Skip to main content


Log in

Management of endoscopic retrograde cholangiopancreatography: related duodenal perforations

  • Published:
Surgical Endoscopy Aims and scope Submit manuscript



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 endocopists, 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.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Subscribe and save

Springer+ Basic
EUR 32.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or Ebook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others


  1. Barthet M, Lesavre N, Desjeux A, Gasmi M, Berthezene P, Berdah S, Viviand X, Grimaud JC (2002) Complications of endoscopic sphincterotomy: results from a single tertiary referral center. Endoscopy 34:991–997

    Article  PubMed  CAS  Google Scholar 

  2. Enns R, Eloubeidi MA, Mergener K, Jowell PS, Branch MS, Pappas TM, Baillie J (2002) ERCP-related perforations: risk factors and management. Endosocpy 34:293–298

    Article  CAS  Google Scholar 

  3. Freeman ML, Nelson DB, Sharman S, Haber GB, Herman ME, Dorsher PJ, Moore JP, Fennerty MB, Ryan ME, Shaw MJ, Lande JD, Pheley AM (1999) Complications of endoscopic biliary sphincterotomy. N Engl J Med 335:909–918

    Article  Google Scholar 

  4. Martin DF, Tweedle DE (1990) Retroperitoneal perforation during ERCP and endoscopic sphincterotomy: causes, clinical features, and management. Endoscopy 22:174–175

    Article  PubMed  CAS  Google Scholar 

  5. Stapfer M, Selby RR, Stain SC, Kathouda N, Parekh D, Jabbour N, Garry D (2000) Management of duodenal perforation after endoscopic retrograde cholagio-pancreatography and sphincterotomy. Ann Surg 232:191–198

    Article  PubMed  CAS  Google Scholar 

  6. Booth FV, Doerr RJ, Khalafi RS, Luchette FA, Flint LM (1990) Surgical management of complications of endoscopic sphincterotomy with precut papillotomy. Am J Surg 159:132–136

    Article  PubMed  CAS  Google Scholar 

  7. Cotton PB, Lehman G, Vennes J, Greenen JE, Russell RC, Meyers WC, Liguory C, Nickl N (1991) Endoscopic sphincterotomy complications and their management: an attempt at consensus. Gastrointest Endosc 37:383–393

    Article  PubMed  CAS  Google Scholar 

  8. Dunham F, Bourgeouis N, Gelin M, Jeanmart J, Toussaint J, Cremer M (1982) Retroperitoneal perforations following endoscopic sphincterotomy: clinical course and management. Endoscopy 14:92–96

    Article  PubMed  CAS  Google Scholar 

  9. Lizcano JGC, Martin JAG, Arino JM, Sola AP (2004) Complications of endoscopic retrograde cholagiopancreatography: a study in a small ERCP unit. Rev Esp Enferm Dig 96:163–173

    Google Scholar 

  10. Preetha M, Chung YF, Chan WH, Ong HS, Chow PK, Wong WK, Ooi LL, Soo KC (2003) Surgical management of endoscopic retrograde cholagiopancreatography-related perforations. ANZ J Surg 73:1011–1014

    Article  PubMed  Google Scholar 

  11. Howard TJ, Lehman GA, Sherman S, Madura JA, Fogel E, Swack ML, Kopecky KK (1999) Classification and management of perforations complicating endoscopic sphincterotomy. Surgery 126:658–665

    PubMed  CAS  Google Scholar 

  12. Assalia A, Suissa A, Ilivitzki A, Mahajna A, Yassin K, Hashmonai M, Krausz MM (2007) Validity of clinical criteria in the management of endoscopic retrograde cholagiopancreatography-related duodenal perforations. Arch Surg 142:1059–1064

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations


Corresponding author

Correspondence to I. Michael Leitman.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Avgerinos, D.V., Llaguna, O.H., Lo, A.Y. et al. Management of endoscopic retrograde cholangiopancreatography: related duodenal perforations. Surg Endosc 23, 833–838 (2009).

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: