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Nadeem A, Husnain A, Zia MT, Ahmed A. Concurrent acute pancreatitis, pneumoperitoneum, pneumoretroperitoneum, and pneumomediastinum following ERCP-related perforation: A rare and insightful case study. Radiol Case Rep 2024; 19:1419-1423. [PMID: 38292793 PMCID: PMC10827534 DOI: 10.1016/j.radcr.2023.12.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Accepted: 12/27/2023] [Indexed: 02/01/2024] Open
Abstract
This case report details an extraordinary occurrence following endoscopic retrograde cholangiopancreatography (ERCP) in a 42-year-old woman. Despite ERCP being a commonly performed procedure, this case presented an unusual combination of acute pancreatitis, pneumoperitoneum, pneumoretroperitoneum, and pneumomediastinum resulting from a Stapfer type III perforation. The patient managed conservatively with nil per os, nasogastric tube, intravenous fluids, pain relief, and antibiotics, exhibited clinical improvement. Remarkably, resolution of complications occurred without surgical intervention. This case underscores the significance of vigilance in diagnosing and appropriately managing ERCP-related complications, contributing to the broader understanding of these rare events and fostering improved patient outcomes.
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Affiliation(s)
- Arsalan Nadeem
- Department of Medicine, Allama Iqbal Medical College, Lahore, Punjab, Pakistan
| | - Ali Husnain
- Department of Interventional Radiology, Northwestern Medicine, Chicago, IL, USA
| | - Muhammad Tayyab Zia
- Department of Radiology, Pakistan Kidney & Liver Institute and Research Centre, Lahore, Punjab, Pakistan
| | - Abdullah Ahmed
- Department of Medicine, Allama Iqbal Medical College, Lahore, Punjab, Pakistan
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Dufera RR, Berake TB, Maliakkal B. Post-endoscopic Retrograde Cholangiopancreatography Complications: A Case of Duodenal Perforation and Literature Review. Cureus 2023; 15:e40303. [PMID: 37313285 PMCID: PMC10259486 DOI: 10.7759/cureus.40303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2023] [Indexed: 06/15/2023] Open
Abstract
A duodenal perforation is a serious complication that can occur during endoscopic retrograde cholangiopancreatography (ERCP), particularly if it is associated with therapeutic endoscopic sphincterotomy. Therefore, it is crucial to identify and manage it early to achieve the best possible outcome. Conservative management may be attempted; however, surgical intervention is required if signs of sepsis or peritonitis are present. In this case report, we present the case of post-ERCP duodenal perforation in a 33-year-old female with sickle cell disease who presented on account of abdominal pain. The patient was diagnosed with post-ERCP duodenal perforation, type 4 according to the Stapfer classification. She was subsequently treated conservatively with intravenous antibiotics, bowel rest, and serial abdominal exams. The patient noted significant interval improvement in symptoms and was subsequently discharged home. The early detection and management of suspected complications of ERCP provide a critical prognostic value.
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Affiliation(s)
| | | | - Benedict Maliakkal
- Gastroenterology and Hepatology, Nashville General Hospital, Nashville, USA
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A case of endoscopic retrograde cholangiopancreatography-related main pancreatic duct perforation salvaged by endoscopic ultrasonography-guided pancreatic duct drainage. Clin J Gastroenterol 2022; 15:1179-1184. [DOI: 10.1007/s12328-022-01699-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 09/04/2022] [Indexed: 11/26/2022]
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Bozbiyik O, Cetin B, Gumus T, Tekin F, Uguz A. Fully covered self-expandable metal stent for intraprocedural or late-diagnosed Type-II endoscopic retrograde cholangiopancreatography-related perforations. BMC Gastroenterol 2022; 22:385. [PMID: 35965340 PMCID: PMC9375919 DOI: 10.1186/s12876-022-02466-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 08/01/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
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.
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Kokas B, Szijártó A, Farkas N, Ujváry M, Móri S, Kalocsai A, Szücs Á. Percutaneous transhepatic drainage is safe and effective in biliary obstruction-A single-center experience of 599 patients. PLoS One 2021; 16:e0260223. [PMID: 34793565 PMCID: PMC8601527 DOI: 10.1371/journal.pone.0260223] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 11/04/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Historically, surgical bilioenteric bypass was the only treatment option for extrahepatic bile duct obstruction, but with technological advancements, percutaneous transhepatic drainage (PTD) and endoscopic solutions were introduced as a less invasive alternative. Endoscopic methods may lead to a decreasing indication of PTD in the future, but today it is still the standard treatment method, especially in hilar obstructions. METHODS In our retrospective data analysis, we assessed technical success rate, reintervention rate, morbidity, mortality, and the learning curve of patients treated with PTD over 12 years in a tertiary referral center. RESULTS 599 patients were treated with 615 percutaneous interventions. 94.5% (566/599) technical success rate; 2.7% (16/599) reintervention rate were achieved. 111 minor and 22 major complications occurred including 1 case of death. In perihilar obstruction, cholangitis were significantly more frequent in cases where endoscopic retrograde cholangiopancreatography had also been performed prior to PTD compared to PTD alone, with 39 (18.2%) and 15 (10.5%) occurrences, respectively. DISCUSSION The results and especially the excellent success rates demonstrate that PTD is safe and effective, and it is appropriate for first choice in the treatment algorithm of perihilar stenosis. Ultimately, we concluded that PTD should be performed in experienced centers to achieve low mortality, morbidity, and high success rates.
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Affiliation(s)
- Bálint Kokas
- Department of Surgery, Transplantation and Gastroenterology, Semmelweis University, Budapest, Hungary
| | - Attila Szijártó
- Department of Surgery, Transplantation and Gastroenterology, Semmelweis University, Budapest, Hungary
| | - Nelli Farkas
- Institute of Bioanalysis, University of Pécs, Pécs, Hungary
| | - Miklós Ujváry
- Department of Surgery, Transplantation and Gastroenterology, Semmelweis University, Budapest, Hungary
| | - Szabolcs Móri
- Department of Surgery, Transplantation and Gastroenterology, Semmelweis University, Budapest, Hungary
| | - Adél Kalocsai
- Department of Surgery, Transplantation and Gastroenterology, Semmelweis University, Budapest, Hungary
| | - Ákos Szücs
- Department of Surgery, Transplantation and Gastroenterology, Semmelweis University, Budapest, Hungary
- * E-mail:
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KARAOĞULLARINDAN Ü. Tek Endoskopist Deneyimi; ERCP Sonuçları, Komplikasyonlar ve İlgili Faktörler. MUSTAFA KEMAL ÜNIVERSITESI TIP DERGISI 2021. [DOI: 10.17944/mkutfd.810551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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Zhu F, Guan Y, Wang J. Efficacy and safety of the rotatable sphincterotome during ERCP in patients with prior Billroth II gastrectomy (with videos). Surg Endosc 2021; 35:4849-4856. [PMID: 33733322 DOI: 10.1007/s00464-021-08417-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Accepted: 02/23/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Selective biliary cannulation (SBC) is currently accepted as the first challenge of endoscopic retrograde cholangiopancreatography (ERCP), especially in patients with altered anatomy such as Billroth II gastrectomy. A rotatable sphincterotome (RS) might be considered useful for guiding the directional axis of SBC. This study aimed to evaluate the efficacy and safety of RS for biliary cannulation in patients with prior Billroth II gastrectomy. METHODS This is a retrospective cohort study conducted to compare the efficacy and safety between RS (RS group) and conventional sphincterotome of pulling arciform knife (PAF, PAF group). The success rate of SBC and endoscopic sphincterotomy (EST) were evaluated in both the groups. Moreover, the outcomes of the procedure and adverse events were also compared between the two groups. RESULTS Eighty-six consecutive prior Billroth II gastrectomy patients who underwent ERCP with RS or PAF during the study period were enrolled. After excluding 7 patients, there were 41 patients in the RS group and 38 in the PAF group. The baseline characteristics were similar in both the groups. There was no significant difference in the clinical success rates of SBC in RS group (95.12%) versus PAF group (84.21%), (P = 0.1082). Successful SBC within 5 min was 87.80% in RS group and 23.68% in PAF group (P < 0.0001). The success rate of EST was 89.74% in RS group and 28.13% in PAF group (P < 0.0001). The incidence of post-ERCP pancreatitis (PEP) showed significant differences between RS (2.44%) and PAF groups (21.05%; P = 0.0061). CONCLUSIONS Although RS has comparable success rates of SBC over PAF in patients with prior Billroth II gastrectomy, RS has facilitated the procedure by increasing the success rate of EST and SBC within 5 min, and the incidence of PEP was lowered as well.
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Affiliation(s)
- Feng Zhu
- Department of Gastroenterology, Shanghai East Hospital, Tongji University School of Medicine, No. 150 Jimo Road, Pudong New District, Shanghai, 200120, China.
| | - Yaping Guan
- Department of Gastroenterology, Shanghai East Hospital, Tongji University School of Medicine, No. 150 Jimo Road, Pudong New District, Shanghai, 200120, China
| | - Jing Wang
- Department of Gastroenterology, Shanghai East Hospital, Tongji University School of Medicine, No. 150 Jimo Road, Pudong New District, Shanghai, 200120, China
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Varshney VK, Nayar R, Sreesanth KS, Soni S, Varshney B. Emergency Pancreatoduodenectomy for Ampullary Cancer Post-Iatrogenic Duodenal Perforation: No Option but to Strike. Cureus 2020; 12:e11384. [PMID: 33312785 PMCID: PMC7725210 DOI: 10.7759/cureus.11384] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Endoscopic retrograde cholangiography related duodenal perforation is an infrequent complication and associated with significant morbidity. The management of such perforations, especially in the setting of malignancy, is not standardized given the paucity of literature. We encountered a patient who was diagnosed with periampullary carcinoma and had a perforation in the duodenum during endoscopy. Emergency pancreatoduodenectomy (EPD) was performed considering it to be a resectable disease with minimal contamination. He had a prolonged hospital course due to surgical site infection and hepaticojejunostomy leak, however, which was managed successfully. At one year follow up, he is healthy with no evidence of recurrence. We conclude that EPD can be attempted for selected iatrogenic duodenal perforations with co-existent resectable malignancy in a stable patient. It may help to avoid the morbidity of a second surgery in the setting of a distorted anatomy and simultaneously preventing the probable upstaging of disease due to peritoneal seedling.
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Affiliation(s)
- Vaibhav K Varshney
- Surgical Gastroenterology, All India Institute of Medical Sciences, Jodhpur, Jodhpur, IND
| | - Raghav Nayar
- Surgical Gastroenterology, All India Institute of Medical Sciences, Jodhpur, Jodhpur, IND
| | - Kelu S Sreesanth
- Surgical Gastroenterology, All India Institute of Medical Sciences, Jodhpur, Jodhpur, IND
| | - Subhash Soni
- Surgical Gastroenterology, All India Institute of Medical Sciences, Jodhpur, Jodhpur, IND
| | - Bharti Varshney
- Pathology, All India Institute of Medical Sciences, Jodhpur, Jodhpur, IND
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A comparative study of side-viewing duodenoscope and forward-viewing gastroscope to perform endoscopic retrograde cholangiopancreatography in patients with Billroth II gastrectomy. Surg Endosc 2020; 35:4222-4230. [PMID: 32860133 DOI: 10.1007/s00464-020-07904-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Accepted: 08/17/2020] [Indexed: 01/15/2023]
Abstract
BACKGROUND/AIM Endoscopic retrograde cholangiopancreatography (ERCP) in patients with Billroth II gastrectomy is a difficult procedure. Although different endoscopes are used in these patients, comparative studies are limited. The aim of this study was to assess the efficacy and the safety of the forward-viewing gastroscope compared with the side-viewing duodenoscope. MATERIALS AND METHODS This study was conducted on 75 Billroth II gastrectomy patients who underwent ERCP by the same experienced endoscopist. Procedures were performed using side-viewing duodenoscope in the first 41 patients and forward-viewing gastroscope in the subsequent 34 patients. The success and complication rates of ERCP were compared between the two groups. RESULTS Afferent loop intubation was achieved in 39 patients (95.1%) in the side-viewing duodenoscope group and in 34 patients (100%) in the forward-viewing gastroscope group (P = 0.49). The rates of reaching the papilla was 70.7% (n = 29) and 91.1% (n = 31), respectively (P = 0.06). Cannulation success rate after reaching the papilla was 100% in the side-viewing duodenoscope group and 90.3% in the forward-viewing gastroscope group. In the side-viewing duodenoscope group, 11 patients underwent sphincterotomy (EST), 14 patients underwent both EST and endoscopic papillary balloon dilatation (EPBD), and 4 patients underwent only EPBD. All but one patients in the forward-viewing gastroscope group underwent EPBD without EST. The technical and the clinical success rate did not statistically differ between the groups (70.7% vs. 82.3%, 68.3% vs. 79.4%, respectively). Adverse events included jejunal perforation in one patient (2.4%) in the side-viewing duodenoscope group, and pancreatitis in one patient (2.9%) in the forward-viewing gastroscope group (P > 0.05). CONCLUSION This study indicates that forward-viewing gastroscope is as effective as side-viewing duodenoscope for ERCP in patients with Billroth II gastrectomy. Furthermore, EPBD without prior EST appears to be a safe and effective procedure in these patients.
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Wang X, Qu J, Li K. Duodenal perforations secondary to a migrated biliary plastic stent successfully treated by endoscope: case-report and review of the literature. BMC Gastroenterol 2020; 20:149. [PMID: 32398025 PMCID: PMC7216602 DOI: 10.1186/s12876-020-01294-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 05/05/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Endoscopic retrograde biliary drainage (ERBD) is the most frequently performed procedure for treating benign or malignant biliary obstruction. Although duodenal perforations secondary to the biliary plastic stent are quite rare, they can be life-threatening. The treatment strategies for such perforations are diverse and continue to be debated. CASE PRESENTATION We report three cases of duodenal perforation due to the migration of biliary plastic stents that were successfully managed using an endoscope. The three patients were admitted on complaints of abdominal pain after they underwent ERBD. Abdominal computerized tomography (CT) revealed migration of the biliary plastic stents and perforation of the duodenum. Endoscopy was immediately performed, and perforation was confirmed. All migrated stents were successfully extracted endoscopically by using snares. In two of the three cases, the duodenal defects were successfully closed with haemostatic clips after stent retrieval, and subsequently, endoscopic nasobiliary drainage tubes were inserted. After the endoscopy and medical treatment, all three patients recovered completely. CONCLUSIONS Duodenal perforations due to the migration of biliary stents are rare, and the treatment strategies remain controversial. Our cases and cases in the literature demonstrate that abdominal CT is the preferred method of examination for such perforations, and endoscopic management is appropriate as a first-line treatment approach.
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Affiliation(s)
- Xiaopeng Wang
- Department of Biliary- Pancreatic Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, No. 160, Pujian Road, Pudong New Area, Shanghai, 200127, China
| | - Junwen Qu
- Department of Biliary- Pancreatic Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, No. 160, Pujian Road, Pudong New Area, Shanghai, 200127, China
| | - Kewei Li
- Department of Biliary- Pancreatic Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, No. 160, Pujian Road, Pudong New Area, Shanghai, 200127, China.
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Fully Covered Self-Expandable Metal Stens eliminate surgical repair requirement in both endoscopic sphincterotomy and precut sphincterotomy-related perforation (with video). Eur J Gastroenterol Hepatol 2020; 32:557-562. [PMID: 31851096 DOI: 10.1097/meg.0000000000001633] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Endoscopic retrograde cholangiopancreatography (ERCP)-related perforations occur in 0.3-0.6% of patients. The treatment of retroperitoneal paravaterian perforations (type II), which develop during endoscopic sphincterotomy or precut sphincterotomy, remains a matter of debate. We aimed to evaluate the efficacy of fully covered self expandable metal stent (Fc-SEMS) placement in the treatment of type II perforations. METHODS The study was conducted in a tertiary ERCP reference center of Turkey between December 2013 and June 2016. Patients with type II ERCP-related perforation constituted the study group. Type II perforations were treated by insertion of an Fc-SEMS (10 mm × 60 mm) during the ERCP procedure or intraoperatively by surgery-endoscopy rendezvous technique, if biliary cannulation could not be achieved. RESULTS A total of 2689 ERCPs were performed. ERCP-related perforation was observed in 12 procedures (0.4%). Eight patients had Stapfer type II perforations, which developed during endoscopic sphincterotomy in seven patients and precut sphincterotomy in one patient. Fc-SEMSs were inserted during the ERCP procedure in seven patients and intraoperatively by surgery-endoscopy rendezvous technique in one patient. None of the patients developed fever, hemodynamic instability, or peritoneal signs. Stents were removed after a median duration of 9 (3-14) days. All of the patients were uneventfully discharged after an average hospital length of stay of median 5 (1-9) days. CONCLUSION Fc-SEMSs are highly effective in the nonoperative treatment of type II perforations and their intraoperative insertion in patients with unsuccessful cannulation may facilitate surgery by eliminating the need for duodenum repair surgery.
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Selman K, Sodhi S, Filippone L, Nyce A. Pneumoretroperitoneum after Blunt Trauma. J Emerg Med 2020; 58:810-812. [PMID: 32354593 DOI: 10.1016/j.jemermed.2020.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 02/03/2020] [Accepted: 03/18/2020] [Indexed: 06/11/2023]
Affiliation(s)
| | - Sarab Sodhi
- Cooper University Hospital, Camden, New Jersey
| | | | - Andrew Nyce
- Cooper University Hospital, Camden, New Jersey
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13
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Management of bile duct stones at cholecystectomy: an Australian single-centre experience over 2 years. Surg Endosc 2020; 35:1247-1253. [PMID: 32152676 DOI: 10.1007/s00464-020-07495-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 03/02/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Bile duct stones with an intact gallbladder can be treated with either bile duct exploration at cholecystectomy or endoscopic retrograde cholangiopancreatography (ERCP) before or after cholecystectomy. The aim of this study was to evaluate the management of bile duct stones at cholecystectomy at our institution. We also aimed to identify risk factors for failure of ductal clearance in our series. METHODS A retrospective review of 690 laparoscopic cholecystectomies over a 2-year period was performed. Patients who underwent laparoscopic bile duct exploration formed the study population. RESULTS Of 69 patients with suspected bile duct stones at cholecystectomy 67 (97%) patients underwent laparoscopic bile duct exploration upfront. Complete ductal clearance was achieved in 52 (78%) patients. Postoperative complications (10/67, 15%) included postoperative bleeding (2/67, 3%), bile leak (1/67, 1%), and superficial wound infection (1/67, 1%). There was no mortality. The mean operative time was 126 min and the median length of stay was 2 (1-4) days. A wider common bile duct (CBD) (≥ 8 mm) increased the risk of failed ductal clearance (OR 4.50; 95% confidence interval (CI) 1.15-19.23). CONCLUSION This study found that laparoscopic bile duct exploration can effectively and safely treat bile duct stones suspected at cholecystectomy.
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Endoscopic Retrograde Cholangiopancreatography-Related Complications and Their Management Strategies: A "Scoping" Literature Review. Dig Dis Sci 2020; 65:361-375. [PMID: 31792671 DOI: 10.1007/s10620-019-05970-3] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 11/16/2019] [Indexed: 12/12/2022]
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is a well-known procedure with both diagnostic and therapeutic utilities in managing pancreaticobiliary conditions. With the advancements of endoscopic techniques, ERCP has become a relatively safe and effective procedure. However, as ERCP is increasingly being utilized for different advanced techniques, newer complications have been noticed. Post-ERCP complications are known, and mostly include pancreatitis, infection, hemorrhage, and perforation. The risks of these complications vary depending on several factors, such as patient selection, endoscopist's skills, and the difficulties involved during the procedure. This review discusses post-ERCP complications and management strategies with new and evolving concepts.
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ERCP-related perforations: a population-based study of incidence, mortality, and risk factors. Surg Endosc 2019; 34:1939-1947. [PMID: 31559577 PMCID: PMC7113211 DOI: 10.1007/s00464-019-06966-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Accepted: 07/01/2019] [Indexed: 02/06/2023]
Abstract
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.
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Sugimoto M, Takagi T, Suzuki R, Konno N, Asama H, Sato Y, Irie H, Watanabe K, Nakamura J, Kikuchi H, Takasumi M, Hashimoto M, Hikichi T, Ohira H. Prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis using pancreatic stents: A review of efficacy, diameter and length. World J Meta-Anal 2019; 7:259-268. [DOI: 10.13105/wjma.v7.i6.259] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Revised: 06/02/2019] [Accepted: 06/10/2019] [Indexed: 02/06/2023] Open
Abstract
Although endoscopic retrograde cholangiopancreatography (ERCP) is an important procedure for the diagnosis and treatment of pancreaticobiliary diseases, post-ERCP pancreatitis (PEP) is the most frequent adverse event that can sometimes be fatal. However, prophylactic pancreatic stent (PS) insertion has been performed to prevent PEP in high-risk patients. In some randomized controlled trials (RCTs) and meta-analyses, the efficacy of prophylactic PS insertion has been shown to prevent PEP. In addition, several types of stents have been used to decrease PEP. In this review, we introduce the details of these RCTs and meta-analyses and reveal the specifications for stent placement, for example, the stent diameter and length and the pancreatic region into which the stent should be inserted.
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Affiliation(s)
- Mitsuru Sugimoto
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima 9601247, Japan
| | - Tadayuki Takagi
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima 9601247, Japan
| | - Rei Suzuki
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima 9601247, Japan
| | - Naoki Konno
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima 9601247, Japan
| | - Hiroyuki Asama
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima 9601247, Japan
| | - Yuki Sato
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima 9601247, Japan
| | - Hiroki Irie
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima 9601247, Japan
| | - Ko Watanabe
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima 9601247, Japan
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima 9601295, Japan
| | - Jun Nakamura
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima 9601247, Japan
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima 9601295, Japan
| | - Hitomi Kikuchi
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima 9601247, Japan
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima 9601295, Japan
| | - Mika Takasumi
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima 9601247, Japan
| | - Minami Hashimoto
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima 9601247, Japan
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima 9601295, Japan
| | - Takuto Hikichi
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima 9601295, Japan
| | - Hiromasa Ohira
- Department of Gastroenterology, Fukushima Medical University, School of Medicine, Fukushima 9601247, Japan
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Evans N, Buxbaum JL. Endoscopic treatment of ERCP-related duodenal perforation. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2019. [DOI: 10.1016/j.tgie.2019.04.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Niu DG, Huang Q, Yang F, Tian WL, Zhao YZ. Role of Double-Lumen Irrigation-Suction Tube Drainage in Severe Intra-Abdominal Infection Induced by Endoscopic Sphincterotomy– Related Perforation. Am Surg 2019. [DOI: 10.1177/000313481908500428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This study aimed to assess the efficacy of double-lumen irrigation-suction tube (DLIST) in treating severe intra-abdominal infection (SIAI) induced by endoscopic sphincterotomy–related perforation (EST-rP). We enrolled 34 consecutive patients who had been transferred to our hospital with SIAI induced by EST-rP from January 2000 to June 2018. Then they were assigned into two groups based on whether or not rescue surgery had been performed: failed nonoperative treatment group (n = 9) and failed rescue surgery treatment group (n = 25). All 34 patients received DLIST for positive draining by surgery in our hospital. Data collection included demographics, indication for endoscopic retrograde cholangiopancreatography, time to rescue surgery, surgical procedure, surgical success rate, complications, hospital stay, and postoperative outcome. The research enrolled 34 patients (ages 27–79 years, mean of 57.8 ± 12.1 years). There were no significant differences in age and gender between two groups ( P > 0.05). After being admitted, they were diagnosed with sepsis induced by SIAI (Sequential Organ Failure Assessment score range of 2–6, mean of 3.6 ± 0.95). The time from endoscopic retrograde cholangiopancreatography to rescue surgery was 12 to 336 hours (mean of 73.7 ± 72.2 hours); overall hospital stay was 15 to 405 (mean of 127.5 ± 81.5) days. The hospital stay was significantly longer in the failed rescue surgery group than that of the failed nonoperative treatment group ( P < 0.05). The overall mortality rate was 11.8 per cent (4/34). The mortality rate was 16 per cent (4/25) and 0 per cent (0/9), respectively. As a modified suction technology, DLIST placement can effectively treat SIAI induced by EST-rP and lower the mortality rate of rescue surgery treatment.
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Affiliation(s)
- Dong-Guang Niu
- Department of General Surgery, Jinling Clinical College of Nanjing Medical University, Nanjing, China
| | - Qian Huang
- Department of General Surgery, Jinling Clinical College of Nanjing Medical University, Nanjing, China
| | - Fan Yang
- Department of General Surgery, Jinling Clinical College of Nanjing Medical University, Nanjing, China
| | - Wei-Liang Tian
- Department of General Surgery, Jinling Clinical College of Nanjing Medical University, Nanjing, China
| | - Yun-Zhao Zhao
- Department of General Surgery, Jinling Clinical College of Nanjing Medical University, Nanjing, China
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19
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Bai Y, Li DF, Wang SL, Zhao SB, Ma SR, Zhang ST, Li ZS. Chinese expert consensus on perioperative medications for endoscopic retrograde cholangiopancreatography (ERCP). J Dig Dis 2019; 20:103-113. [PMID: 30604509 DOI: 10.1111/1751-2980.12699] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 12/22/2018] [Accepted: 01/02/2019] [Indexed: 02/06/2023]
Affiliation(s)
- Yu Bai
- Department of Gastroenterology, Changhai Hospital, The Naval Medical University (Second Military Medical University), Shanghai, China
| | - De Feng Li
- Department of Gastroenterology, Shenzhen People's Hospital (Second Clinical Medical College of Jinan University, Shenzhen, Guangdong Province, China
| | - Shu Ling Wang
- Department of Gastroenterology, Changhai Hospital, The Naval Medical University (Second Military Medical University), Shanghai, China
| | - Sheng Bing Zhao
- Department of Gastroenterology, Changhai Hospital, The Naval Medical University (Second Military Medical University), Shanghai, China
| | - Shu Ren Ma
- Department of Gastroenterology, The General Hospital of Northern Theater Command, Shenyang, Liaoning Province, China
| | - Shu Tian Zhang
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Zhao Shen Li
- Department of Gastroenterology, Changhai Hospital, The Naval Medical University (Second Military Medical University), Shanghai, China
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Jiménez Cubedo E, López Monclús J, Lucena de la Poza JL, González Alcolea N, Calvo Espino P, García Pavia A, Sánchez Turrión V. Review of duodenal perforations after endoscopic retrograde cholangiopancreatography in Hospital Puerta de Hierro from 1999 to 2014. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2018; 110:515-519. [PMID: 29667417 DOI: 10.17235/reed.2018.5255/2017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
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.
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Affiliation(s)
| | | | | | - Natalia González Alcolea
- Cirugía General y del Aparato Digestivo, Hospital Universitario Puerta de Hierro Majadahonda, España
| | - Pablo Calvo Espino
- Cirugía General y Aparato Digestivo, Hospital Universitario Puerta de Hierro Majadahond, España
| | | | - Victor Sánchez Turrión
- Cirugía General y del Aparato Digestivo, Hospital Universitario Puerta de Hierro Majadahonda
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Tringali A, Pizzicannella M, Andrisani G, Cintolo M, Hassan C, Adler D, Dioscoridi L, Pandolfi M, Mutignani M, Di Matteo F. Temporary FC-SEMS for type II ERCP-related perforations: a case series from two referral centers and review of the literature<sup/>. Scand J Gastroenterol 2018; 53:760-767. [PMID: 29688094 DOI: 10.1080/00365521.2018.1458894] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIM Some case reports have shown that fully covered self-expandable metal stents (FC-SEMS) are effective in cases of Stapfer Type II perforation as rescue treatment. The aim of the study was to assess the efficacy and safety of temporary placement of FC-SEMS as primary treatment for Type II perforations and review the literature regarding the use of FC-SEMS in this setting. PATIENTS AND METHOD Retrospective analysis of consecutive patients with Type II perforation treated with immediate placement of FC-SEMS. Primary outcomes were need for surgery and mortality rate. Secondary outcomes were complications, technical and clinical success, time to post-operative feeding, length of the hospitalization and time to stent removal. RESULTS Overall, 18 consecutive patients were enrolled (median age 71.5). All patients were treated with FC-SEMS (6-10 mm, 4-8 cm long). In all patients, there were no need for surgery, and no patient died. Technical and clinical success were achieved both in 100% of cases. The median time to stent removal was 43 (2-105) days. The median hospital stay was of 10 (4-21) days. Median time to post-operative feeding was 4 days (2-15). CONCLUSION FC-SEMS placement could be a safe and effective treatment in Type II perforations and represent a valuable development and innovation of conservative treatment.
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Affiliation(s)
- Alberto Tringali
- a Endoscopy Unit , Azienda Socio Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda , Milan , Italy
| | | | | | - Marcello Cintolo
- a Endoscopy Unit , Azienda Socio Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda , Milan , Italy
| | - Cesare Hassan
- c Endoscopy Unit , Nuovo Regina Margherita Hospital , Rome , Italy
| | - Douglas Adler
- d Division of Gastroenterology and Hepatology , University of Utah Hospital , Salt Lake City , UT , USA
| | - Lorenzo Dioscoridi
- a Endoscopy Unit , Azienda Socio Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda , Milan , Italy
| | - Monica Pandolfi
- b Endoscopy Unit , Universita' Campus Bio-Medico di Roma , Roma , Italy
| | - Massimiliano Mutignani
- a Endoscopy Unit , Azienda Socio Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda , Milan , Italy
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Bill JG, Smith Z, Brancheck J, Elsner J, Hobbs P, Lang GD, Early DS, Das K, Hollander T, Doyle MBM, Fields RC, Hawkins WG, Strasberg SM, Hammill C, Chapman WC, Edmundowicz S, Mullady DK, Kushnir VM. The importance of early recognition in management of ERCP-related perforations. Surg Endosc 2018; 32:4841-4849. [PMID: 29770887 DOI: 10.1007/s00464-018-6235-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 05/09/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Iatrogenic perforations related to endoscopic retrograde cholangiopancreatography (ERCP) are rare events, carrying with it a mortality of up to 8%. Given the rarity of this adverse event, there remains limited data and continued uncertainties when choosing therapeutic strategies. Our aims were to evaluate the management of ERCP-related perforations and compare outcomes based on timing of recognition. METHODS The endoscopic databases of two tertiary care centers were interrogated to identify consecutive adult patients who sustained ERCP-related perforation over a 10-year period from 2006 to 2016. Electronic medical records were reviewed to extract demographic data, perforation type, management strategies, clinical data, and patient outcomes. RESULTS 14,045 ERCP's were performed during our 10-year study period. Sixty-three patients (average age 62.3 ± 2.38 years, 76% female) with ERCP-related perforations were included. Stapfer I perforations were found in 14 (22.2%) patients, Stapfer II in 24 (38.1%), and Stapfer III and IV perforations were identified in 16 (25.4%) and 9 (14.28%), respectively. Forty-seven (74.6%) perforations were recognized immediately during the ERCP, whereas 16 (25.4%) were recognized late. Endoscopic therapy was attempted in 35 patients in whom perforations were identified immediately, and was technically successful in 33 (94.3%). In all, 4 (1 immediate/ 3 delayed) patients required percutaneous drainage and 9 (5 immediate/ 4 delayed) surgery. Length of hospital stay, ICU admission were significantly shorter and incidence of SIRS was significantly lower when perforation was recognized immediately. CONCLUSIONS Immediate recognition of ERCP-related perforations leads to more favorable patient outcomes; with lower incidence of SIRS, less need for ICU level care, and shorter hospital stay.
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Affiliation(s)
- Jason G Bill
- Division of Gastroenterology, Washington University School of Medicine, 660 S. Euclid Ave, Campus Box 8124, St. Louis, MO, 63110, USA.
| | - Zachary Smith
- Division of Gastroenterology, Washington University School of Medicine, 660 S. Euclid Ave, Campus Box 8124, St. Louis, MO, 63110, USA
- Division of Gastroenterology and Liver Disease, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Joseph Brancheck
- Division of Gastroenterology, Washington University School of Medicine, 660 S. Euclid Ave, Campus Box 8124, St. Louis, MO, 63110, USA
| | - Jeffrey Elsner
- Division of Gastroenterology, Washington University School of Medicine, 660 S. Euclid Ave, Campus Box 8124, St. Louis, MO, 63110, USA
| | - Paul Hobbs
- Division of Gastroenterology, Washington University School of Medicine, 660 S. Euclid Ave, Campus Box 8124, St. Louis, MO, 63110, USA
| | - Gabriel D Lang
- Division of Gastroenterology, Washington University School of Medicine, 660 S. Euclid Ave, Campus Box 8124, St. Louis, MO, 63110, USA
| | - Dayna S Early
- Division of Gastroenterology, Washington University School of Medicine, 660 S. Euclid Ave, Campus Box 8124, St. Louis, MO, 63110, USA
| | - Koushik Das
- Division of Gastroenterology, Washington University School of Medicine, 660 S. Euclid Ave, Campus Box 8124, St. Louis, MO, 63110, USA
| | - Thomas Hollander
- Division of Gastroenterology, Washington University School of Medicine, 660 S. Euclid Ave, Campus Box 8124, St. Louis, MO, 63110, USA
| | | | - Ryan C Fields
- Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - William G Hawkins
- Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Steven M Strasberg
- Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Chet Hammill
- Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - William C Chapman
- Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Steven Edmundowicz
- Division of Gastroenterology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Daniel K Mullady
- Division of Gastroenterology, Washington University School of Medicine, 660 S. Euclid Ave, Campus Box 8124, St. Louis, MO, 63110, USA
| | - Vladimir M Kushnir
- Division of Gastroenterology, Washington University School of Medicine, 660 S. Euclid Ave, Campus Box 8124, St. Louis, MO, 63110, USA
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A Case of Unresolved and Worsening Retroperitoneal Abscess. Case Rep Gastrointest Med 2018; 2018:6740734. [PMID: 29593917 PMCID: PMC5822869 DOI: 10.1155/2018/6740734] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 10/30/2017] [Accepted: 11/02/2017] [Indexed: 12/22/2022] Open
Abstract
Retroperitoneal abscess is a rare condition which is difficult to diagnose and treat because of its insidious onset. Herein, we present a case of retroperitoneal abscess secondary to a perforation that occurred during an ERCP. A 54-year-old female patient was admitted to an outside hospital with gallstone pancreatitis and underwent ERCP with sphincterotomy followed by laparoscopic cholecystectomy. An abdominal CT scan was performed at the outside hospital 10 days later for worsening abdominal pain which showed multiple loculated pockets in the right upper and lower quadrant. Her condition improved after IV antibiotics and percutaneous drainage. Her symptoms recurred a month later and she presented to our hospital. Repeat abdominal CT scan at our hospital revealed recurrence of her abscesses. Multiple drains were placed and the abscess cavity was washed out without much improvement. EGD revealed a small mucosal defect in the distal portion of the duodenal bulb which was closed successfully using an over-the-scope clip. Repeat CT scan after 8 weeks from the endoscopic closure showed near complete resolution of the abscess. ERCP-associated perforation is a rare complication and can be challenging to diagnose and treat; prompt recognition is mandatory for favorable prognosis. Our patient was managed successfully via nonsurgical approach.
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Ryozawa S, Itoi T, Katanuma A, Okabe Y, Kato H, Horaguchi J, Fujita N, Yasuda K, Tsuyuguchi T, Fujimoto K. Japan Gastroenterological Endoscopy Society guidelines for endoscopic sphincterotomy. Dig Endosc 2018; 30:149-173. [PMID: 29247546 DOI: 10.1111/den.13001] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 12/10/2017] [Indexed: 02/06/2023]
Abstract
The Japan Gastroenterological Endoscopy Society (JGES) has recently compiled guidelines for endoscopic sphincterotomy (EST) using evidence-based methods. Content regarding actual clinical practice, including detailed endoscopic procedures, instruments, device types and usage, has already been published by the JGES postgraduate education committee in May 2015 and, thus, in these guidelines we avoided duplicating such content as much as possible. The guidelines do not address pancreatic sphincterotomy, endoscopic papillary balloon dilation (EPBD), and endoscopic papillary large balloon dilation (EPLBD). The guidelines for EPLBD are planned to be developed separately. The evidence level in this field is often low and, in many instances, strong recommendation has to be determined on the basis of expert consensus. At this point in time, the guidelines are divided into six items including indications, techniques, specific cases, adverse events, outcomes, and postoperative follow up.
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Affiliation(s)
- Shomei Ryozawa
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Takao Itoi
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Akio Katanuma
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | | | - Hironari Kato
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Jun Horaguchi
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Naotaka Fujita
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Kenjiro Yasuda
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
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McCarthy C, Butros S, Dawson S, Arellano R. Image-guided percutaneous management of duodenal perforation following endoscopic retrograde cholangiopancreatography (ERCP): assessment of efficacy and safety. Clin Radiol 2018; 73:319.e9-319.e15. [DOI: 10.1016/j.crad.2017.09.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2017] [Revised: 09/21/2017] [Accepted: 09/29/2017] [Indexed: 02/07/2023]
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Khan MS, Jamal F, Khan Z, Tiwari A, Simo H, Sharma H. ERCP-Related Duodenal Perforation Presenting as Pneumoscrotum. Case Rep Gastroenterol 2018. [PMID: 29515338 PMCID: PMC5836279 DOI: 10.1159/000485557] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Duodenal perforation is a rare but life-threatening complication of endoscopic retrograde cholangiopancreatography (ERCP). Duodenal perforation can cause air leak into the extraperitoneal space. In rare instances, the air in the extraperitoneal space could dissect along the fascial planes of the abdomen to reach scrotum, leading to pneumoscrotum. We present the case of a 35-year-old male patient who developed scrotal pain and swelling following ERCP. He was found to have extensive pneumoscrotum, pneumoretroperitoneum, pneumomediastinum, and subcutaneous emphysema. The patient was diagnosed with retroperitoneal duodenal perforation. He was managed conservatively with close monitoring and supportive care.
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Affiliation(s)
- Mohammad Saud Khan
- aDepartment of Internal Medicine, University of Toledo Medical Center, Toledo, OH, USA
| | - Faisal Jamal
- bDepartment of Radiology, Apollo Hospitals, New Delhi, India
| | - Zubair Khan
- aDepartment of Internal Medicine, University of Toledo Medical Center, Toledo, OH, USA
| | - Abhinav Tiwari
- aDepartment of Internal Medicine, University of Toledo Medical Center, Toledo, OH, USA
| | - Hermann Simo
- aDepartment of Internal Medicine, University of Toledo Medical Center, Toledo, OH, USA
| | - Himani Sharma
- aDepartment of Internal Medicine, University of Toledo Medical Center, Toledo, OH, USA
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Tringali A, Cintolo M, Hassan C, Adler DG, Mutignani M. Type II-III ERCP-related perforations treated with temporary Fully covered self-expandable stents. Dig Liver Dis 2017; 49:1169-1170. [PMID: 28734775 DOI: 10.1016/j.dld.2017.06.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 06/13/2017] [Indexed: 12/11/2022]
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Cirocchi R, Kelly MD, Griffiths EA, Tabola R, Sartelli M, Carlini L, Ghersi S, Di Saverio S. A systematic review of the management and outcome of ERCP related duodenal perforations using a standardized classification system. Surgeon 2017; 15:379-387. [PMID: 28619547 DOI: 10.1016/j.surge.2017.05.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 05/16/2017] [Indexed: 02/06/2023]
Abstract
INTRODUCTION The incidence of duodenal perforation after ERCP ranges from 0.09% to 1.67% and mortality up to 8%. METHODS This systematic review was registered in Prospective Register of Systematic Reviews, PROSPERO. Stapfer classification of ERCP-related duodenal perforations was used. RESULTS The systematic search yielded 259 articles. Most frequent post-ERCP perforation was Stapfer type II (58.4%), type I second most frequent perforation (17.8%) followed by Stapfer type III in 13.2% and type IV in 10.6%. Rate of NOM was lowest in Stapfer type I perforations (13%), moderate in type III lesions (58.1%) and high in other types of perforations (84.2% in type II and 84.6% in IV). In patients underwent early surgical treatment (<24 h from ERCP) the most frequent operation was simple duodenal suture with or without omentopexy (93.7%). In patients undergoing late surgical treatment (>24 h from ERCP) interventions performed were more complex. In type I lesions post-operative mortality rate was higher in patients underwent late operation (>24 h). In type I lesions, failure of NOM occurred in 42.8% of patients. In type II failure of NOM occurred in 28.9% of patients and in type III there was failure of NOM in only 11.1%, none in type IV. Postoperative mortality after NOM failure was 75% in type I, 22.5% in type II and none died after surgical treatment for failure of NOM in type III perforations. CONCLUSIONS This systematic review showed that in patients with Stapfer type I lesions, early surgical treatment gives better results, however the opposite seems true in Stapfer III and IV lesions.
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Affiliation(s)
- Roberto Cirocchi
- Department of General and Oncologic Surgery, University of Perugia, Terni, Italy.
| | | | - Ewen A Griffiths
- Department of Gastrointestinal and General Surgery, Medical University of Wrocław, Wrocław, Poland.
| | - Renata Tabola
- Department of Upper Gastrointestinal Surgery, University Hospitals Birmingham NHS Foundation Trust, Edgbaston, Birmingham B15 2WB, United Kingdom.
| | | | - Luigi Carlini
- Section of Legal Medicine, University of Perugia, Terni, Italy.
| | - Stefania Ghersi
- Unit of Gastroenterology and Digestive Endoscopy, AUSL Bologna, Bellaria-Maggiore Hospital, Bologna, Italy.
| | - Salomone Di Saverio
- Emergency Surgery and Trauma Surgery Unit, Maggiore Hospital Trauma Center, Bologna, Italy.
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29
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Guerra F, Giuliani G, Coletta D, Bonapasta SA, Levi Sandri GB. Clinical outcomes of ERCP-related retroperitoneal perforations. Hepatobiliary Pancreat Dis Int 2017; 16:160-163. [PMID: 28381379 DOI: 10.1016/s1499-3872(16)60106-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP)-related perforations represent rare but often severe conditions. While lesions with intraperitoneal perforation have an almost imperative indication to surgery, whether or not to manage retroperitoneal perforations surgically is still an area of debate. The aim of the present work was to review the available clinical evidence on the operatively and medically treated ERCP-related retroperitoneal perforations. From MEDLINE/PubMed databases 137 patients with retroperitoneal perforation were included from 12 studies that met the selection criteria for data investigation and analysis. Twenty-four patients were treated by prompt surgery; 113 were primarily managed conservatively and about 20% of these patients required surgery subsequently. Overall, the morbidity and mortality were 15.4% and 6.6%, respectively. Although most patients with retroperitoneal perforation may benefit from a non-operative management, a considerable number of patients fail to respond to medical treatment and require surgery afterwards. Identifying those patients who are at highest risk of poor outcome after conservative treatment should be considered a research priority.
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Affiliation(s)
- Francesco Guerra
- Department of Surgery, Umberto I University Hospital, Rome, Italy.
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30
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Tarnasky PR, Kedia P. Endoscopic retrograde cholangiopancreatography complications: Techniques to reduce risk and management strategies. GASTROINTESTINAL INTERVENTION 2017. [DOI: 10.18528/gii170004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Paul R. Tarnasky
- Methodist Dallas Medical Center, Methodist Digestive Institute, Dallas, TX, USA
| | - Prashant Kedia
- Methodist Dallas Medical Center, Methodist Digestive Institute, Dallas, TX, USA
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31
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Bray MS, Borgert AJ, Folkers ME, Kothari SN. Outcome and management of endoscopic retrograde cholangiopancreatography perforations: A community perspective. Am J Surg 2017; 214:69-73. [PMID: 28173939 DOI: 10.1016/j.amjsurg.2017.01.034] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 01/20/2017] [Accepted: 01/29/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) carries a small but significant risk of perforation. Recent data suggest that select patients can be managed non-operatively. We sought to evaluate the management of ERCP perforations at our community medical center. METHODS ERCPs performed from 2004 to 2015 were reviewed. RESULTS Twenty-one of 2423 patients who underwent ERCP had a perforation (0.9%). ERCP procedures included balloon sweep with/without sphincterotomy and pancreatic duct stent (71%), common bile duct brushing (10%), and pancreatic duct stenting (5%). Duodenal diverticula were present in 3 (14%), and altered anatomy was present in 6 (29%). Seventeen patients were treated nonoperatively; 3 (14%) underwent percutaneous drain placement. Two patients failed nonoperative treatment and required surgery. Four patients required ICU stay, and median post-ERCP LOS was 5 days. The 30-day mortality rate was 1/21 (4.8%). CONCLUSIONS Perforations remain a rare, but serious, complication of ERCPs. Nonoperative management is highly successful in carefully selected patients. Early recognition with initiation of antibiotics is paramount. Our community-based practice patterns are similar to those previously published for successful nonoperative management of ERCP perforations.
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Affiliation(s)
- Mallory S Bray
- Department of Medical Education, Gundersen Medical Foundation, La Crosse, WI, USA
| | - Andrew J Borgert
- Department of Medical Research, Gundersen Medical Foundation, La Crosse, WI, USA
| | - Milan E Folkers
- Department of Gastroenterology, Gundersen Health System, La Crosse, WI, USA
| | - Shanu N Kothari
- Department of General Surgery, Gundersen Health System, La Crosse, WI, USA.
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Chandrasekhara V, Khashab MA, Muthusamy VR, Acosta RD, Agrawal D, Bruining DH, Eloubeidi MA, Fanelli RD, Faulx AL, Gurudu SR, Kothari S, Lightdale JR, Qumseya BJ, Shaukat A, Wang A, Wani SB, Yang J, DeWitt JM. Adverse events associated with ERCP. Gastrointest Endosc 2017; 85:32-47. [PMID: 27546389 DOI: 10.1016/j.gie.2016.06.051] [Citation(s) in RCA: 438] [Impact Index Per Article: 62.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 06/30/2016] [Indexed: 02/07/2023]
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Management of endoscopic retrograde cholangiopancreatography-related perforations: Experience of a tertiary center. Surgery 2016; 161:920-929. [PMID: 28027817 DOI: 10.1016/j.surg.2016.10.029] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 10/11/2016] [Accepted: 10/27/2016] [Indexed: 12/18/2022]
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography-induced perforation (EP) is a rare but severe complication. We describe the risk factors, management, and outcome of ERCP-induced perforations in a tertiary center. METHODS This is a case-control study. All EP cases between March 2004 and February 2015 were compared to a control group without perforation. Data on patients, procedures, presentation, perforation type, radiologic findings, management, and outcome were assessed. RESULTS Of 6,934 endoscopic retrograde cholangiopancreatographies, 37 patients (0.53%) had EP. Independent risk factors included failure of cannulation, a procedure described as "difficult," performing a precut and resection of a periampullary adenoma. Perforation was diagnosed during the procedure in 7 patients (19%). Median interval for diagnosis was 11 hours (range: 0-201 hours), with 84% diagnosed within 30 hours. The periampullary region was the most common EP site (51%). Twenty-nine patients (78%) were managed conservatively and 8 (22%) were operated. Three patients failed conservative management and required delayed operation. Failure of conservative management had a detrimental effect on morbidity and duration of stay. All patients who required operative intervention had perforation of either the duodenal free wall or the periampullary region. CONCLUSION Clear risk factors can be used to raise suspicion of EP. Early diagnosis and management are critical for better outcome. This is especially important when operative intervention is indicated. Nonetheless, the majority of patients may be managed conservatively.
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Kumbhari V, Sinha A, Reddy A, Afghani E, Cotsalas D, Patel YA, Storm AC, Khashab MA, Kalloo AN, Singh VK. Algorithm for the management of ERCP-related perforations. Gastrointest Endosc 2016; 83:934-43. [PMID: 26439541 DOI: 10.1016/j.gie.2015.09.039] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Accepted: 09/28/2015] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
- Vivek Kumbhari
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Amitasha Sinha
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Aditi Reddy
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Elham Afghani
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Deanna Cotsalas
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Yuval A Patel
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Andrew C Storm
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Mouen A Khashab
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Anthony N Kalloo
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Vikesh K Singh
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
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Angsuwatcharakon P, Rerknimitr R. Endoscopic closure of iatrogenic perforation. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2016. [DOI: 10.18528/gii150009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Affiliation(s)
- Phonthep Angsuwatcharakon
- Department of Anatomy, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Rungsun Rerknimitr
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
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Parenchymal Guidewire Perforation during ERCP: An Unappreciated Injury. Case Rep Surg 2015; 2015:670323. [PMID: 26693377 PMCID: PMC4674614 DOI: 10.1155/2015/670323] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Accepted: 11/12/2015] [Indexed: 01/30/2023] Open
Abstract
ERCP is attended with certain complications, the majority of which are well known to the medical community. Other less-known complications also exist. Guidewire injury to the hepatic or pancreatic parenchyma represents one of the much less appreciated, albeit preventable, complications. In this report, we present the clinical course of three patients who sustained guidewire perforation of the pancreatic or hepatic parenchyma. In one patient, the clinical deterioration was confidently attributed to guidewire perforation of the pancreatic parenchyma. Conservative treatment was successful and unnecessary emergency surgery was thus avoided. In the other two, in whom the cause of the clinical deterioration was unclear, an emergency surgery was performed. Guidewire injury to the hepatic parenchyma was then confirmed which needed only intraperitoneal drainage, with successful outcome.
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Yang HY, Chen JH. Endoscopic fibrin sealant closure of duodenal perforation after endoscopic retrograde cholangiopancreatography. World J Gastroenterol 2015; 21:12976-12980. [PMID: 26668519 PMCID: PMC4671050 DOI: 10.3748/wjg.v21.i45.12976] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Revised: 08/05/2015] [Accepted: 10/13/2015] [Indexed: 02/06/2023] Open
Abstract
Traditionally, perivaterian duodenal perforation can be managed conservatively or surgically. If a large volume of leakage results in fluid collection in the retroperitoneum, surgery may be necessary. Our case met the surgical indication for perivaterian duodenal perforation after endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and endoscopic papillary balloon dilatation. The patient developed a retroperitoneal abscess after the procedures, and a perivaterian perforation was suggested on computed tomography (CT). CT-guided abscess drainage was performed immediately. We unsuccessfully attempted to close the perforation with hemoclips initially. Subsequently, we used fibrin sealant (Tisseel) injection to occlude the perforation. Fibrin sealant injections have been previously used during endoscopy for wound closure and fistula repair. Based on our report, fibrin sealant injection can be considered as an alternative method for the treatment of ERCP-related type II perforations.
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Vezakis A, Fragulidis G, Polydorou A. Endoscopic retrograde cholangiopancreatography-related perforations: Diagnosis and management. World J Gastrointest Endosc 2015; 7:1135-1141. [PMID: 26468337 PMCID: PMC4600179 DOI: 10.4253/wjge.v7.i14.1135] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Revised: 07/31/2015] [Accepted: 09/08/2015] [Indexed: 02/05/2023] Open
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) has become an important therapeutic modality for biliary and pancreatic disorders. Perforation is one of the most feared complications of ERCP and endoscopic sphincterotomy. A MEDLINE search was performed from 2000-2014 using the keywords “perforation”, “ERCP” and “endoscopic sphincterotomy”. All articles including more than nine cases were reviewed. The incidence of ERCP-related perforations was low (0.39%, 95%CI: 0.34-0.69) with an associated mortality of 7.8% (95%CI: 3.80-13.07). Endoscopic sphincterotomy was responsible for 41% of perforations, insertion and manipulations of the endoscope for 26%, guidewires for 15%, dilation of strictures for 3%, other instruments for 4%, stent insertion or migration for 2% and in 7% of cases the etiology was unknown. The diagnosis was made during ERCP in 73% of cases. The mechanism, site and extent of injury, suggested by clinical and radiographic findings, should guide towards operative or non-operative management. In type I perforations early surgical repair is indicated, unless endoscopic closure can be achieved. Patients with type II perforations should be treated initially non-operatively. Non-operative treatment includes biliary stenting, fasting, intravenous fluid resuscitation, nasogastric drainage, broad spectrum antibiotics, percutaneous drainage of fluid collections. Non-operative treatment was successful in 79% of patients with type II injuries, with an overall mortality of 9.4%. Non-operative treatment was sufficient in all patients with type III injuries. Surgical technique depends on timing, site and size of defect and clinical condition of the patient. In conclusion, diagnosis is based on clinical suspicion and clinical and radiographic findings. Whilst surgery is usually indicated in patients with type I injuries, patients with type II or III injuries should be treated initially non-operatively. A minority of them will finally require surgical intervention.
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Alkhateeb HM, Aljanabi TJ, Al-Azzawi KH, Alkarboly TA. Huge biloma after endoscopic retrograde cholangiopancreatography and endoscopic biliary sphincterotomy. Int J Surg Case Rep 2015; 16:7-11. [PMID: 26402876 PMCID: PMC4643346 DOI: 10.1016/j.ijscr.2015.08.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2015] [Accepted: 08/27/2015] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Biliary leak can occur as a complication of biliary surgery, endoscopic retrograde cholangiopancreatography manipulations and endoscopic biliary sphincterotomy. Consequently, bile may collect in the abdominal cavity, a condition called biloma. Rarely, it may reach a massive size. CASE PRESENTATION A 72-year-old man presented with gastric upset with gradual abdominal distension reaching a large size due to intra-abdominal bile collection (biloma) after endoscopic retrograde cholangiopancreatography plus endoscopic biliary sphincterotomy and stenting for post laparoscopic cholecystectomy common bile duct stricture. This huge biloma was treated by percutaneous insertion of a tube drain for a few days, evacuating the collection successfully without recurrence. DISCUSSION This patient might sustain injury to the common bile duct either by the guide wire or stent, or the injury occurred at the angle between the common bile duct and duodenum during sphincterotomy of the ampulla. Although any of these rents may lead to a bile leak, causing a huge biloma, they could be successfully treated by percutaneous drainage. CONCLUSIONS (1) Following endoscopic retrograde cholangiopancreatography, a patient's complaints should not be ignored. (2) A massive biloma can occur due to such procedures. (3) Conservative treatment with minimal invasive technique can prove to be effective.
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Affiliation(s)
| | | | | | - Taha A Alkarboly
- Kurdistan Center for Gastroenterology and Hepatology, Assulaymaniah, Kurdistan, Iraq.
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Mathew J, Parker C, Wang J. Pulseless electrical activity arrest due to air embolism during endoscopic retrograde cholangiopancreatography: a case report and review of the literature. BMJ Open Gastroenterol 2015; 2:e000046. [PMID: 26462286 PMCID: PMC4599162 DOI: 10.1136/bmjgast-2015-000046] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Revised: 06/04/2015] [Accepted: 06/05/2015] [Indexed: 12/12/2022] Open
Abstract
While most gastroenterologists are aware of the more common complications of endoscopy such as bleeding, infection and perforation, air embolism remains an under-recognised and difficult to diagnose problem due to its varying modes of presentation. This is the case of a 55-year-old man with right upper quadrant pain and imaging notable for cholecystitis and choledocholithiasis, who underwent endoscopic retrograde cholangiopancreatography (ERCP). During the ERCP, and shortly after a sphincterotomy was performed, he became hypotensive and hypoxic, quickly decompensating into pulseless electrical activity. While advanced cardiac life support was initiated, the patient passed away. Autopsy revealed air in the pulmonary artery suggestive of a pulmonary embolism. While air embolism remains a rare complication of upper endoscopy, increased awareness and prompt recognition of signs that may point to this diagnosis may potentially save lives by allowing for earlier possible interventions.
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Affiliation(s)
- Jacob Mathew
- Department of Medicine , Tripler Army Medical Center , Honolulu, Hawaii , USA
| | - Calvin Parker
- Department of Medicine , Tripler Army Medical Center , Honolulu, Hawaii , USA
| | - James Wang
- Department of Medicine , Tripler Army Medical Center , Honolulu, Hawaii , USA
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Chertoff J, Khullar V, Burke L. Duodenal perforation following esophagogastroduodenoscopy (EGD) with cautery and epinephrine injection for peptic ulcer disease: An interesting case of nonoperative management in the medical intensive care unit (MICU). Int J Surg Case Rep 2015; 10:121-5. [PMID: 25837967 PMCID: PMC4429852 DOI: 10.1016/j.ijscr.2015.03.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Revised: 03/04/2015] [Accepted: 03/05/2015] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION The utilization of esophagogastroduodenoscopy (EGD) and related procedures continues to rise. Due to this increase in utilization is an inevitable rise in serious complications such as hemorrhage and perforation. One understudied and dreaded complication of EGD causing significant morbidity and mortality is duodenal perforation. PRESENTATION OF CASE We present the case of a 63-year-old male who presented to our institution's emergency room with dyspepsia, melanic stools, tachycardia, and hypotension. Initial laboratory evaluation was significant for severe anemia, lactic acidosis, and acute kidney injury, while CT scan of the abdomen pelvis did not suggest retroperitoneal hematoma or bowel perforation. An emergent EGD was performed which showed multiple bleeding duodenal ulcers that were cauterized and injected with epinephrine. Post-procedure the patient developed worsening abdominal pain, distension, diaphoresis, and tachypnea, requiring emergent intubation. A CT scan of the abdomen and pelvis with oral contrast confirmed pneumoperitoneum and duodenal perforation. DISCUSSION Due to the patient's hemodynamic instability and multiple comorbidities, he was treated non-operatively with strict bowel rest and intravenous antibiotics. The patient ultimately had a 19-day hospital course complicated by renal failure requiring hemodialysis and an ischemic limb necessitating above knee amputation. CONCLUSION This case describes an unsuccessful attempt at nonoperative management of duodenal perforation following EGD.
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Affiliation(s)
- Jason Chertoff
- University of Florida, College of Medicine, 1600 SW Archer Road, Gainesville, FL 32608, USA.
| | - Vikas Khullar
- University of Florida, College of Medicine, 1600 SW Archer Road, Gainesville, FL 32608, USA
| | - Lucas Burke
- University of Florida, College of Medicine, 1600 SW Archer Road, Gainesville, FL 32608, USA
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Armas Ojeda MD, Ojeda Marrero V, Roque Castellano C, Cabrera Marrero JC, Mathías Gutierrez MDP, Ceballos Santos D, Marchena Gómez J. [Duodenal perforations after endoscopic retrograde cholangiopancreatography]. Cir Esp 2015; 93:403-10. [PMID: 25702308 DOI: 10.1016/j.ciresp.2015.01.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Revised: 12/23/2014] [Accepted: 01/05/2015] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Duodenal perforations after endoscopic retrograde cholangiopancreatography (ERCP) are an uncommon complication. The management of this kind of perforation is controversial. The aim of this study was to analyze the results of the management of a series of 15 patients who were diagnosed with this complication. METHODS Retrospective study of duodenal perforations after ERCP diagnosed at a tertiary level hospital, between 2001 and 2011. The variables age, sex, ERCP indication, type of perforation, time of diagnosis, clinical presentation, radiographic findings, management, surgical technique, length of stay and intrahospital mortality were recorded and analyzed. RESULTS Out of a total of 1923 ERCP performed, 15 duodenal perforations were detected (0,78%). Perforation site was the duodenal wall (3 cases) and periampullary (12 cases). Eleven perforations were suspected during the procedure. Patients with duodenal wall perforations underwent immediate surgery. Seven of 12 periampullary perforations were managed conservatively with a favorable outcome in 5 of them. Subsequent scheduled surgery was performed in 4 cases. The mean length of hospital stay was 21,2 days (range: 3-49) and intra-hospital mortality was 20%. CONCLUSIONS Perforations after ERCP have high mortality rates, and require a complicated therapeutic approach that needs to be individualized. Selective conservative management is a valid and safe option in selected patients.
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Affiliation(s)
- María Desirée Armas Ojeda
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario de Gran Canaria Doctor Negrín, Las Palmas de Gran Canaria, España.
| | - Vanesa Ojeda Marrero
- Servicio de Digestivo, Hospital Universitario de Gran Canaria Doctor Negrín, Las Palmas de Gran Canaria, España
| | - Cristina Roque Castellano
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario de Gran Canaria Doctor Negrín, Las Palmas de Gran Canaria, España
| | - José Carlos Cabrera Marrero
- Servicio de Digestivo, Hospital Universitario de Gran Canaria Doctor Negrín, Las Palmas de Gran Canaria, España
| | | | - Daniel Ceballos Santos
- Servicio de Digestivo, Hospital Universitario de Gran Canaria Doctor Negrín, Las Palmas de Gran Canaria, España
| | - Joaquín Marchena Gómez
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario de Gran Canaria Doctor Negrín, Las Palmas de Gran Canaria, España
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Kodali S, Mönkemüller K, Kim H, Ramesh J, Trevino J, Varadarajulu S, Wilcox CM. ERCP-related perforations in the new millennium: A large tertiary referral center 10-year experience. United European Gastroenterol J 2015; 3:25-30. [PMID: 25653856 DOI: 10.1177/2050640614560784] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2014] [Accepted: 10/01/2014] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION Endoscopic retrograde cholangiopancreatography (ERCP) is an important diagnostic and therapeutic modality for pancreatic and biliary disorders. Perforation is one of the most dreaded complications of ERCP. Since it is uncommon, there has been little study of incidence, risk factors, and outcomes of management. OBJECTIVES We aim to assess the incidence of ERCP-related perforations and outcomes at a large tertiary referral center. METHODS We undertook a review of an ERCP database for all perforations from 2002 to December 2012. RESULTS The cumulative incidence of ERCP-related perforations was 0.14% (12 out of 8264), and sphincterotomy-related perforations constituted the most common cause. The mean age of these 12 patients was 58.6 years and majority were female (83.3%). The most common indications for ERCP were: suspected sphincter of Oddi dysfunction (SOD) 41%, and common bile duct stones (CBD stones) 41%. Nine of the 12 patients (75%) had a leak and were managed medically, and four who had a perforation had surgical repair (25%). CONCLUSIONS In our study, leaks were much more common than perforations and the majority of patients were successfully managed with conservative therapy alone. We report a very low perforation rate and most perforations can be managed conservatively with a good outcome.
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Affiliation(s)
- Sudha Kodali
- Division of Gastroenterology and Hepatology, Basil I. Hirschowitz Endoscopic Center of Excellence, University of Alabama at Birmingham, Alabama, USA
| | - Klaus Mönkemüller
- Division of Gastroenterology and Hepatology, Basil I. Hirschowitz Endoscopic Center of Excellence, University of Alabama at Birmingham, Alabama, USA
| | - Hwasoon Kim
- Division of Gastroenterology and Hepatology, Basil I. Hirschowitz Endoscopic Center of Excellence, University of Alabama at Birmingham, Alabama, USA
| | - Jayapal Ramesh
- Division of Gastroenterology and Hepatology, Basil I. Hirschowitz Endoscopic Center of Excellence, University of Alabama at Birmingham, Alabama, USA
| | - Jessica Trevino
- Division of Gastroenterology and Hepatology, Basil I. Hirschowitz Endoscopic Center of Excellence, University of Alabama at Birmingham, Alabama, USA
| | - Shyam Varadarajulu
- Division of Gastroenterology and Hepatology, Basil I. Hirschowitz Endoscopic Center of Excellence, University of Alabama at Birmingham, Alabama, USA
| | - C Mel Wilcox
- Division of Gastroenterology and Hepatology, Basil I. Hirschowitz Endoscopic Center of Excellence, University of Alabama at Birmingham, Alabama, USA
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Rustagi T, Jamidar PA. Endoscopic retrograde cholangiopancreatography-related adverse events: general overview. Gastrointest Endosc Clin N Am 2015; 25:97-106. [PMID: 25442961 DOI: 10.1016/j.giec.2014.09.005] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) represents a monumental advance in the management of patients with pancreaticobiliary diseases, but is a complex and technically demanding procedure with the highest inherent risk of adverse events of all routine endoscopic procedures. Overall adverse event rates for ERCP are typically reported as 5-10%. The most commonly reported adverse events include post-ERCP pancreatitis, bleeding, perforation, infection (cholangitis), and cardiopulomary or "sedation related" events. This article evaluates patient-related and procedure-related risk factors for ERCP-related adverse events, and discusses strategies for the prevention, diagnosis and management of these events.
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Affiliation(s)
- Tarun Rustagi
- Section of Digestive Diseases, Department of Internal Medicine, Yale University School of Medicine, 333 Cedar Street, 1080 LMP, New Haven, CT 06520, USA
| | - Priya A Jamidar
- Section of Digestive Diseases, Department of Internal Medicine, Yale University School of Medicine, 333 Cedar Street, 1080 LMP, New Haven, CT 06520, USA.
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Koc B, Bircan HY, Adas G, Kemik O, Akcakaya A, Yavuz A, Karahan S. Complications following endoscopic retrograde cholangiopancreatography: minimal invasive surgical recommendations. PLoS One 2014; 9:e113073. [PMID: 25426633 PMCID: PMC4245110 DOI: 10.1371/journal.pone.0113073] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2014] [Accepted: 10/23/2014] [Indexed: 12/28/2022] Open
Abstract
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.
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Affiliation(s)
- Bora Koc
- Department of Surgery, Okmeydani Training and Research Hospital, Istanbul, Turkey
| | - Huseyin Yuce Bircan
- Department of Surgery, Baskent University Faculty of Medicine, Istanbul Research Hospital, Istanbul, Turkey
| | - Gokhan Adas
- Department of Surgery, Okmeydani Training and Research Hospital, Istanbul, Turkey
| | - Ozgur Kemik
- Department of Surgery, Yuzuncu Yil University Faculty of Medicine, Van, Turkey
- * E-mail:
| | - Adem Akcakaya
- Department of Surgery, Okmeydani Training and Research Hospital, Istanbul, Turkey
| | - Alpaslan Yavuz
- Department of Radiology, Yuzuncu Yil University Faculty of Medicine, Van, Turkey
| | - Servet Karahan
- Department of Surgery, Okmeydani Training and Research Hospital, Istanbul, Turkey
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Motomura Y, Akahoshi K, Gibo J, Kanayama K, Fukuda S, Hamada S, Otsuka Y, Kubokawa M, Kajiyama K, Nakamura K. Immediate detection of endoscopic retrograde cholangiopancreatography-related periampullary perforation: Fluoroscopy or endoscopy? World J Gastroenterol 2014; 20:15797-15804. [PMID: 25400465 PMCID: PMC4229546 DOI: 10.3748/wjg.v20.i42.15797] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2014] [Revised: 05/17/2014] [Accepted: 06/26/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the causes and intraoperative detection of endoscopic retrograde cholangiopancreatography (ERCP)-related perforations to support immediate or early diagnosis.
METHODS: Consecutive patients who underwent ERCP procedures at our hospital between January 2008 and June 2013 were retrospectively enrolled in the study (n = 2674). All procedures had been carried out using digital fluoroscopic assistance with the patient under conscious sedation. For patients showing alterations in the gastrointestinal anatomy, a short-type double balloon enteroscope had been applied. Cases of perforation had been identified by the presence of air in or leakage of contrast medium into the retroperitoneal space, or upon endoscopic detection of an abdominal cavity related to the perforated lumen. For patients with ERCP-related perforations, the data on medical history, endoscopic findings, radiologic findings, diagnostic methods, management, and clinical outcomes were used for descriptive analysis.
RESULTS: Of the 2674 ERCP procedures performed during the 71-mo study period, only six (0.22%) resulted in perforations (male/female, 2/4; median age: 84 years; age range: 57-97 years). The cases included an endoscope-related duodenal perforation, two periampullary perforations related to endoscopic sphincterotomy, two periampullary perforations related to endoscopic papillary balloon dilation, and a periampullary or bile duct perforation secondary to endoscopic instrument trauma. No cases of guidewire-related perforation occurred. The video endoscope system employed in all procedures was only able to immediately detect the endoscope-related perforation; the other five perforation cases were all detected by subsequent digital fluoroscope applied intraoperatively (at a median post-ERCP intervention time of 15 min). Three out of the six total perforation cases, including the single case of endoscope-related duodenal injury, were surgically treated; the remaining three cases were treated with conservative management, including trans-arterial embolization to control the bleeding in one of the cases. All patients recovered without further incident.
CONCLUSION: ERCP-related perforations may be difficult to diagnose by video endoscope and digital fluoroscope detection of retroperitoneal free air or contrast medium leakage can facilitate diagnosis.
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Prachayakul V, Aswakul P. Endoscopic retrograde cholangiopancreatography-related perforation: Management and prevention. World J Clin Cases 2014; 2:522-527. [PMID: 25325062 PMCID: PMC4198404 DOI: 10.12998/wjcc.v2.i10.522] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Revised: 07/07/2014] [Accepted: 07/29/2014] [Indexed: 02/05/2023] Open
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is a procedure that can result in serious complications, and thus should be handled by a skilled endoscopist to minimize the risk of complications and to enhance the success rate. The incidence of ERCP-related complications is 5%-10%, most commonly involving post-ERCP pancreatitis and clinically significant post-endoscopic sphincterotomy bleeding. Although ERCP-related perforation has a relatively lower incidence of 0.14%-1.6%, this complication is associated with a high mortality rate of 4.2%-29.6%. A classification of perforation type based on the instrument that caused the perforation was recently described that we postulated could affect the implementation of perforation management. In the present article, an algorithm for management and prevention of ERCP-related perforations is proposed that is based on the perforation type and delay of diagnosis. Available evidence demonstrates that a delayed diagnosis and/or treatment of perforation results in a poorer prognosis, and thus should be at the forefront of procedural consideration. Furthermore, this review provides steps and recommendations from the pre-procedural stage through the post-procedural evaluation with consideration of contributing factors in order to minimize ERCP-related complication risk and improve patient outcome. To avoid perforation, endoscopists must evaluate the risks related to the individual patient and the procedure and perform the procedure gently. Once a perforation occurs, immediate diagnosis and early management are key factors to minimize mortality.
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Kumbhari V, Khashab MA. Perforation due to ERCP. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2014. [DOI: 10.1016/j.tgie.2014.08.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Computed Tomography of Iatrogenic Complications of Upper Gastrointestinal Endoscopy, Stenting, and Intubation. Radiol Clin North Am 2014; 52:1055-70. [DOI: 10.1016/j.rcl.2014.05.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Cho KB. The management of endoscopic retrograde cholangiopancreatography-related duodenal perforation. Clin Endosc 2014; 47:341-5. [PMID: 25133122 PMCID: PMC4130890 DOI: 10.5946/ce.2014.47.4.341] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Revised: 07/04/2014] [Accepted: 07/08/2014] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Kwang Bum Cho
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
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