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

Evaluation of ERCP-related perforation: a single-center retrospective study

Background

Endoscopic retrograde cholangiopancreatography (ERCP)-related perforation is a rare and serious adverse event. The aim of our study was to evaluate the risk factors and management of ERCP-related perforation, and to further determine the predictive factors associated with perforation outcome.

Methods

A total of 27,018 ERCP procedures performed at the First Affiliated Hospital of Nanchang University (Nanchang, China) between January 2007 and March 2022 were included in the investigation of ERCP-related perforation. Medical records and endoscopic data were extracted to analyse the risk factors, management, and clinical outcome of ERCP-related perforation.

Results

Seventy-six patients (0.28%) were identified as having experienced perforation following ERCP. Advanced age, Billroth II anatomy, precut sphincterotomy, and papillary balloon dilatation were significantly associated with ERCP-related perforation. Most patients with perforation (n = 65) were recognized immediately during ERCP whereas 11 were recognized later on. The delay in recognition primarily resulted from stent migration (n = 9). In addition, 12 patients experienced poor clinical outcome including death or hospice discharge (n = 3), ICU admission for >3 days (n = 6), and prolonged hospital stay for >1 month due to perforation (n = 3). Cancer and systemic inflammatory response syndrome (SIRS) are associated with a higher risk of poor outcome.

Conclusions

Advanced age, Billroth II anatomy, precut sphincterotomy, and balloon dilation increase the risk of ERCP-related perforation whereas cancer and SIRS independently predicted poor clinical outcome.

Exerting Forces and Wall Load during Duodenoscopy for ERCP: An Experimental Measurement in an Artificial Model

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is crucial to the treatment of biliopancreatic diseases with iatrogenic perforation as a potential complication. As of yet, the wall load during ERCP is unknown, as it is not directly measurable during an ERCP in patients.

METHODS

In a life-like, animal-free model, a sensor system consisting of five load cells was attached to the artificial intestines (sensors 1 + 2: pyloric canal-pyloric antrum, sensor 3: duodenal bulb, sensor 4: descending part of the duodenum, sensor 5: distal to the papilla). Measurements were made with five duodenoscopes (n = 4 reusable and n = 1 single use).

RESULTS

Fifteen standardized duodenoscopies were performed. Peak stresses were found at the antrum during the gastrointestinal transit (sensor 1 max. 8.95 N, sensor 2 max. 2.79 N). The load reduced from the proximal to the distal duodenum and the greatest load in the duodenum was discovered at the level of the papilla in 80.0% (sensor 3 max. 2.06 N).

CONCLUSIONS

For the first time, intraprocedural load measurements and exerting forces obtained during a duodenoscopy for ERCP in an artificial model were recorded. None of the tested duodenoscopes were classified as dangerous for patient safety.

Post-ERCP Complication Analysis of an Experienced Center

BACKGROUND/AIM

Post-ERCP pancreatitis (PEP), post-sphincterotomy bleeding (PSB), and Post-ERCP perforation are the most common complications of endoscopic retrograde cholangiopancreatography (ERCP). Identification of risk factors for post-ERCP complications is critical for postoperative follow-up. This study aimed to evaluate the most common post-ERCP complication risk factors in an experienced center.

METHODS/DESIGN

The sample consisted of 1288 patients with naive papillae. Demographic characteristics, patient-related risk factors, procedure-related risk factors and postoperative complications were recorded.

RESULTS

Patients had a mean age of 61.5±18.4 years. The prevalence of PEP, PSB, and post-ERCP perforation was 7.9%, 11.9%, and 0.5%, respectively. Among patient-related factors, female sex (OR 1.672 95% Cl 1.046 to 2.672) and narrowing of the choledochal diameter (OR 2.910 95% Cl 1.830 to 4.626) were associated with PEP. From procedure-related factors; precut sphincterotomy (OR 2.172 95% Cl 1.182 to 3.994), difficult cannulation (OR 5.110 95% Cl 2.731 to 9.560), pancreatic cannulation (OR 5.692 95% Cl 0.994 to 32.602) and postprocedure residual stone (OR 2.252 95% Cl 1.403 to 3.614) were found to be associated with PEP. The successful procedure (OR 0.378 95% Cl 0.204 to 0.699) had a protective effect on PEP. Choledocholithiasis indication (OR 3.594 95% Cl 1.444 to 8.942) and small papilla (OR 2.042 95% Cl 1.170 to 3.562) were associated with the development of PSB. Choledochal stenosis, periampullary-diverticulum, oral anticoagulant, and oral antiaggregant use were not associated with the development of PSB. Of the patients with post-ERCP perforation, 85.7% had difficult cannulation, 57.1% had precut sphincterotomy, and 28.6% had periampullary-diverticulum.

CONCLUSION

Female sex, biliary stricture, precut sphincterotomy, difficult cannulation, pancreatic cannulation, and postoperative residual stone were associated with PEP. Choledocholithiasis indication and the presence of small papilla were associated with PSB.

A scoping review on acute gastrointestinal surgical complications in immunocompromised pediatric patients

Background

Gastrointestinal complications are becoming increasingly more common and pose a significant risk on the health of children with compromised immunity caused by various etiologies such as chemotherapy and posttransplantation immunosuppression. We aim to review abdominal complications in immunocompromised children and their respective management.

Main body

This is a scoping review of the literature. PubMed, MEDLINE, Google Scholar, and Scopus libraries were searched for relevant articles. Extracted data included the etiologies of immunocompromised immunity, gastrointestinal and abdominal complications in immunocompromised children, diagnosis, and treatment of these pathologies. Examples of gastrointestinal complications in immunocompromised children include, but not limited to, neutropenic enterocolitis, acute appendicitis, bowel perforation, acalculous cholecystitis, and acute pancreatitis. Our literature review showed that bacterial and fungal infections are the major causes of exacerbation and mortality. The main cause of immunosuppression in children with neutropenic enterocolitis and acute pancreatitis is chemotherapy, and management of these pathologies using intravenous fluids, antibiotic therapy, and granulocyte-stimulating factors is the current standard of care. Surgical intervention is uncommon and reserved for complicated cases. That said, in acute appendicitis and bowel perforation, laparoscopy is the mainstay treatment. However, in systemic infections, nonsurgical interventions such as transfusion and bowel rest are the gold standard. As for acalculous cholecystitis, percutaneous cholecystectomy is superior to laparotomy and other surgical interventions.

Conclusion

Timely diagnosis and management of gastrointestinal complications in the immunocompromised children is key in reducing mortality and morbidity. Both surgical and nonsurgical interventions are needed and should be further studied in order to improve outcomes.

Classification und Treatment Algorithm of Small Bowel Perforations Based on a Ten-Year Retrospective Analysis

Background: Small bowel perforations are a rare diagnosis compared with esophageal, gastric, and colonic perforations. However, small bowel perforations can be fatal if left untreated. A classification of small bowel perforations or treatment recommendations do not exist to date. Methods: A retrospective, monocentric, code-related data analysis of patients with small bowel perforations was performed for the period of 2010 to 2019. Results: Over a 10-year period, 267 cases of small bowel perforation in 257 patients (50.2% male and 49.8% female; mean age of 60.28 years) were documented. Perforation’s localization was 5% duodenal, 38% jejunal, 39% ileal, and 18% undocumented. Eight etiologies were differentiated: iatrogenic (41.9%), ischemic (20.6%), malignant (18.9%), inflammatory (8.2%), diverticula-associated (4.5%), traumatic (4.5%), foreign-body-associated (1.9%), and cryptical (1.5%) perforations. Operative treatment combined with antibiotics was the most commonly used therapeutic approach (94.3%). The mortality rate was 14.23%, with highest rate for patients with ischemic perforations. Discussion: An algorithm for diagnostic and therapeutic steps was established. Furthermore, it was found that small bowel perforations are rare events with poor outcomes. Time to diagnosis and grade of underlying disease are the most essential parameters to predict perforation-associated complications.

Fully covered self-expandable metal stent for intraprocedural or late-diagnosed Type-II endoscopic retrograde cholangiopancreatography-related perforations

Background

Perforations related to endoscopic retrograde cholangiopancreatography (ERCP) are rare but life-threatening complications. The treatment of Type-II-periampullary perforations that develop during endoscopic sphincterotomy remains a topic of discussion. This study aimed to evaluate the usefulness of fully covered self-expanding metal stenting (FCSEMS) for treating Type-II perforations.

Methods

The files of all patients who underwent the ERCP procedures between January 2015 and October 2021 were retrospectively reviewed; patients with Stapher Type-II perforation were included in the current study. Patients with FCSEMS were classified into two groups: those who underwent FCSEMS and those who were conventionally followed up. Moreover, patients with FCSEMS were classified into two subgroups: those who underwent simultaneous stenting and those who underwent late stenting. Mortality, surgical intervention, percutaneous drainage, length of hospital stay, and inflammatory markers were all compared between the groups.

Results

Of the 9253 patients undergoing ERCP during the study period, 28 patients (0.3%) were found to have Type-II perforation. The mean age of these patients was 67.7 ± 3.9 years, and 15 patients were female. FCSEMS was performed on 19 patients, whereas 9 patients were on conventional follow-up. None of the patients developed mortality. In the conventional follow-up group, one patient required percutaneous drainage and one required surgical intervention. In contrast, none of the patients in the FCSEMS group required additional intervention. At a statistically significant level, the length of hospital stay was found to be shorter in the FCSEMS group. There was no difference in inflammatory markers between the two groups. In nine patients, FCSEMS was performed simultaneously, whereas, in ten patients, FCSEMS was performed later because they required a second intervention. These two subgroups did not differ in terms of outcomes.

Conclusions

FCSEMS is a safe and effective treatment modality for patients with Type-II perforation. Moreover, it can be safely used in patients whose perforations are diagnosed during the ERCP procedure and in patients whose diagnoses are made after the procedure.

A rare clinical presentation of third part duodenal perforation due to post-endoscopic retrograde cholangiopancreatography stent migration on advanced stage peri-ampullary tumor

As a diagnostic and therapeutic treatment role on malignant biliary obstruction, endoscopic retrograde cholangiopancreatography (ERCP) has already been used as a routine procedure, especially for palliative treatment on advanced stage peri‐ampullary tumor. This minimal invasive procedure has many early or late complications such as bleeding, post‐ERCP pancreatitis, perforation, cholangitis, and the rare duodenal perforation from the stent migration. The current review reported the incidence of stent erosion associated with duodenal perforation was only 1% for this palliative procedure. We report a 75 years old male patient with diffuse abdominal tenderness 7 days after palliative ERCP stent placement for malignant biliary obstruction, metal stent could not be placed, and plastic stent placement had been done. There was no post‐ERCP pancreatitis found during the first 24 h. The patient came to the emergency with clinical sign and symptoms of diffuse peritonitis; abdominal X‐ray found no free intraperitoneal air. Exploratory laparotomy was performed, and we found bile leak from the third part of perforated duodenal with 5 mm in diameter, plastic stent exposed from the perforation site, and no active bleeding. We performed primary suture of the duodenum, cholecysto‐enteric bypass, pyloric exclusion, gastro‐jejunostomy bypass, and braun anastomosis. Jejunostomy feeding has been placed. There were no postoperative cardiopulmonary complication, and the patient could tolerate well for oral intake and discharged from hospital at 10th postoperative day (POD). This rare duodenal perforation complication could happen even in plastic stent placement during the ERCP procedure, and early management was needed to gain the favorable outcome.

ERCP-related perforations: a population-based study of incidence, mortality, and risk factors

Background

Perforations related to endoscopic retrograde cholangiopancreatography (ERCP) are rare but feared adverse events with highly reported morbidity and mortality rates. The aim was to evaluate the incidence and outcome of ERCP-related perforations and to identify risk factors for death due to perforations in a population-based study.

Methods

Between May 2005 and December 2013, a total of 52,140 ERCPs were registered in GallRiks, a Swedish nationwide, population-based registry. A total of 376 (0.72%) were registered as perforations or extravasation of contrast during ERCP or as perforation in the 30-day follow-up. The patients with perforation were divided into fatal and non-fatal groups and analyzed for mortality risk factors. The case volume of centers and endoscopists were divided into the upper quartile (Q4) and the lower three quartile (Q1–3) groups. Furthermore, fatal group patients’ records were reviewed.

Results

Death within 90 days after ERCP-related perforations or at the index hospitalization occurred in 20% (75 out of 376) for all perforations and 0.1% (75 out of 52,140) for all ERCPs. The independent risk factors for death after perforation were malignancy (OR 11.2, 95% CI 5.8–21.6), age over 80 years (OR 3.8, 95% CI 2.0–7.4), and sphincterotomy in the pancreatic duct (OR 2.8, 95% CI 1.1–7.5). In Q4 centers, the mortality was similar with or without pancreatic duct sphincterotomy (14% vs. 13%, p = 1.0), but in Q1–3 centers mortality was higher (45% vs. 21%, p = 0.024).

Conclusions

ERCP-related perforations are severe adverse events with low incidence (0.7%) and high mortality rate up to 20%. Malignancy, age over 80 years, and sphincterotomy in the pancreatic duct increase the risk to die after a perforation. The risk of a fatal outcome in perforations after pancreatic duct sphincterotomy was reduced when occurred at a Q4-center. In the case of a complicated perforation a transfer to a Q4-center may be considered.