Complications following endoscopic retrograde cholangiopancreatography: minimal invasive surgical recommendations

Results of endoscopic retrograde cholangiopancreatography procedures at surgical clinics: A multicenter observational study in Türkiye

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is an invasive endoscopic procedure used mainly to treat hepato-pancreato-biliary (HPB) diseases. The need for ERCP has increased with the rising number of HPB diseases over the past decade. Thus, due to increased demand, ERCP is performed at more centers. Currently, it is performed by general surgeons, gastroenterology and invasive radiology specialists in the United States and Europe as recommended by the British Society of Gastroenterology (BSG).

AIM

To present the results of ERCP procedures from fourteen surgical centers in Türkiye.

METHODS

Fourteen surgical centers performing ERCP were included in the present study. The age, gender, ERCP indication, success status, post-ERCP complications, ERCP reports and the files of 66993 patients who underwent ERCP were collected from the participating centers. The results are discussed according to the targets declared by the BSG, which are volume load per annum, proportion of successful cannulation (> 85%), bile duct clearance rate (> 75%), stenting rate for strictures (> 80%) and complications (< 6%).

RESULTS

A total of 66993 ERCP procedures were performed in the centers included in the study up to August 2024. 29250 (43.6%) of the procedures were performed urgently, especially for suppurative cholangitis, biliary tract injuries, etc. The remaining 37743 (56.4%) cases were performed electively. 50.2% of the patients were female and 49.8% were male. The average ages were 56.5 years for women and 55.9 years for men. General anesthesia was used in 84.1% of the patients while sedation was used in 15.9%. The indications were bile duct stone (78.7%), pancreatic tumor (3.9%), papillary tumor (3.3%), cholangiocarcinoma (2.6%), Oddi sphincter dysfunction (2.4%), bile leakage after cholecystectomy (2%), bile leakage after hydatid cyst surgery (1.9%), biliary stricture (1.7%), and other diseases (3.1%). Hyperamylasemia and post-ERCP pancreatitis were the most common complications as observed in 8.1% of the patients. They were usually self-limited and responded to supportive measures. The frequency of the other complications was also consistent with the literature.

CONCLUSION

There is a huge shortage of ERCP endoscopists worldwide due to insufficient ERCP training and centers especially in developing and underdeveloped countries. As patients requiring ERCP usually present to surgical practitioners, the incorporation of surgeons into this training program is an effective and reliable solution. The BSG recommends the incorporation of surgeons and radiologists in addition to gastroenterology specialists. This study is the first to present the results of ERCP procedures from fourteen surgical centers throughout Türkiye. The results suggest that the surgical centers included were able to achieve the targets set by the BSG. This study demonstrated that the surgical ERCP units in the present work have reached satisfactory results and provided a reliable and successful ERCP service. There are currently no issues regarding the validity and appropriateness of the surgeons performing ERCP. Therefore, ERCP training should be encouraged in surgeons and more surgical ERCP centers should be provided.

Diagnosis and management of type II endoscopic retrograde cholangiopancreatography-related perforations: a multicenter retrospective study

BACKGROUND

The management of type II endoscopic retrograde cholangiopancreatography (ERCP)-related perforation is still controversial. This study aimed to compare the effects of covered self-expandable metallic stent (SEMS), surgery, and conservative treatment for type II perforation.

METHODS

From January 2010 to December 2021, this study collected relevant data from five large hospitals in China. The data of ERCP difficulty grading and ERCP-related perforation in 26,673 cases that underwent ERCP during 11 years were retrospectively analyzed. Of 55 patients with type II perforation, 41 patients were implanted with a biliary covered SEMS (stent group), 10 underwent surgery (surgery group), and 4 received conservative treatment (conservative group).

RESULTS

Among the 55 patients with type II perforation, ERCP and computed tomography diagnostic rates of type II perforation were 10.91% (6/55) and 89.09% (49/55), respectively. The incidence of type II perforation in grade 5 ERCP (0.43%, 11/2,537) was significantly higher than that in grade 1-3 ERCP (0.16%, 32/19,471). (P = 0.004) and grade 1-4 ERCP (0.26%,12/4,665) (P = 0.008), respectively. Among the 10 patients in the surgical group, primary repair was performed in only 7 patients in whom location of the perforation could be identified. The incidence of retroperitoneal abscess was significantly lower in the stent group than in the surgery group (P = 0.018) and the conservative group (P = 0.001), respectively. The average hospital stay in the stent group was shorter than that in the surgery group (P = 0.000) and conservative group (P = 0.001), respectively.

CONCLUSIONS

The incidence of type II perforation was dependent on the degree of difficulty of ERCP. The treatment of type II perforation with a covered SEMS can significantly reduce the incidence of retroperitoneal abscess and shorten the hospital stay, with better results than surgical and conservative treatments.

Post-endoscopic Retrograde Cholangiopancreatography Hemorrhagic Pancreatitis in a Young Female: A Case Report

Hemorrhagic pancreatitis following endoscopic retrograde cholangiopancreatography (ERCP) is an adverse event that has received limited attention in medical studies. We describe a 28-year-old female who was admitted with symptoms of abdominal pain, nausea, and vomiting, along with tenderness in the right upper quadrant upon physical examination. CT abdomen revealed the presence of a gallstone obstructing the common bile duct. The patient underwent an ERCP procedure, which included a biliary sphincterotomy and the balloon-assisted removal of the obstructing stone. Unfortunately, the procedure was complicated with acute pancreatitis characterized by fluid accumulation in the abdomen, suggestive of hemorrhagic pancreatitis. There was a notable decrease in hemoglobin levels and hypotension, indicating the need for a higher level of care. Patients were managed conservatively with hydration and pain control. Follow-up in the clinic confirmed the resolution of symptoms and stabilization of the hemoglobin. Prompt recognition of post-ERCP hemorrhagic pancreatitis is crucial and warrants a high index of suspicion. Furthermore, the discussion explored the various risk factors and pathological events behind post-ERCP pancreatitis to understand the mechanisms of the disease. Various previously used intervention and prevention strategies were critically discussed for the awareness of future researchers and healthcare practitioners.

Shahwan S, Al-qaoud D, Fataftah J. ERCP-induced perforation: review and revisit after half a century

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is an invasive procedure. We aimed to investigate ERCP-induced perforations at our institution and conduct a comprehensive review of literature on ERCP-induced perforations (EIP) since the introduction of this procedure as a therapeutic intervention.

METHODS

This was a case-control study, in which charts of all patients diagnosed with ERCP-induced duodenal perforation were reviewed and compared to a control group without perforation. Patient's sociodemographic and clinical data, including ERCP procedure-related data, were gathered.

RESULTS

A total of 996 ERCP procedures were performed; only 13 patients proved to have EIP. Obstructive jaundice was the most common indication for ERCP. The main predisposing factor was difficult cannulation (P = 0.003). In total, five patients required surgical treatment; the majority of them had type I perforation, whereas type IV was the most common in patients who were treated conservatively. The overall mortality rate was 15%, the surgical group had a slightly higher mortality rate.

CONCLUSIONS

Fifty years after the introduction of ERCP for therapy, it remains an invasive procedure that carries significant morbidity and mortality, even in skilled hands or at high- volume units. Conservative management of perforation yields favorable outcomes in selected patients.

Prospective evolution of body compositions based on bioelectrical impedance analysis and water intake on patients with gallstone

BACKGROUND

We aimed to compare bioelectrical impedance analysis (BIA) body composition and to reveal predictive factors that may help prevent gallstone formation.

METHODS

Patients with gallstones by ultrasonography were selected as the case group, while participants without stones were selected as the control group. The body composition of the participants in both groups was measured by BIA. Demographic charac-teristics, mean water intake daily of the participants (MWID) and body mass index (BMI), total body fat mass (TBFM), total body fat percentage (BFP), total body water (TBW), body fat mass of trunk (BFM of trunk), and visceral fat level (VFL) measured by BIA were recorded. Predictive risk factors for gallstone formation were revealed by statistical analysis.

RESULTS

The data of a total of 191 participants, including 83 participants in the group with gallstones and 108 participants in the group without gallstones, were analyzed. Both groups were statistically similar in terms of age and sex (P>0.05). In univariate analysis, BMI, TBFM, BFP, BFM of trunk, and VFL were statistically significantly higher (P = 0.007, P=0.004, P=0.003, P=0.003, and P=0.005, respectively) while MWID was lower (P<0.001) in the group with gallstone. In multivariate analysis, MWID (ref: ≥1.5 odds ratio [OR]: 7.786 95% confidence interval [CI]: 3.612-16.781) and BFP (ref: ≥0.24 OR: 3.102 95%CI: 1.207-7.972) were independent factors in gallstone formation.

CONCLUSION

The MWID and BFP level measured by the BIA technique, which is an easily applicable, noninvasive method, are independent risk factors for gallstone formation.

A Novel Cause of Biliary Peritonitis after Endoscopic Retrograde Cholangiopancreatography: Case Report and Literature Review

Background

Endoscopic retrograde cholangiopancreatography (ERCP) can lead to several complications such as duodenal or bile duct perforation. The incidence of pneumoperitoneum post-ERCP is rarely seen (<1%) and is associated with perforations of the duodenum or common bile duct in therapeutic ERCP after sphincterotomy. In this case, we disclose a novel cause of biliary peritonitis after ERCP. Case Presentation. A 65-year-old man presented with abdominal pain and distended abdomen after uneventful ERCP with sphincterotomy. An abdominal computed tomography (CT) was performed whose finding indicated duodenal perforation. The patient was rushed to an emergency laparotomy where only a rupture of an otherwise normal subcapsular intrahepatic bile duct was found. The surrounding liver parenchyma was healthy. The cause of this condition was probably post-ERCP pneumobilia and the increase of pressure in the biliary tract.

Conclusions

This is the first case in literature describing the rupture of a subcapsular healthy bile duct as cause of biliary peritonitis after ERCP. This case also suggests that in the management of post-ERCP complications, the cooperation of radiologists and surgeons is vital for the patient's wellbeing.

3D Laparoscopic common bile duct exploration with primary repair by absorbable barbed suture is safe and feasible

BACKGROUND AND AIM

Endoscopic retrograde cholangiopancreatography (ERCP), with interval laparoscopic cholecystectomy (LC), is the most common treatment approach for common bile duct (CBD) stones. However, recent studies show that single-stage laparoscopic CBD exploration (LCBDE) is safe and feasible. Three-dimensional (3D) laparoscopy enhances depth perception and facilitates intracorporeal suturing. The application of 3D technology for LCBDE is emerging, and we report our case series of 3D LCBDE.

METHODS

We audited the 27 consecutive 3D LCBDE performed from July 2017 to January 2020. We have a liberal policy for magnetic resonance cholangiopancreatography (MRCP) in patients with deranged liver function tests (LFT). All CBD explorations were done through choledochotomy with a 5 mm flexible choledochoscope and primarily repaired with an absorbable barbed suture without a stent or T-tube.

RESULTS

The mean age of patients was 68 (range 44-91) years, and 12 (44%) were male. The indications for surgery were choledocholithiasis 67% (n=18), cholangitis 22% (n=6), and gallstone pancreatitis 11% (n=3). About 67% (n=18) had pre-operative ERCP. About 37% (n=10) had pre-operative biliary stent. Pre-operative MRCP was done in 74% (n=20), and the mean diameter of CBD was 14.5 mm (range 7-30). The median operative time was 160 (range 80-265) min. The operative drain was inserted in 18 patients. One patient each (4%) had a bile leak and a retained stone. There was no open conversion, readmission, or mortality.

CONCLUSION

3D LCBDE with primary repair by an absorbable barbed suture is safe and feasible.

RELEVANCE FOR PATIENTS

This paper emphasized that one stage LCBDE should be a treatment option which is comparable with two stage ERCP followed by LC to treat CBD stones. In addition, 3D technology and barbed sutures use in LCBDE are safe and useful.

Recent advances in prevention and management of endoscopic retrograde cholangiopancreatography-related duodenal perforation

Endoscopic retrograde cholangiopancreatography (ERCP) is the main diagnosis and treatment for biliary and pancreatic diseases; however, ERCP requires a high level of technical skill and experience, and there is always a risk of complications. ERCP-related duodenal perforation is one of the most serious complications of ERCP, and although the incidence rate is relatively low, the mortality rate is high. Recently, the introduction of new classification methods and the development of endoscopic technology and equipment have made endoscopic therapy a new trend. This may change the management strategy of perforation. Therefore, we reviewed the latest developments in endoscopic management, surgical management, and conservative internal medicine management. In addition to introducing many new endoscope treatment methods, we also discussed the timing of interventions, the progress of endoscope and surgical indications, and corresponding prevention strategies. We aim to retrospectively analyse these treatment modalities to propose appropriate solutions to improve dynamic clinical therapy.

Prevalence of Endoscopic Retrograde Cholangiopancreatography Complications and Amylase Sensitivity for Predicting Pancreatitis in ERCP Patients

Endoscopic retrograde cholangiopancreatography (ERCP) is a complex procedure that is widely used for diagnosis and treatment of biliary and pancreatic diseases. With respect to its growing application, the present study aims to evaluate ERCP outcomes and complications. This cross-sectional study was performed using the data from 824 patients who underwent ERCP during 2014-2017 in Qom Shahid Beheshti hospital. Data were collected by a checklist and analyzed using SPSS V22. Among 824 patients, 397 (48.18%) were male and 427 (51.82%) were female with a mean age of 47 ± 6 years. The most common indications for ERCP were choledocholithiasis (78.28%) and cholestasis (20.27%), respectively. Total prevalence of complications was 15.66% and mortality rate was 0.72%. The most common complications were pancreatitis (9.59%) and bleeding (3.28%), respectively. A serum amylase level of greater than 160 could predict pancreatitis with sensitivity of 93.3% and specificity of 90.3%. Endoscopic retrograde cholangiopancreatography-related complications are inevitable but can be controlled by early diagnosis and clinical experience. Severe complications and high-risk patients may increase the mortality of the procedure.

Recognizing Post-Endoscopy Complications: A Database Filter Reduces Quality Assurance Workload for Inpatients

BACKGROUND AND AIMS

Documentation of complications of gastrointestinal endoscopy within the commonly used endoscopy documentation systems are mostly limited to acute complications during endoscopy included in the post-procedural endoscopy report. We tested a documentation system-based filter to reduce the workload by maintaining a high sensitivity to recognize post-endoscopy complications.

METHODS

Of all inpatient endoscopic resections during 1 year and all endoscopic retrograde cholangiopancreatography (ERCP) procedures during 4 months in 1 tertiary referral centre, post-procedural complications during hospital stay were individually analyzed retrospectively from the hospital databases (gold standard). In comparison, information technology-based filters were assessed searching for specific tests and data within 2 days after endoscopy and/or until discharge. These were second endoscopy, surgery, or an abdominal computed tomography (CT) or haemoglobin drop ≥2 g/dL for endoscopic resection. For ERCP cases, any case with lipase determination and post-ERCP CT scan was selected. Main outcomes were the sensitivity of these filters to recognize post-endoscopy complications and the percentage of workload reduction.

RESULTS

Three hundred twenty-two inpatients who underwent endoscopic resections and 302 ERCP cases (all inpatients) were included. Post-endoscopy complications occurred in 7.14% (endoscopic resection) and 3.7% (ERCP). The above-mentioned filters identified 100% of all resection and post-ERCP complications compared to detailed case file analysis, at the same time reducing the quality management workload to 14 and 31%, respectively.

CONCLUSIONS

Post-procedural monitoring of advanced endoscopic procedures performed on inpatient procedures has a high sensitivity (100%) and reduces case-by-case screening workload for complications by 70-85%. Outpatient interventions, however, require a different system for monitoring of post-endoscopy complications after discharge.

Effect of hospital teaching status on endoscopic retrograde cholangiopancreatography mortality and complications in the USA

BACKGROUND

Our aim was to assess the differences in outcomes of cholecystitis, pancreatitis, gastrointestinal (GI) bleed, GI perforation, and mortality in teaching versus nonteaching hospitals nationwide among therapeutic and diagnostic ERCPs. We hypothesized that complication rates would be higher in teaching hospitals given greater patient complexity.

METHODS

Inpatient diagnostic and therapeutic ERCPs were identified from the National Inpatient Sample (NIS) from 2008 to 2012. The presence of ACGME-approved residency programs is required to qualify as a teaching hospital. Nonteaching urban and rural hospitals were grouped together. We identified hospital stays complicated by pancreatitis, cholecystitis, GI hemorrhage, perforation, and mortality. Logistic regression propensity-matched analysis was performed in SPSS to compare differences in complication rates between teaching and nonteaching hospitals.

RESULTS

A total of 1,466,356 weighted cases of inpatient ERCPs were included in this study: of those, 367 and188 were diagnostic, 1,099,168 were therapeutic, 766,230 were at teaching hospitals, and 700,126 were at nonteaching hospitals. Mortality rates were higher in teaching hospitals when compared to nonteaching hospitals for diagnostic (OR 1.266, p < 0.001) and therapeutic ERCPs (OR 1.157, p = 0.001). There was no significant difference in rates of post-ERCP cholecystitis, pancreatitis, or perforation between the two groups. Among diagnostic ERCPs, GI hemorrhage was higher in teaching compared to nonteaching hospitals (OR 1.181, p = 0.003). Likewise, length of stay was increased in teaching hospitals (7.9 vs 6.9 days, p < 0.001, for diagnostic and 6.5 vs 5.8 days, p < 0.001, for therapeutic ERCPs).

CONCLUSIONS

In conclusion, teaching hospitals were noted to have a higher mortality rate associated with inpatient ERCPs as well as higher rates of GI hemorrhage in diagnostic ERCPs, which may be due to a higher comorbidity index in those patients admitted to teaching hospitals.

Computed tomography classification of endoscopic retrograde cholangiopancreatography-related perforation

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

Prevalence of Anesthetic and Gastrointestinal Complications of Endoscopic Retrograde Cholangiopancreatography

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is an endoscopic method for treatment of many biliary diseases. With respect to rapid recovery and more patient comfort, this procedure is currently performed under light general anesthesia (GA) or conscious sedation.

OBJECTIVES

The current study aimed to clarify that intravenous sedation or light general anesthesia can be performed without great fear of anesthesia related complications in ERCP patients and sedative doses of propofol can be used safely in outpatient settings under the supervision of an expert anesthesiologist.

METHODS

This is a cross-sectional study on 1023 ERCP patients under light GA during 2014 - 2018 in Qom, Shahid Beheshti Hospital. Data were collected by a checklist and were analyzed by using chi-square test in SPSS V.22.

RESULTS

From 1023 patients, 501 (48.97 %) were male and 522 (51.03 %) were female with a mean age of 47.2 ± 6.7 years. The most common finding in ERCP was choledocholithiasis (76.15 %). The most common complication was hemodynamic instability (37.01 %) followed by desaturation (11.65 %) both of them ware anesthesia related. Prevalence of GI (gastrointestinal) related complications was 13.39 %. The most common GI related complications were pancreatitis (7.92 %) and bleeding (3.32 %). Total mortality rate was 0.88 %.

CONCLUSIONS

ERCP-related complications are inevitable but can be controlled by early diagnosis and clinical experience. Severe complications and high risk patients may increase the mortality and morbidity of the procedure. Anesthesia related complications are more frequent than GI related unwanted events. Fortunately, the most common anesthesia related complications are readily manageable and are minor in nature when an expert anesthesiologist is present in the scene. Close monitoring of the patient's vital signs should be the mainstay of the safe procedure.

Endoscopic Treatment of Endoscopic Retrograde Cholangiopancreatography-Related Duodenal Perforations

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP)-related duodenal perforation is a rare complication associated with significant morbidity and mortality. This study evaluated endoscopic management experience and outcomes of ERCP-related duodenal perforations.

MATERIALS AND METHODS

Between March 2005 and March 2017, a total of 19,468 ERCP procedures were performed in three endoscopy units of three hospitals in China. Diagnoses, management, and outcomes were identified and retrospectively reviewed in 58 of these patients.

RESULTS

According to the classification system, 58 patients included 8 with type I, 44 with type II, 4 with type III, and 2 with type IV perforation. Of type I perforations, 7 patients underwent endoscopic closure with endoclips, and 1 patient was treated with surgical repair. Of type II perforations, 11 patients were actively managed using the fully covered self-expandable metallic stents (SEMS) to seal the perforation, and 33 patients were passively managed using nose-biliary drainage, in which 13 cases had retroperitoneal abscess formation and were successfully treated by abdominal computed tomography (CT)-guided percutaneous external drainage, but 1 patient died due to sepsis. One patient with type III perforation (pancreatic duct perforation) underwent endoscopic pancreatic duct stent placement after surgery failure. The mean hospital stay of 11 cases with type II perforation treated actively by endoscopy (26.5 ± 3.3 days) was lower compared with 33 cases who received passive conservative treatment (34.6 ± 3.9 days).

CONCLUSION

Many (especially type I and II) ERCP-related duodenal perforations can be successfully treated with endoscopic management. Active endoscopic therapy may be better than passive conservative treatment for type II perforations.

Management of iatrogenic injuries due to endoscopic sphincterotomy: Surgical or conservative approaches

OBJECTIVE

The best therapeutic approach for endoscopic retrograde cholangiopancreatography-related perforations remains controversial; while some authors suggest routine conservative management, others advocate mandatory surgical exploration. We aimed to evaluate our clinical experience of perforations during endoscopic sphincterotomy.

MATERIAL AND METHODS

A retrospective chart review from January 2010 to October 2015 identified 20 patients with endoscopic retrograde cholangiopancreatography-related perforations. Data collection included demographics, time to diagnosis, type of perforation, treatment strategy, surgical procedure, complications, hospital stay, and outcome. All patients were classified into two groups on the basis of radiological and operative findings.

RESULTS

Only five patients underwent surgical treatment, whereas 15 patients were managed conservatively. The mean time to diagnosis was 7.8 hrs (range: 1 to 36 hrs). In patients who underwent surgical treatment, the types of perforations included type I and III in one patient each and type II in three patients. Surgical procedures included laparoscopic and open cholecystectomy with t-tube drainage in two patients each and primary repair of duodenal injury with hepaticojejunostomy in one patient. Among conservatively managed patients, eight, four, and three had type II, type III, and type IV injuries, respectively. Of these 15 patients, 60% (n=9) underwent percutaneous procedures. The mean length of hospital stay was similar for conservatively and surgically treated patients (12 vs. 12.4 days, respectively, p=0.790). One patient (5%) with type I injury died of multiorgan deficiency.

CONCLUSION

With close close clinical follow-up, medical treatment can be beneficial for most patients, and surgical procedures should be reserved for patients with type I (definite) and type II/III injuries; in patients with these clinical parameters, conservative management will likely be unsuccessful.

A systematic review of the management and outcome of ERCP related duodenal perforations using a standardized classification system

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.

ACR Appropriateness Criteria® Nonvariceal Upper Gastrointestinal Bleeding

Upper gastrointestinal bleeding (UGIB) remains a significant cause of morbidity and mortality with mortality rates as high as 14%. This document addresses the indications for imaging UGIB that is nonvariceal and unrelated to portal hypertension. The four variants are derived with respect to upper endoscopy. For the first three, it is presumed that upper endoscopy has been performed, with three potential initial outcomes: endoscopy reveals arterial bleeding source, endoscopy confirms UGIB without a clear source, and negative endoscopy. The fourth variant, "postsurgical and traumatic causes of UGIB; endoscopy contraindicated" is considered separately because upper endoscopy is not performed. When endoscopy identifies the presence and location of bleeding but bleeding cannot be controlled endoscopically, catheter-based arteriography with treatment is an appropriate next study. CT angiography (CTA) is comparable with angiography as a diagnostic next step. If endoscopy demonstrates a bleed but the endoscopist cannot identify the bleeding source, angiography or CTA can be typically performed and both are considered appropriate. In the event of an obscure UGIB, angiography and CTA have been shown to be equivalent in identifying the bleeding source; CT enterography may be an alternative to CTA to find an intermittent bleeding source. In the postoperative or traumatic setting when endoscopy is contraindicated, primary angiography, CTA, and CT with intravenous contrast are considered appropriate. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.