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The importance of early recognition in management of ERCP-related perforations

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Abstract

Background

Iatrogenic perforations related to endoscopic retrograde cholangiopancreatography (ERCP) are rare events, carrying with it a mortality of up to 8%. Given the rarity of this adverse event, there remains limited data and continued uncertainties when choosing therapeutic strategies. Our aims were to evaluate the management of ERCP-related perforations and compare outcomes based on timing of recognition.

Methods

The endoscopic databases of two tertiary care centers were interrogated to identify consecutive adult patients who sustained ERCP-related perforation over a 10-year period from 2006 to 2016. Electronic medical records were reviewed to extract demographic data, perforation type, management strategies, clinical data, and patient outcomes.

Results

14,045 ERCP’s were performed during our 10-year study period. Sixty-three patients (average age 62.3 ± 2.38 years, 76% female) with ERCP-related perforations were included. Stapfer I perforations were found in 14 (22.2%) patients, Stapfer II in 24 (38.1%), and Stapfer III and IV perforations were identified in 16 (25.4%) and 9 (14.28%), respectively. Forty-seven (74.6%) perforations were recognized immediately during the ERCP, whereas 16 (25.4%) were recognized late. Endoscopic therapy was attempted in 35 patients in whom perforations were identified immediately, and was technically successful in 33 (94.3%). In all, 4 (1 immediate/ 3 delayed) patients required percutaneous drainage and 9 (5 immediate/ 4 delayed) surgery. Length of hospital stay, ICU admission were significantly shorter and incidence of SIRS was significantly lower when perforation was recognized immediately.

Conclusions

Immediate recognition of ERCP-related perforations leads to more favorable patient outcomes; with lower incidence of SIRS, less need for ICU level care, and shorter hospital stay.

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Authors and Affiliations

  1. Division of Gastroenterology, Washington University School of Medicine, 660 S. Euclid Ave, Campus Box 8124, St. Louis, MO, 63110, USA

    Jason G. Bill, Zachary Smith, Joseph Brancheck, Jeffrey Elsner, Paul Hobbs, Gabriel D. Lang, Dayna S. Early, Koushik Das, Thomas Hollander, Daniel K. Mullady & Vladimir M. Kushnir

  2. Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA

    Maria B. Majella Doyle, Ryan C. Fields, William G. Hawkins, Steven M. Strasberg, Chet Hammill & William C. Chapman

  3. Division of Gastroenterology, University of Colorado School of Medicine, Aurora, CO, USA

    Steven Edmundowicz

  4. Division of Gastroenterology and Liver Disease, Case Western Reserve University School of Medicine, Cleveland, OH, USA

    Zachary Smith

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  1. Jason G. Bill
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Contributions

JGB concept, design, data analysis, drafting the article; ZS manuscript revision; JB data collection and analysis; JE data analysis and collection; PH data collection, manuscript revision; GDL manuscript revision; DSE manuscript revision; KD manuscript revision; TH study design and data collection; MD manuscript revision; RCF manuscript revision; WGH manuscript revision; SMS manuscript revision; CH manuscript revision; WCC manuscript revision; SE manuscript revision; DKM concept, design, manuscript revision; VMK concept, design, data analysis, and critical revision of the article.

Corresponding author

Correspondence to Jason G. Bill.

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Disclosures

Dr. Maria B. Majella Doyle receives speaking fees from Novartis; Dr William G Hawkins reports other from Accuronix; Dr. Chet Hammil reports personal fees from Medtronics; Dr. William C. Chapman receives personal fees from Novartis, XOR Labs Toronto and Pathfinder; Dr. Steven Edmundowicz receives personal fees from Olympus and Elsevier publications. Also receives personal fees from Check-cap, Motus, Freehold Surgical, Elira, Paion, Orchestra Medical, Medtronic and Spironetics, Dr. Daniel K Mullady receives personal fees from Boston Scientific; Jason G Bill, Zachary Smith, Joseph Brancheck, Jeffrey Elsner, Paul Hobbs, Gabriel D Lang, Dayna S Early, Koushik Das, Thomas Hollander, Ryan C. Fields, Steven M. Strasberg, and Vladimir Kushnir have no conflicts of interest or financial ties to disclose.

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Bill, J.G., Smith, Z., Brancheck, J. et al. The importance of early recognition in management of ERCP-related perforations. Surg Endosc 32, 4841–4849 (2018). https://doi.org/10.1007/s00464-018-6235-8

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  • DOI: https://doi.org/10.1007/s00464-018-6235-8

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