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Surgical Endoscopy

, Volume 27, Issue 6, pp 2005–2012 | Cite as

Management of duodeno-pancreato-biliary perforations after ERCP: outcomes from an Italian tertiary referral center

  • Sergio Alfieri
  • Fausto RosaEmail author
  • Caterina Cina
  • Antonio Pio Tortorelli
  • Andrea Tringali
  • Vincenzo Perri
  • Guido Costamagna
  • Giovanni Battista Doglietto
Article

Abstract

Background

The management of post-endoscopic retrograde cholangiopancreatography (ERCP) perforation is often unknown by many physicians, and there is a paucity of literature regarding the best surgical management approach.

Patients and methods

A retrospective review of ERCP-related perforations to the duodeno-pancreato-biliary tract observed at the Digestive Surgery Department of the Catholic University of Rome was conducted to identify their optimal management and clinical outcome.

Results

From January 1999 to December 2011, 30 perforations after ERCP were observed. Seven patients underwent ERCP at another institution, and 23 patients underwent an endoscopic procedure at our hospital. Diagnosis of perforation was both clinical and instrumental. Fifteen patients (50 %) were successfully treated conservatively. Fifteen patients (50 %) underwent surgery after a mean time of 8.1 days (range 1–26 days) from ERCP: ten received a retroperitoneal laparostomy approach, three of them both an anterior and posterior laparostomy approach, and two an anterior laparostomy approach. Duodenal leak closure was observed after a mean (±standard deviation, SD) of 12.6 (±4.6) and 24.6 (±7.9) days after conservative and surgical treatment, respectively (p < 0.001). The overall and postoperative mortality rates were 13.3 % (4 of 30 patients) and 26.6 % (4 of 15 patients), respectively.

Conclusions

Post-ERCP perforation is burdened by a high risk of mortality. Early clinical and radiographic features have to be used to determine which type of surgical or conservative treatment is indicated. Half of patients can be treated conservatively, but in case of sepsis or unstable general conditions, early surgical procedure is indicated as the only possible chance of recovery.

Keywords

Complications G-I Endoscopy Surgical Technique 

Notes

Disclosures

Drs. Sergio Alfieri, Fausto Rosa, Caterina Cina, Antonio Pio Tortorelli, Andrea Tringali, Vincenzo Perri, Guido Costamagna, and Giovanni Battista Doglietto have no conflicts of interest or financial ties to disclose.

References

  1. 1.
    Freeman ML, Nelson DB, Sherman S, Haber GB, Herman ME, Dorsher PJ, Moore JP, Fennerty MB, Ryan ME, Shawn MJ, Lande JD, Pheley AM (1996) Complications of endoscopic biliary sphincterotomy. N Engl J Med 335:909–918PubMedCrossRefGoogle Scholar
  2. 2.
    Trap R, Adamsen S, Hart-Hansen O, Henriksen M (1999) Severe and fatal complications after diagnostic and therapeutic ERCP: a prospective series of claims to insurance covering public hospitals. Endoscopy 31:125–130PubMedCrossRefGoogle Scholar
  3. 3.
    Dunham F, Bourgois N, Gelin M et al (1982) Retroperitoneal perforations following endoscopic sphincterotomy: clinical course and management. Endoscopy 14:92–96PubMedCrossRefGoogle Scholar
  4. 4.
    Cotton PB, Lehman G, Vennes J et al (1991) Endoscopic sphincterectomy complications and their management: an attempt consensus. Gastrointest Endosc 37:383–393PubMedCrossRefGoogle Scholar
  5. 5.
    Chung RS, Sivak MV, Ferguson DR (1993) Surgical decisions in the management of duodenal perforation complicating endoscopic sphincterotomy. Am J Surg 165:700–703PubMedCrossRefGoogle Scholar
  6. 6.
    Chaudhary A, Aranya RC (1996) Surgery in perforation after endoscopic sphincterotomy: sooner, later, or not at all? Ann R Coll Surg Engl 78:206–208PubMedGoogle Scholar
  7. 7.
    Mustard R, Mackenzie R, Jamieson C, Haber GB (1984) Surgical complications of endoscopic sphincterotomy. Can J Surg 27:215–217PubMedGoogle Scholar
  8. 8.
    Leese T, Neoptolemos JP, Carr-Locke DL (1985) Successes, failures, early complications and their management following endoscopic sphincterotomy: results in 394 consecutive patients from a single centre. Br J Surg 72:215–219PubMedCrossRefGoogle Scholar
  9. 9.
    Isozaki H, Okajima K, Mizutani H, Takeda Y (1993) The successful surgical management of perforation after endoscopic sphincterotomy: report of two cases. Surg Today 23:1018–1022PubMedCrossRefGoogle Scholar
  10. 10.
    Meyer C, Jobard D, Thiry L, De Manzini Rohr S (1995) Retro-duodenal papillary perforation after endoscopic sphincterotomy. Role of surgical treatment by exclusion of the duodenum. A propos of 3 cases. J Chir 132:118–122Google Scholar
  11. 11.
    Bosscha K, Koningsberger JC, Hennipman A (1995) Duodenal isolation for the treatment of perforation after endoscopic sphincterotomy. Eur J Surg 161:447–449PubMedGoogle Scholar
  12. 12.
    Baron TH, Gostout CJ, Herman L (2000) Hemoclip repair of a sphincterotomy-induced duodenal perforation. Gastrointest Endosc 52:566–568PubMedGoogle Scholar
  13. 13.
    Enns R, Eloubeidi MA, Mergener K, Jowell PS, Branch MS, Pappas TM, Baillie J (2002) ERCP-related perforations: risk factors and management. Endoscopy 34:293–298PubMedCrossRefGoogle Scholar
  14. 14.
    Preetha MP, Chung YFA, Chan WH, Ong HS, Chow PK, Wong WK, Ooi LL, Soo KC (2003) Surgical management of endoscopic retrograde cholangiopancreatography-related perforation. ANZ J Surg 73:1011–1014PubMedCrossRefGoogle Scholar
  15. 15.
    Doglietto GB, Pacelli F, Caprino P, Alfieri S, Tortorelli AP, Mutignani M (2004) Posterior laparostomy through the bed of the 12th rib to drain retroperitoneal infection after endoscopic sphincterotomy. Br J Surg 91:730–733PubMedCrossRefGoogle Scholar
  16. 16.
    Sarli L, Porrini C, Costi R, Regina G, Violi V, Ferro M, Roncoroni L (2007) Operative treatment of periampullary retroperitoneal perforation complicating endoscopic sphincterotomy. Surgery 142:26–32PubMedCrossRefGoogle Scholar
  17. 17.
    Howard TJ (2000) Re: Stapfer M et al. Management of duodenal perforations after endoscopic retrograde cholangiopancreatography and sphincterotomy. Ann Surg 232:191–198 Ann Surg 2001; 234: 132–133CrossRefGoogle Scholar
  18. 18.
    Stapfer M, Selby RR, Stain SC, Katkhoumda N, Parekh D, Jabbour N, Garry D (2000) Management of duodenal perforation after endoscopic retrograde cholangiopancreatography and sphincterotomy. Ann Surg 232:191–198PubMedCrossRefGoogle Scholar
  19. 19.
    Mutignani M, Iacopini F, Dokas S, Larghi A, Familiari P, Tringali A, Costamagna G (2006) Successful endoscopic closure of a lateral duodenal perforation at ERCP with fibrin glue. Gastrointest Endosc 63:725–727PubMedCrossRefGoogle Scholar
  20. 20.
    Scarlett PY, Falk GL (1994) The management of perforation of the duodenum following endoscopic sphincterotomy: a proposal for selective therapy. Aust N Z J Surg 64:843–846PubMedCrossRefGoogle Scholar
  21. 21.
    Avgerinos DV, Llaguna OH, Lo AY et al (2009) Management of endoscopic retrograde cholangiopancreatography: related duodenal perforations. Surg Endosc 23:833–838PubMedCrossRefGoogle Scholar
  22. 22.
    Fatima J, Baron TH, Topazian MD, Houghton SG et al (2007) Pancreaticobiliary and duodenal perforations after periampullary endoscopic procedures: diagnosis and management. Arch Surg 142:448–455PubMedCrossRefGoogle Scholar
  23. 23.
    Sarr MG, Fishman EK, Milligan FD et al (1986) Pancreatitis or duodenal perforation after peri-Vaterian therapeutic endoscopic procedures: diagnosis, differentiation and management. Surgery 100:461–466PubMedGoogle Scholar
  24. 24.
    Howard TJ, Tan T, Lehman GA et al (1999) Classification and management of perforations complicating endoscopic sphincterotomy. Surgery 126:658–665PubMedCrossRefGoogle Scholar
  25. 25.
    Lucas CE, Ledgerwood AM (1975) Factors influencing outcome after blunt duodenal injury. J Trauma 15:839–846PubMedCrossRefGoogle Scholar
  26. 26.
    Safrany L (1977) Duodenoscopic sphincterotomy and gallstone removal. Gastroenterology 72:338–343PubMedGoogle Scholar
  27. 27.
    Assalia A, Suissa A, Ilivitzki A et al (2007) Validity of clinical criteria in the management of endoscopic retrograde cholangiopancreatography-related duodenal perforations. Arch Surg 142:1059–1064PubMedCrossRefGoogle Scholar
  28. 28.
    Kuhlman JE, Fishman EK, Milligan FD et al (1989) Complications of endoscopic retrograde sphincterotomy: computed tomographic evaluation. Gastrointest Radiol 14:127–132PubMedCrossRefGoogle Scholar
  29. 29.
    Nam JS, Yi SY (2004) Massive pneumoperitoneum and pneumomediastinum with subcutaneous emphysema after endoscopic sphincterotomy. Clin Gastroenterol Hepatol 2:22CrossRefGoogle Scholar
  30. 30.
    Huibregtse K (1996) Complications of endoscopic sphincterotomy and their prevention. N Engl J Med 335:961–963PubMedCrossRefGoogle Scholar
  31. 31.
    Machado NO (2012) Management of duodenal perforation post-endoscopic retrograde cholangiopancreatography. When and whom to operate and what factors determine the outcome? A review article. JOP 13:18–25PubMedGoogle Scholar
  32. 32.
    Genzlinger JL, McPPhee MS, Fisher JK et al (1999) Significance of retroperitoneal air after endoscopic retrograde cholangiopancreatography with sphincterotomy. Am J Gastroenterol 94:1267–1270PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  • Sergio Alfieri
    • 1
  • Fausto Rosa
    • 1
    Email author
  • Caterina Cina
    • 1
  • Antonio Pio Tortorelli
    • 1
  • Andrea Tringali
    • 2
  • Vincenzo Perri
    • 2
  • Guido Costamagna
    • 2
  • Giovanni Battista Doglietto
    • 1
  1. 1.Digestive Surgery DepartmentCatholic University, “A. Gemelli” HospitalRomeItaly
  2. 2.Digestive Endoscopy DepartmentCatholic University, “A. Gemelli” HospitalRomeItaly

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