in carefully selected patients. Early recognition with initiation of antibiotics is paramount. Our community-based practice patterns are similar to those previously published for successful nonoperative management of ERCP perforations.