ERCP-related Perforations Research Articles

Clinical Course and Proposal for Treatment Strategy in the ERCP-Related Duodenal Perforation: A Multicenter Study

Clinical Course and Proposal for Treatment Strategy in the ERCP-Related Duodenal Perforation: A Multicenter Study

Management of ERCP-Related Perforations: Outcomes of Single Institution in Korea

IntroductionThe aim of this study was to analyze clinicoradiologic findings and treatment outcomes of patients with endoscopic retrograde cholangiopancreatography (ERCP)-related perforations. Between May 2003 and November 2007, 2,247 ERCP procedures with or without sphincterotomy were performed at Ajou University Medical Center, Suwon, Korea, and 20 perforations (0.89%) were identified. DiscussionWe retrospectively reviewed medical and surgical records of each patient. Of 18 patients, 11 patients (61.1%) underwent nonsurgical management, and seven patients (38.9%) received surgical management. There were no significant differences in age, gender, and laboratory findings between two groups (P > 0.05). The hospital stay was significantly longer in the operative group than that of the conservative group (P < 0.05, respectively). The most common cause of perforation was sphincterotomy (n = 8) in the conservative group whereas scope itself (n = 6) in operative group, showing a significant difference between the two groups (P < 0.05). The retroperitoneal air was most common findings in eight patients (72.7%) of the conservative group, while six (85.7%) patients of the operative group presented with intraperitoneal air, displaying a significant difference in location of air between the two groups (P < 0.05). Most of sphincterotomy-related perforations were managed nonsurgically. However, the scope-related perforations were usually large and required immediate surgery. Moreover, the delayed operation resulted in a longer hospital stay and high morbidity. Therefore, the selective early surgical intervention is suggested when scope-related perforations are discovered.

A Devastating Complication: Duodenal Perforation Due to Biliary Stent Migration

Endoscopic retrograde cholangiopancreatography (ERCP) plays an important diagnostic and potentially therapeutic role in the management of a broad range of biliary and pancreatic disorders. However, it is an invasive procedure with an associated complication rate in the vicinity of 5% to 15% and mortality rate of 1%. We present an unusual case of a patient who sustained a stent-related duodenal perforation after undergoing ERCP. We reviewed the current literature in regard to risk factors, etiology, diagnosis, management, and prognosis of ERCP-related perforations, aiming to provide a brief, updated overview of this devastating complication.

Management of endoscopic retrograde cholangiopancreatography: related duodenal perforations

As the performance of upper gastrointestinal endoscopy, especially endoscopic retrograde cholangiopancreatography (ERCP), has increased since 1968, so has the incidence of duodenal perforations. The frequency of ERCP use varies among hospitals and depends on the availability of trained endoscopists, equipment, and facilities. A retrospective review of ERCP-related perforations to the duodenum was conducted to identify their incidence, optimal management, and clinical outcome. Charts were reviewed for the following data: ERCP indication, clinical presentation, diagnostic methods, time to diagnosis and treatment, type of injury, management, length of hospital stay, and clinical outcome. From April 1999 to February 2008, 4,358 ERCP were performed, 15 of which (0.34%) resulted in perforation to the duodenum. Only four of the perforations were discovered during ERCP, with another eight requiring computed tomography or abdominal radiography for diagnosis. Surgery was performed for 13 of the patients (87%), and 2 patients died (15%). One patient was managed conservatively with a successful outcome. Nine patients underwent surgery within 24 h after the ERCP, with only one patient undergoing surgery after 24 h. The overall mortality rate was 20% (3 of 15 patients). Clinical and radiographic features can be used to determine the surgical or conservative treatment of ERCP-related duodenal perforations, whereas patient age and intraoperative findings can determine the final outcome and morbidity or mortality. The interval between the perforation and the operation is of great significance. The mortality rate increases dramatically with late surgical management (>24 h). An algorithm for the selective management of ERCP-induced duodenal perforations is proposed.

Management of Post- ERCP Perforation

Purpose: BACKGROUND: The patient and clinical factors which influence the clinical course in patients who suffer an ERCP related perforation are poorly characterized. AIM: To identify patient and clinical factors that affect outcome in patients who suffer an ERCP-related perforation. Methods: The study was approved by our institutional IRB. All cases of ERCP related perforation that occurred at our institution between 2000 and 2008 were identified from the ERCP database. Patient and clinical factors that affected outcome were analyzed. Variables defining poor outcome were (1) length of stay (LOS) exceeding 2 weeks (2) operative intervention (defined as having a percutaneous or surgical procedure). Results: 47 of the 4109 (1.1%) ERCPs were complicated by a perforation. The mean length of hospitalization was 16 days (range 1–81 days), with 40.4% of the perforations being detected within 24 hours of procedure. The management strategy for these patients was stratified based on the decision within the first 24 hours of the perforation. 40 out of the 47 patients were managed nonoperatively while 7 patients were managed operatively. Patients who underwent initial operative management had a longer mean length of stay (22.9 days) than patients who were managed non-operatively (15 days, P= NS). Of the 40 patients initially managed nonoperatively, only 7 required operative intervention. The LOS was longer (30 days vs. 10 days, P= 0.04) in those patients who failed initially nonoperative management. Factors associated with failure of the initial nonoperative management strategy and factors associated with increased LOS are shown in Tables 1 and 2, respectively.Table 2: Factors Associated with LOS >2 weeksTable 1: Factors Associated with Failure of Initial Nonoperative Management.Conclusion: CONCLUSION The incidence of ERCP related perforation in our institution is 1.1%. Successful conservative management was possible in most patients (33/47, 70.2%) with post ERCP perforation. Concerning features associated with poor outcome were presence of systemic signs (fever/leukocytosis), symptoms (local abdominal tenderness), retroperitoneal fluid or intra-abdominal abscess on CT scan, and a delay in detection (>24 hours after the procedure). The presence of these concerning features may for the basis of a future clinical algorithm that would appropriately triage patients to operative versus non-operative management strategies for ERCP-related perforation.

ERCP-Related Perforations: Analysis of Patient-Outcome After ERCP in Over 2700 Patients

ERCP-related perforation is a serious complication. Identifying clinical factors that influence hospital course may lead to better targeted clinical intervention and improve patient outcome. AIM: To identify the clinical factors that affect outcome in patients who suffered an ERCP-related perforation. Methods: IRB-approved, retrospective analysis of ERCP-related perforations at our institution from January 2003 to November 2007. Patient demographics, procedural factors, laboratory and radiographic imaging results, and post-ERCP complications were recorded and analyzed using length of stay (LOS), surgical intervention, and readmission rates as primary endpoints. All procedures were performed by ERCP experts. Results: 2759 ERCP procedures were performed during this time period, and 30 (1.1%) patients (21 Females, mean age 47.4 years) suffered an ERCP-related perforation. Indications for ERCP were: SOD (40.0%), pancreatitis (16.7%), stone/stricture (13.3%), ampullary mass (10.0%), pancreas divisum (6.7%), PSC, abdominal pain, biloma, dilated pancreatic duct (3.3% each). The odds of perforation were higher (OR 40, CI 18-87) in SOD patients, as compared to non-SOD patients. 25 patients underwent endoscopic sphincterotomy and 16 patients had an endoprosthesis placed. 96.7% (29/30) of the perforations were detected within 72 hours; 85.7% were detected by CT. A delay in perforation diagnosis significantly increased the mean LOS (7.0 days if detected at ERCP vs. 15.7 days if detected within 24 hours vs. 23.0 days if detected between 24-72 hours; p = 0.048), as did the presence or development of one or more of the following clinical features: ascites, abscess, fluid collection, pneumothorax, pneumomediastinum, pleural effusion, thrombophlebitis. In 13 patients who had concomitant post-ERCP pancreatitis, the odds of developing a retroperitoneal fluid collection (OR 13.2; p = 0.006) was higher than in patients with perforation alone; however, there was no increase in LOS or need for surgical intervention. Patients who underwent surgical intervention (9/30) had a significantly longer LOS (37.7 days vs. 11.1 days; p = 0.006) as compared to patients managed non-operatively, and surgical patients were more likely to be re-admitted (p < 0.03). There was no mortality in this cohort. Conclusions: Early diagnosis of the perforation and non-operative management was associated with shorter hospitalization. LOS is increased with the development of several clinical features. Surgical patients had higher readmission rates compared to non-operative patients. This is the first study to identify clinical factors associated with patient outcome after suffering an ERCP-related perforation.

Surgical management of endoscopic retrograde cholangiopancreatography‐related perforations

A retrospective review was carried out of consecutive cases of endoscopic retrograde cholangiopancreatography (ERCP)-related perforation to identify risk factors and technique affecting surgical outcome. Eighteen patients (0.45%) out of 4030 ERCP performed were operated on for ERCP-related perforation at Singapore General Hospital. The group's median age was 72.5 years and 14 patients had ductal stone disease. Five perforations were discovered at ERCP while 10 required computed tomography for diagnosis. Eight patients were operated on within 24 h whereas 10 patients had surgery after 24 h. Five of six with type I (lateral duodenal) perforations had early surgery versus one of seven with type II (peri-Vaterian; P = 0.03). There were four type III (bile duct) perforations and one type IV (retroperitoneal air). Five of six patients with type I perforation had simple repair compared with five of seven type II requiring the complex duodenal diversion procedure (P = 0.10). Three patients (16.7%) succumbed after surgery due to sepsis and myocardial infarction. Advanced age>70 years resulted in higher mortality of 30% versus none in patients <70 years (P = 0.22). Early diagnosis is important but difficult especially for the type II perforations. Duodenal diversion is used more frequently in patients with type II perforations and those operated on late. Advanced age contributes to poorer outcome in surgical treatment of ERCP perforations.