Papillary injuries and duodenal perforation during endoscopic retrograde sphincterotomy (ERS): radiological findings

Management of iatrogenic perforation

Iatrogenic perforation of the gastrointestinal tract is a medical emergency and is inevitable. An endoscopist must maintain a high index of suspicion despite minimal or atypical symptoms and negative radiologic studies, because perforation is a complication with tremendous morbidity and mortality. The endoscopist must know how to manage this complication appropriately and to seek immediate surgical consultation. There is ongoing controversy about when a patient should undergo nonoperative or surgical therapy. An evidence-based approach to manage iatrogenic perforation is not possible. The trend in the modern era is to less invasive, nonoperative therapy, given advancements in ICU care and antibiotics. Laparoscopy or laparoscopic-assisted (minilaparotomy) surgery is also being increasingly used with outcomes comparable with conventional laparotomy. Experience and advancements in accessories have enabled endoscopic repair of iatrogenic perforation in many situations [84]. The management algorithms provided synthesize the pertinent literature into reasonable guidelines to follow. Ultimately, an individualized approach must be taken to manage the patient with an iatrogenic perforation.

Classification and management of perforations complicating endoscopic sphincterotomy

BACKGROUND

The management of perforations after endoscopic sphincterotomy (ES) is controversial. The purpose of this study was to analyze the treatments and outcome of patients with ES perforations.

METHODS

Between January 1994 and July 1998, in a series of 6040 endoscopic retrograde cholangiopancreatographies, 2874 (48%) ESs were performed: 40 patients (0.6%) with perforation were identified and retrospectively reviewed.

RESULTS

All patients (n = 14) with guidewire perforation (group I) were recognized early, managed medically, and discharged after a mean hospital stay of 3.5 days. Twenty of 22 patients with periampullary perforation (group II) were identified early; 18 patients (90%) had aggressive endoscopic drainage, and none required operation. Of the 2 patients identified late, 1 patient required operation and subsequently died. Mean hospital stay for this group was 8.5 days. Only 1 of 4 patients with duodenal perforations (group III) was identified early; all required operation; 1 patient died, and the mean hospital stay was 19.5 days.

CONCLUSIONS

ES perforation has 3 distinct types: guidewire, periampullary, and duodenal. Guidewire perforations are recognized early and resolve with medical treatment. Periampullary perforations diagnosed early respond to aggressive endoscopic drainage and medical treatment. Postsphincterotomy perforations diagnosed late (particularly duodenal) require surgical drainage, which carries a high morbidity and mortality rate.