The use of fully-covered self-expanding metallic stents for intraprocedural management of post-sphincterotomy perforations: a single-center study (with video)

Management of ERCP-related perforation: a large multicenter study

BACKGROUND AND AIMS

Perforation is a rare but serious adverse event associated with ERCP. There is no consensus to guide clinicians in the management of ERCP-related duodenal perforations, making it difficult to determine whether surgical or endoscopic treatment is optimal. The present study retrospectively evaluated the characteristics and clinical outcomes of patients who experienced ERCP-related duodenal perforations according to the mechanism of injury.

METHODS

This study evaluated the incidence of ERCP-related duodenal perforations among 51,957 patients who underwent ERCP at 21 tertiary care hospitals in Japan between April 2017 and March 2022. ERCP-related duodenal perforations were categorized according to the Stapfer classification system. Serious adverse events, length of stay (LOS), and mortality associated with ERCP-related duodenal perforations were evaluated according to the mechanism of injury, time of diagnosis, and treatment modality.

RESULTS

Of 51,957 patients who underwent ERCP, 58 (.12%) experienced ERCP-related duodenal perforations. The mean LOS was 27.1 days, and the mortality rate was 2%. LOS (P = .031) and time to healing (P = .009) were significantly shorter in patients who underwent endoscopic than surgical treatment. Multivariate Cox regression analysis showed that endoscopic treatment (P = .017) and intraprocedural diagnosis (P = .019) were independently associated with a good clinical course.

CONCLUSIONS

Diagnosing a perforation during the ERCP procedure can prevent serious adverse events. Fluoroscopic and endoscopic images should be carefully reviewed. Endoscopic management should be the treatment of choice for patients diagnosed with perforation during ERCP procedures.

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

Background

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

Methods

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

Results

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

Conclusions

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

Goff Septotomy Is a Safe and Effective Salvage Biliary Access Technique Following Failed Cannulation at ERCP

BACKGROUND

Biliary cannulation is readily achieved in > 85% of patients undergoing endoscopic retrograde cholangiopancreatography (ERCP). When standard cannulation techniques fail, salvage techniques utilized include the needle knife precut, double wire technique, and Goff septotomy.

METHODS

Records of patients undergoing ERCP from 2005 to 2016 were retrospectively examined using a prospectively maintained endoscopy database. Patients requiring salvage techniques for biliary access were analyzed together with a control sample of 20 randomly selected index ERCPs per study year. Demographic and clinical variables including indications for ERCP, cannulation rates, and adverse events were collected.

RESULTS

A total of 7984 patients underwent ERCP from 2005 to 2016. Biliary cannulation was successful in 94.9% of control index ERCPs, 87.2% of patients who underwent Goff septotomy (significantly higher than for all other salvage techniques, p ≤ 0.001), 74.5% of patients in the double wire group and 69.6% of patients in the needle knife precut group. Adverse event rates were similar in the Goff septotomy (4.1%) and index ERCP control sample (2.7%) groups. Adverse events were significantly higher in the needle knife group (27.2%) compared with all other groups.

CONCLUSIONS

This study represents the largest study to date of Goff septotomy as a salvage biliary access technique. It confirms the efficacy of Goff septotomy and indicates a safety profile similar to standard cannulation techniques and superior to the widely employed needle knife precut sphincterotomy. Our safety and efficacy data suggest that Goff septotomy should be considered as the primary salvage approach for failed cannulation, with needle knife sphincterotomy restricted to Goff septotomy failures.