Retroperitoneal perforation during endoscopic sphincterotomy: imaging findings

Bilateral pneumothorax: The cause of hypoxia during endoscopic retrograde cholangiopancreatography

Background:

Endoscopic retrograde cholangiopancreatography (ERCP) is recognized as a significant diagnostic and therapeutic procedure for the administration of different pancreatic and biliary problems. This procedure runs a considerable risk of complications despite its substantial safety. The rate of significant inconveniences is reported to range from 5.4% to 23.0% and the general mortality from 0.1 to 1%. Post-ERCP pneumothorax is an uncommon complication that is usually underestimated

Case Presentation:

In the present study, we report a 65-year-old woman who develops hypoxemia during the ERCP. Based on the obtained results, it was revealed that this patient had perforation-related bilateral pneumothorax and hypoxemia.

Conclusion:

Based on the obtained results, it was revealed that this patient had perforation-related bilateral pneumothorax and hypoxemia.

Computed tomography classification of endoscopic retrograde cholangiopancreatography-related perforation

Endoscopic retrograde cholangiopancreatography (ERCP)-related perforation leads to high morbidity and mortality. The Stapfer classification divides patients with different perforation locations and suggests management accordingly. The classification may be unknown if perforation is not detected during endoscopy. We classified patients with ERCP-related perforation (ERP) through computed tomography (CT) and observed the clinical outcomes with varyingly invasive management. Fifty-two cases of ERP between July 2009 and December 2017 were retrospectively reviewed. Of them, 41 who underwent CT for ERCP were included. According to their CT findings, we divided patients into air-alone (n = 16), air-fluid (n = 18), and fluid-alone (n = 7) groups. Perforation severity was graded using the Clavien-Dindo classification for surgical complications. Demographic data and clinical outcomes among different groups were analyzed. Fifteen patients (37%) had an unknown Stapfer classification. More than half of the patients in the air-fluid group had a Clavien-Dindo complication grade of >3. Four patients underwent surgical repair; all of them were from the air-fluid group. All patients in the air- and fluid-alone groups underwent medical treatment without need for subsequent salvage surgery. The air-fluid group had the longest mean hospital stay (25.1 ± 21.9 days) and the exclusive two mortality cases in this study. Patients with ERCP can be divided into groups with different outcomes according to the presence of air or fluid on CT images. Because patients with both air and fluid have the worst clinical outcome, they may require more aggressive treatment than patients with either air or fluid alone.

Review of duodenal perforations after endoscopic retrograde cholangiopancreatography in Hospital Puerta de Hierro from 1999 to 2014

INTRODUCTION

endoscopic retrograde cholangiopancreatography (ERCP) remains the gold standard in biliary and pancreatic pathology. Although the procedure has a significant morbidity and mortality rate. Algorithms are needed for the management and treatment of the associated complications.

OBJECTIVE

to review the post-ERCP perforations treated in the Department of General Surgery of the Hospital Puerta de Hierro from 1999 to 2014. The results were evaluated according to the types of perforation and treatment.

METHODS AND RESULTS

this is a descriptive and observational study of all post-ERCP perforations reported and treated by the Department of General Surgery of the Hospital Puerta de Hierro from 1999 to 2014. The following data were collected: indication for the test and findings, type of perforation, time and method of diagnosis, time to surgery and the technique used; the subsequent complications as well as the evolution and time of admission were registered. Results were evaluated according to the type of perforation (Stapfer classification) and the treatment performed. Thirty-six perforations were reported (21 type I, eight type II, two type III and five type IV), with an associated incidence of less than 1%. The diagnosis was immediate (in the first 24 hours) in 67% of cases; type I was the most frequent: 28 of 36 patients (77.7%) required surgery. The majority underwent a cholecystectomy followed by suture, intraoperative cholangiography, bile duct exploration and drainage whenever possible. Four patients died with type I perforations; two were intervened and two were managed conservatively. The most frequent complication was a collection/fistula which occurred in 21.42% of patients who underwent surgery.

CONCLUSIONS

periduodenal perforations secondary to ERCP treatment should be oriented according to the clinical and radiological findings. In our experience, type I perforations require immediate surgical intervention, whereas type II and III perforations can be managed conservatively in some cases when there are no complications such as associated abdominal collections, peritoneal irritation and/or sepsis. Type IV perforations respond to conservative management.

Algorithm for the management of ERCP-related perforations

BACKGROUND AND AIMS

Perforation is a rare but serious adverse event of ERCP. There is no consensus to guide the clinician on the management of ERCP-related perforations, with particular controversy surrounding the immediate surgical management of postprocedurally detected duodenal perforation because of overextension of a sphincterotomy. Our aim was to assess patient outcomes using a predetermined algorithm based on managing ERCP-related duodenal perforations according to the mechanism of injury.

METHODS

A retrospective single-center study of all consecutive patients with Stapfer type I and II perforations between 2000 and 2014 were included. Our institutional algorithm since 2000 dictated that Stapfer type I perforations (duodenal wall perforation, endoscope related) should be managed surgically unless prohibited by underlying comorbidities and Stapfer type II perforations (periampullary, sphincterotomy related) managed nonsurgically unless a deterioration in clinical status necessitated surgery.

RESULTS

Sixty-one patients (mean age, 51 years; 80% women) were analyzed with Stapfer type I perforations diagnosed in 7 (11%) and type II in 54 (89%). A postprocedural diagnosis of perforation was made in 55 patients (90%). Four patients (7%) had Stapfer type II perforations that failed medical management and required surgery. The mean length of stay (LOS) in the entire cohort was 9.6 days with a low mortality rate of 3%. Systemic inflammatory response syndrome was observed in 18 patients (33%) with Stapfer type II perforations and was not associated with the need for surgery. Concurrent post-ERCP pancreatitis was diagnosed in 26 patients (43%) and was associated with an increased LOS.

CONCLUSIONS

Stapfer type II perforations have excellent outcomes when managed medically. We validate an algorithm for the management of ERCP-related perforations and propose that it should function as a guide.

Cross-sectional imaging of common and unusual complications after endoscopic retrograde cholangiopancreatography

Endoscopic retrograde cholangiopancreatography (ERCP) is currently a primarily therapeutic procedure that is extensively employed to treat several biliopancreatic disorders. Although widely considered a safe procedure, ERCP is associated with a non-negligible morbidity and occasional mortality. Due to the number and complexity of operative ERCPs performed, radiologists are increasingly faced with urgent requests for investigation of suspected post-procedural complications, which often have similar clinical and laboratory manifestations. This pictorial essay reviews the usual post-procedural CT findings, the clinical features and imaging appearances of common and unusual post-ERCP occurrences including interstitial oedematous and necrotising acute pancreatitis, haemorrhages, retroperitoneal and intraperitoneal duodenal perforations, infections and stent-related complications. Emphasis is placed on the pivotal role of multidetector CT, which is warranted after complex or prolonged ERCP procedures as it represents the most effective modality to detect and grade ERCP-related complications and to monitor nonsurgically treated patients. Timely diagnosis and optimal management require a combination of clinical and laboratory data with imaging appearances; therefore, this article aims to provide an increased familiarity with interpretation of early post-ERCP studies, particularly to triage those occurrences that require interventional or surgical treatment. In selected patients MRI allows imaging pancreatitis and abnormal collections without the use of ionising radiation.

Teaching Points

• Endoscopic retrograde cholangiopancreatography (ERCP) allows treating many biliopancreatic disorders.

• Due to the number and complexity of procedures, post-ERCP complications are increasingly encountered.

• Main complications include acute pancreatitis, haemorrhages, duodenal perforation and infections.

• Diagnosis and management of complications rely on combined clinical, laboratory and imaging data.

• Multidetector CT is most effective to diagnose, categorise and monitor post-ERCP complications.

Complications following endoscopic retrograde cholangiopancreatography: minimal invasive surgical recommendations

Background

ERCP has a complication rate ranging between 4% and 16% such as post-ERCP pancreatitis, hemorrhage, cholangitis and perforation. Perforation rate was reported as 0.08% to 1% and mortality rate up to 1.5%. Besides, injury related death rate is 16% to 18%. In this study we aimed to present a retrospective review of our experience with post ERCP-related perforations, reveal the type of injuries and management recommendations with the minimally invasive approaches.

Methods

Medical records of 28 patients treated for ERCP-related perforations in Okmeydani Training and Research Hospital between March 2007 and March 2013 were reviewed retrospectively. Patient age, gender, comorbidities, ERCP indication, ERCP findings and details were analyzed. All previous and current clinical history, laboratory and radiological findings were used to assess the evaluation of perforations.

Results

Between March 2007 and March 2013, 2972 ERCPs were performed, 28 (0.94%) of which resulted in ERCP-related perforations. 10 of them were men (35.8%) and 18 women (64.2%). Mean age was 53.36±14.12 years with a range of 28 to 78 years. 14 (50%) patients were managed conservatively, while 14 (50%) were managed surgically. In 6 patients, laparoscopic exploration was performed due to the failure of non-surgical management. In 6 of the patients that ERCP-related perforation was suspected during or within 2 hours after ERCP, underwent to surgery primarily. There were two mortalities. The mean length of hospitalization stay was 10.46±2.83 days. The overall mortality rate was 7.1%.

Conclusion

Successful management of ERCP-related perforation requires immediate diagnosis and early decision to decide whether to manage conservatively or surgically. Although traditionally conventional surgical approaches have been suggested for the treatment of perforations, laparoscopic techniques may be used in well-chosen cases especially in type II, III and IV perforations.

The management of endoscopic retrograde cholangiopancreatography-related duodenal perforation

Uneventful duodenal perforation during endoscopic retrograde cholangiopancreatography (ERCP) is an uncommon but occasionally fatal complication. ERCP-related perforations may occur during sphincterotomy and improper manipulation of the equipment and scope. Traditionally, duodenal perforation has been treated with early surgical repair. Recently, nonoperative early endoscopic management techniques including clips or fibrin glue have been reported. In the present paper we review the literature pertaining to the treatment of perforations.

Treatment results of gastrointestinal perforation after endoscopic retrograde cholangiopancreatography

INTRODUCTION

Duodenal perforation, damage to common bile duct or ampulla of Vater complicates from 0.7% to 10% of endoscopic retrograde cholangiopancreatography (ERCP) procedures. This complication is associated with high risk of contracting fatal diseases and death. As the endoscopic and minimally invasive treatment methods develop and gain popularity, it becomes increasingly important to determine the correct procedure in the event of gastrointestinal perforation after ERCP.

AIM

To present the results of treatment of gastrointestinal perforation after ERCP and indicate the correct procedure for such cases.

MATERIAL AND METHODS

The material includes 19 patients who underwent ERCP in the years 2008-2011 and were subsequently diagnosed with duodenal perforation (except for duodenal bulb) and common bile duct (CBD). Women accounted for 68% of patients (13/19), while men constituted 32% (6/19). The mean age of patients was 66.6 years old. Indications for ERCP included cholelithiasis in 95% of cases and bile duct strictures in the remaining 5%. Treatment was conditional on the result of X-ray examination of the abdominal cavity, followed by computed tomography with aqueous contrast medium administered orally.

RESULTS

Four patients were diagnosed with intraperitoneal perforation and 15 patients with retroperitoneal perforation. In the patient group with retroperitoneal perforation the contrast media leakage (10 patients) required surgical intervention - the perforation site was located in 5 cases; in the other 5 the site could not be found. With the absence of active contrast media leakage in computed tomography (CT) (5 patients) conservative treatment was applied. Four patients with intraperitoneal perforation were referred for operative treatment. In patients under conservative treatment no complications were observed and the average hospitalization time was 9 days. Among patients with retroperitoneal perforation, who had undergone surgical treatment, complications occurred in 3 cases. The average hospitalization time in the group in which the perforation site was located was 16 days, while in the group with an unidentified perforation site it was 17 days. Patients with intraperitoneal perforation were given operative treatment, with the average hospitalization time of 12 days.

CONCLUSIONS

Each patient with suspected post-ERCP perforation should undergo CT of the abdominal cavity with aqueous contrast medium administered orally. In the event of no contrast leak in patients with retroperitoneal duodenal perforation, conservative treatment should be applied. In the case of retroperitoneal perforation with active contrast media leakage outside the gastrointestinal tract, and in the case of intraperitoneal perforation, an immediate surgical intervention is recommended.

Perforations following endoscopic retrograde cholangiopancreatography: a single institution experience and surgical recommendations

BACKGROUND

Perforation after endoscopic retrograde cholangiopancreatography (ERCP) is uncommon, and its management is dependent on the mechanism and the graded classification of injury.

METHODS

Records of patients undergoing ERCP were analyzed over a 16-year period, patterning the types of injuries, diagnosis, management, and patient outcome. Type I injuries damage the medial or lateral duodenal wall before sphincter cannulation. Type II injuries are periampullary and occur as a result of a precut or a papillotomy. Type III injuries occur secondary to guidewire insertion or stone extraction from the common bile duct. Type IV injuries are probably microperforations that are noted on excessive insufflation during and after ERCP withdrawal.

RESULTS

Between 1995 and 2011, 27 perforations were identified from 1,638 ERCP procedures (1.6%). Nearly half of the procedures were regarded as difficult by the endoscopist, with 70% of the ERCPs (19 of 27) being for therapeutic indications. There were 5 type I, 12 type II, 5 type III, and 5 type IV perforations, of which 18 cases were diagnosed at the time of ERCP. Delayed diagnosis of type I perforations that were associated with free intraperitoneal air and contrast leakage proved fatal. Most type II perforations required immediate surgery with pyloric exclusion; delayed surgery with simple drainage had a high mortality rate. Most type III and type IV injuries can successfully be managed conservatively without delayed sepsis.

CONCLUSIONS

In perforation, the mechanism of injury during ERCP predicts the need for surgical management. Type I and type II injuries require early diagnosis and aggressive surgery, whereas type III and type IV injuries may be managed conservatively.

Successful Nonsurgical Treatment of Pneumomediastinum, Pneumothorax, Pneumoperitoneum, Pneumoretroperitoneum, and Subcutaneous Emphysema following ERCP

Complications related to endoscopic retrograde cholangiopancreatography (ERCP) include pancreatitis, hemorrhage, cholangitis, and perforation. ERCP-related perforation is uncommon, but mortality rates are high. Diagnosis requires a high clinical suspicion for early detection to allow optimal management of the perforation and a better prognosis. Treatment depends on the location and mechanism and increasingly involves nonoperative management. We report a case of successful nonsurgical treatment of a patient with extensive air involving the peritoneum, retroperitoneum, thorax, mediastinum, and subcutaneous tissues following an ERCP perforation.

Endoscopic Retrograde Cholangiopancreatography Gut Perforations: When to Wait! When to Operate!

Most perforations of the gastrointestinal tract during endoscopic retrograde cholangiopancreatography (ERCP) can be managed nonoperatively. Identifying patients who require operative management is problematic. A clinical endoscopy database was queried for patients who sustained ERCP perforation over a 13-year period. Records were reviewed and analyzed with approval of the Institutional Review Board. During the study period, 12,817 patients underwent ERCP; 24 (0.2%) had an endoscopic perforation. Twelve patients had a retroperitoneal perforation during sphincterotomy and all were successfully managed nonoperatively. Nine of these were undergoing treatment for sphincter of Oddi dysfunction. Twelve patients had perforation remote from the papilla. Of these, 10 required surgical intervention. Six patients had surgically altered anatomy (three postpancreaticoduodenectomy, three post-Billroth II gastrectomy) and one had situs inversus. Six of these seven required surgical intervention. Median length of stay of all patients was 7.5 days, morbidity was 25 per cent, and one patient died 16 days after surgery. Gut perforation after ERCP requires prompt surgical evaluation. Patients with sphincterotomy-related retroperitoneal perforation can be managed safely with nonoperative therapy in most instances. Patients with remote perforation usually need surgical intervention. Altered foregut anatomy leads to injuries that usually require operative management.

Duodenal perforations after endoscopic retrograde cholangiopancreatography: experience and management

OBJECTIVE

The aim of this study was to summary the experiences and lessons from periduodenal perforations related to endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (EST).

METHODS

A retrospective review from 2004 to 2007 identified 9 patients (0.37%) of periduodenal perforation related to ERCP/EST. Charts were reviewed for the following parameters: clinical presentation of patients, ERCP findings, diagnostic methods, treatment (surgical or conservative procedures), complications, and outcome.

RESULTS

Nine patients who had periampullary perforations received ERCP/EST for common bile duct stones. Cannulation was considered difficult in 7 of 9 patients, and the precut technique was used. The diagnosis was made due to subcutaneous emphysema or peritonitis, and 3 patients received emergent operations (e.g., external biliary or retroperitoneal drainage), and 1 patient had a reoperation for a retroperitoneal sealed abscess. Their median length of hospital stay was 50 days. The other 6 were treated conservatively with nasal-duodenal and nasal-biliary drainage. Their median length of hospital stay was 13 days. There was no mortality.

CONCLUSIONS

The precut technical may be a risk factor of duodenal perforation. Early diagnosis of duodenal perforation is essential for an optimum outcome, and subcutaneous emphysema may be a sensitive sign. Although the management of perforation after ERCP/EST is still controversial, a selective management is proposed, based on the features of classification type. Nevertheless, duodenal and biliary drainage is essential in both surgical and conservative therapy.

Benign retropneumoperitoneum developed after endoscopic sphincterotomy and large balloon dilation of biliary sphincter for removal of large biliary stones: a case report

Biliary endoscopic sphincterotomy (ES) followed by biliary orifice dilation (BOD) with large-diameter balloons (> 12 mm) is a relative new technique for extraction of large biliary stones. However, the safety and the potential complications of this combined technique are not known yet. We present a patient who developed benign retroperitoneum after ES plus BOD with large-diameter balloon for removal of a large biliary stone, which was successfully treated conservatively. To the best of our knowledge this is the first report of such a complication after introduction of this method to clinical practice.

CT findings of latrogenic complications following gastrointestinal endoluminal procedures

Abdominal CT, a simple and safe imaging modality, plays an important role in evaluating patients suspected of having abdominal complications following nonsurgical gastrointestinal procedures, to accurately determine the presence or absence of such insults. This pictorial article reviews and demonstrates the CT findings of various complications following upper endoscopy, percutaneous endoscopic gastrostomy, endoscopic retrograde cholangiopancreatography, endoscopic US, colonoscopy, and enemas (barium as well as cleansing).

Management of perforation after endoscopic retrograde cholangiopancreatography (ERCP): a population-based review

BACKGROUND

Perforation related to endoscopic retrograde cholangiopancreatography (ERCP) is a rare complication associated with significant morbidity and mortality. This study evaluated the management and outcomes of these perforations.

PATIENTS AND METHODS

Between July 1996 and December 2002, a total of 6620 ERCPs were performed at our regional endoscopy unit serving the 1.5 million population of Southern Alberta. Thirty perforations (0.45%) were identified and retrospectively reviewed. Results. Seven of these 30 patients were found to have guidewire perforations of the bile duct, 11 perforations were peri-ampullary, 3 duodenal, 1 esophageal, and 1 patient had a perforation of an afferent limb of a Billroth II anastomosis. In seven patients the location of the perforation could not be determined (unknown). All patients with guidewire perforations were recognized during ERCP, and all were managed medically. Of the 11 peri-ampullary perforations, 7 of these patients had a pre-cut sphincterotomy, 5 underwent surgery and 4 patients died. Delay in diagnosis occurred in all patients that died. Of the three duodenal perforations, all required operation and one patient died. Of the seven 'unknown' retroperitoneal perforations, two patients required surgery and there was no mortality. The patients with esophageal and afferent limb perforations both recovered uneventfully after surgery. Most patients who required surgery had retroperitoneal fluid seen on CT scanning.

CONCLUSIONS

We found that most guidewire perforations can be managed medically with little morbidity. Pre-cut sphincterotomy is a risk factor for perforation. Peri-ampullary and duodenal perforations have a high morbidity and mortality rate. In particular, retroperitoneal fluid collections on CT scans, delay in diagnosis and failure of medical therapy requiring salvage surgery are associated with poor outcomes. Early aggressive surgery may improve patient care.

Complications of endoscopic retrograde cholangiopancreatography: spectrum of abnormalities demonstrated with CT

Endoscopic retrograde cholangiopancreatography (ERCP) is an invasive procedure that is performed to diagnose and treat pancreatic and biliary disease. In approximately 5%-10% of cases, the procedure itself causes adverse events. Diagnosis and management of ERCP-induced complications are performed with clinical, laboratory, and radiologic procedures. Evaluation of the type and severity of the complication is necessary and is successfully performed with computed tomography (CT). The most common causes of post-ERCP pain are acute pancreatitis and duodenal perforation. In severe pancreatitis, the pancreas is enlarged and enhances heterogeneously at CT. Pancreatic enhancement is diminished in areas of glandular necrosis. In duodenal perforation, CT may reveal extraluminal air or fluid. CT findings of acute duodenal hemorrhage are duodenal wall thickening and a high-attenuation mass in the duodenal wall. In infection, the bile ducts can be dilated and the attenuation of the bile can be increased at CT. Abscesses appear as hypoattenuating masses with enhancing capsules. CT findings of stent migration are an atypical location of the stent and bowel impaction. Other complications of ERCP are those related to endoscopy and include esophageal, liver, and splenic injury.