Primary endoscopic approximation suture under cap-assisted endoscopy of an ERCP-induced duodenal perforation

Management of ERCP-Related Perforations: A Single-Center Experience

Background/Objectives: Perforations represent rare but serious complications in ERCP. Although several therapeutic algorithms have been proposed to properly address these potentially life-threatening events, there is still no clear consensus on their management. We conducted a single-center retrospective study in order to assess the incidence of ERCP-related perforations and their management, as well as clinical outcomes. Methods: The hospital's electronic database was searched in order to identify all the patients who developed ERCP-related perforations in the period 1 October 2018-30 June 2023. Perforations were classified according to the Stapfer classification. Conservative management included frequent abdominal examinations, the monitoring of vital signs, white blood cell count, complete bowel rest, nasogastric tube placement, and the administration of intravenous fluids and antibiotics. Endoscopic management included biliary stent placement and/or closing observed defects with clips. Results: We recorded eight (1.29%) cases of ERCP-related perforations out of the 619 procedures conducted. We observed six (75%) Stapfer type II and two (25%) type IV perforations. In all but one patient (87.5%), the indication for ERCP was bile duct stones. Seven patients (87.5%) were subjected to sphincterotomy (87.5%) and three (37.5%) to "pre-cuts". All but one patient was treated conservatively (87.5%), with two of them-in which type II perforations were recognized intraprocedurally-also receiving endoscopic treatment with stent placement. On the day of ERCP, one patient with a type II perforation was operated on; suturing of the duodenum followed by duodenal exclusion was applied. Management was successful in all the patients, with a mean hospitalization time of 16.6 ± 4.78 days. Conclusions: Conservative and endoscopic management appear to be associated with good outcomes in Stapfer type II perforations. Nevertheless, an individual multidisciplinary approach involving endoscopists and a hepatobiliary surgeon is essential in order to properly guide the treatment.

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.

Double Iatrogenic Esophageal and Duodenal Injury Induced by Endoscopic Retrograde Cholangiopancreatography: A Case Report

Endoscopic retrograde cholangiopancreatography (ERCP) is a frequently performed procedure in the management of hepatobiliary diseases that can be conducted as a therapeutic or diagnostic procedure. Also, it can be done with or without sphincterotomy and stent insertion. Hemorrhage is one of the most common post-ERCP complications, which can be presented as late as 10 days. Other complications include post-ERCP pancreatitis and perforation. Gut perforation during ERCP is rare but often lethal. Here we present a 35-year-old female who was admitted to the hospital through the ER as a case of obstructive jaundice with common bile duct (CBD) stone. ERCP with stent insertion was performed for the patient to relieve the obstruction; however, intra-procedural retroperitoneal perforation was encountered.

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.

[Endoscopic Band Ligation in Endoscopic Retrograde Cholangiopancreatography Related Duodenal Perforation]

Although ERCP is a therapeutic endoscopic procedure in pacreatico-biliary diseases, its rare complications, including pancreatitis, duodenal perforation, and bleeding, can be fatal. An 87-year-old woman with a history of gallbladder cancer presented with jaundice and general weakness. Her skin color was yellowish and epigastric tenderness was confirmed on a physical examination. On abdomen CT, the gallbladder cancer directly invaded the duodenum, common bile duct, and liver parenchyma. Enlarged portocaval lymph nodes obstructed the extrahepatic bile duct. ERCP was performed for bile duct decompression. When shortening of endoscopy was achieved, the duodenal lateral wall was perforated because of the endoscopic tip pressure. After inserting endoscopic retrograde biliary drainage and endoscopic nasobiliary drainage, endoclips were placed evenly around the defect, and a detachable snare was tightened around the endoclips. Three days later, the duodenal wall was not sealed on the abdomen CT scan. Repeat endoscopy was achieved, and the endoscopic nasobiliary drainage, endoscopic retrograde biliary drainage, endoclips, and detachable snare were removed. From the distal margin of the perforation, band ligation was performed, and a detachable snare was applied. The patient's condition improved after the second procedure. A percutaneous biliary stent was inserted, and she was discharged. This case highlights the successful endoscopic management of ERCP-related duodenal perforation.

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.

Diagnosis and management of iatrogenic endoscopic perforations: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement - Update 2020

1:  ESGE recommends that each center implements a written policy regarding the management of iatrogenic perforations, including the definition of procedures that carry a higher risk of this complication. This policy should be shared with the radiologists and surgeons at each center. 2 : ESGE recommends that in the case of an endoscopically identified perforation, the endoscopist reports its size and location, with an image, and statement of the endoscopic treatment that has been applied. 3:  ESGE recommends that symptoms or signs suggestive of iatrogenic perforation after an endoscopic procedure should be rapidly and carefully evaluated and documented with a computed tomography (CT) scan. 4 : ESGE recommends that endoscopic closure should be considered depending on the type of the iatrogenic perforation, its size, and the endoscopist expertise available at the center. Switch to carbon dioxide (CO2) endoscopic insufflation, diversion of digestive luminal content, and decompression of tension pneumoperitoneum or pneumothorax should also be performed. 5 : ESGE recommends that after endoscopic closure of an iatrogenic perforation, further management should be based on the estimated success of the endoscopic closure and on the general clinical condition of the patient. In the case of no or failed endoscopic closure of an iatrogenic perforation, and in patients whose clinical condition is deteriorating, hospitalization and surgical consultation are recommended.

Emergency Laparoscopic Repair of an Iatrogenic Gastric Perforation in a Hiatal Hernia following a Failed Endoscopic Closure

Iatrogenic gastrointestinal perforation is a rare, life-threatening complication of endoscopic procedures, which requires either endoscopic or surgical repair. We report the account of an 82-year-old woman with an iatrogenic gastric perforation of a hiatal hernia secondary to an endoscopic retrograde cholangiopancreatography (ERCP) procedure. Despite immediate recognition of the complication and endoscopic closure with through-the-scope (TTS) clips, the patient developed mediastinitis, peritonitis, and sepsis. She subsequently underwent an emergency laparoscopic hiatal hernia dissection and repair of the perforation with mediastinal and peritoneal washout. Given the patient's age and the degree of insult, subdiaphragmatic anchoring with abdominal drain placement was performed, and the hiatus was left open for additional drainage. The use of a side-viewing duodenoscope with the presence of a large hiatal hernia contributed to the risk of gastric perforation. We conclude that performing endoscopic procedures in patients with a known hiatal hernia should be carefully undertaken. If a perforation in such patients occurs, laparoscopic repair of such complications is feasible as demonstrated in this case video.

Endoscopic management of duodenal perforations caused by migrated biliary plastic stents

Background and study aims  Duodenal perforation by migration of plastic stents placed to treat biliary lesions is rare but can be life-threatening. Surgical management is preferred, but it may increase risks of mortality and morbidity, especially in patients with underlying comorbidities and those of advanced age. We describe five cases of duodenal perforation that were successfully managed endoscopically. Four patients were elderly, and one had end-stage renal disease. We used cylindrically adapted cap-fitted endoscopy to successfully retrieve migrated plastic stents and to close the perforated walls with hemoclips. No post-procedural complication was noted. In conclusion, endoscopic management is appropriate as a first-line approach in patients with duodenal perforations caused by plastic stent migration.

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.

Repair of an Endoscopic Retrograde Cholangiopancreatography-Related Large Duodenal Perforation Using Double Endoscopic Band Ligation and Endoclipping

Endoscopic closure techniques have been introduced for the repair of duodenal wall perforations that occur during endoscopic retrograde cholangiopancreatography (ERCP). We report a case of successful repair of a large duodenal wall perforation by using double endoscopic band ligation (EBL) and an endoclip. Lateral duodenal wall perforation occurred during ERCP in a 93-year-old woman with acute calculous cholangitis. We switched to a forward endoscope that had a transparent band apparatus. A 2.0-cm oval-shaped perforation was found at the lateral duodenal wall. We repaired the perforation by sequentially performing double EBL and endoclipping. The first EBL was performed at the proximal edge of the perforation orifice, and two-thirds of the perforation were repaired. The second EBL, which also included the contents covered under the first EBL, repaired the defect almost completely. Finally, to account for the possible presence of a residual perforation, an endoclip was applied at the distal end of the perforation. The detection and closure of the perforation were completed within 10 minutes. We suggest that double EBL is an effective method for closure.

New devices and techniques for endoscopic closure of gastrointestinal perforations

Gastrointestinal perforations, which need to be managed quickly, are associated with high morbidity and mortality. Treatments used to close these perforations range from surgery to endoscopic therapy. Nowadays, with the development of new devices and techniques, endoscopic therapy is becoming more popular. However, there are different indications and clinical efficacies between different methods, because of the diverse properties of endoscopic devices and techniques. Successful management also depends on other factors, such as the precise location of the perforation, its size and the length of time between the occurrence and diagnosis. In this study, we performed a comprehensive review of various devices and introduced the different techniques that are considered effective to treat gastrointestinal perforations. In addition, we focused on the different methods used to achieve successful closure, based on the literature and our clinical experiences.

[Endoscopic Duodenal Snare Papillectomy Induced Complication: Prevention and Management]

Tumors of the major duodenal papilla are being recognized more often because of the increased use of diagnostic upper endoscopy and ERCP. The standard of management for ampullary tumor is local surgical excision or pancreaticoduodenectomy, but these procedures are associated with significant mortality, as well as post-operative and long-term morbidity. Endoscopic snare papillectomy was introduced as an alternative to surgery, but post-procedure complications are serious drawback. The most serious complications are perforation, delayed bleeding and pancreatitis. Identification of high risk patients, early recognition of complications, and aggressive management abates frequency and severity. Prevention and management of endoscopic duodenal papillectomy-induced complications will be reviewed in this article.

Recent Advanced Endoscopic Management of Endoscopic Retrograde Cholangiopancreatography Related Duodenal Perforations

The management strategy for endoscopic retrograde cholangiopancreatography-related duodenal perforation can be determined based on the site and extent of injury, the patient’s condition, and time to diagnosis. Most cases of perivaterian or bile duct perforation can be managed with a biliary stent or nasobiliary drainage. Duodenal wall perforations had been treated with immediate surgical repair. However, with the development of endoscopic devices and techniques, endoscopic closure has been reported to be a safe and effective treatment that uses through-the-scope clips, ligation band, fibrin glue, endoclips and endoloops, an over-the-scope clipping device, suturing devices, covering luminal stents, and open-pore film drainage. Endoscopic therapy could be instituted in selected patients in whom perforation was identified early or during the procedure. Early diagnosis, proper conservative management, and effective endoscopic closure are required for favorable outcomes of non-surgical management. If endoscopic treatment fails, or in the cases of clinical deterioration, prompt surgical management should be considered.

Endoscopic "rescue" treatment for gastrointestinal perforations, anastomotic dehiscence and fistula

Luminal perforations and anastomotic leaks of the gastrointestinal tract are life-threatening events with high morbidity and mortality. Early recognition and prompt therapy is essential for a favourable outcome. Surgery has long been considered the "gold standard" approach for these conditions; however it is associated with high re-intervention morbidity and mortality. The recent development of endoscopic techniques and devices to manage perforations, leaks and fistulae has made non-surgical treatment an attractive and reasonable alternative approach. Although endoscopic therapy is widely accepted, comparative data of the different techniques are still lacking. In this review we describe, benefits and limitations of the current options in the management of patients with perforations and leaks, in order to improve outcomes.

Endoluminal Closure of Colon Perforation with Endoscopic Band Ligation: Technical Feasibility and Safety in an In Vivo Canine Model

BACKGROUND/AIMS

Endoscopic band ligation (EBL) is an accepted method in the management of variceal bleeding; however, there is little evidence on the safety and feasibility of EBL for the closure of bowel perforation. In this study, we aimed to evaluate the technical feasibility and efficacy of EBL in iatrogenic colon perforation by using a canine model.

METHODS

We established an iatrogenic colon perforation model by using seven beagle dogs. Longitudinal 1.5- to 1.7-cm colon perforations were created with a needle knife and an insulated-tip knife, and the perforation was subsequently closed with EBL. During a 2-week follow-up period, the animals were carefully monitored and then euthanized for pathologic examination.

RESULTS

The EBL of iatrogenic colon perforations was successful in all dogs. The mean procedure time for EBL closure with one to three bands was 191.7 seconds, and there were no immediate complications. One animal was euthanized after 3 days because of peritonitis. There were no clinical and laboratory features of sepsis or peritonitis in the remaining six animals. On necropsy, we did not find any fecal peritonitis, pericolonic abscess formation, or transmural dehiscence at the perforation site. Histopathology demonstrated inflamed granulation tissue and scar lesions replaced by fibrosis.

CONCLUSIONS

EBL might be a feasible and safe method for the management of iatrogenic colon perforations in an in vivo model.

Endoscopic closure of acute perforations of the GI tract: a systematic review of the literature

BACKGROUND

Surgical repair of endoscopic perforations of the GI tract used to be the standard, but immediate, secure endoscopic closure has become an attractive alternative treatment with the potential to reduce morbidity and mortality.

OBJECTIVE

We aimed to perform a systematic review of the medical literature on endoscopic closure of acute iatrogenic perforations of the GI tract.

DESIGN

A systematic review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines.

SETTING

Available medical literature from 1966 through November 2013.

PATIENTS

Patients with an acute perforation after an endoscopic procedure that was closed endoscopically.

INTERVENTIONS

Endoscopic closure of an acute perforation of the GI tract.

MAIN OUTCOME MEASUREMENTS

Clinically successful endoscopic closure.

RESULTS

In our search, we identified 726 studies, 702 of which had to be excluded. Twenty-four cohort studies (21 retrospective, 3 prospective) were included in the analysis. No randomized trials were identified. Overall, the methodological quality was low. The 24 studies included described 466 acute perforations in which endoscopic closure was attempted. Successful endoscopic closure was achieved in 419 cases (89.9%; 95% CI, 87%-93%). Successful closure was achieved in 90.2% (n = 359; 95% CI, 87%-93%) of cases by using endoclips, in 87.8% (n = 58; 95% CI, 78%-95%) by using the over-the-scope-clip, and in 100% (n = 2) by using a metal stent.

LIMITATIONS

Low methodological quality of included studies.

CONCLUSION

This systematic review suggests that endoscopic perforation closure is a safe and effective alternative for surgical intervention in selected cases; however, the overall methodological quality was low. Prospective, true consecutive studies are needed to define the definitive role of endoscopic closure of perforations.

[Duodenal perforations after endoscopic retrograde cholangiopancreatography]

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.

Endoscopic retrograde cholangiopancreatography-related perforation: Management and prevention

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.

The management of endoscopic retrograde cholangiopancreatography-related duodenal perforation

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.

Endoscopic treatment of iatrogenic gastrointestinal perforations: an overview

In the past, the treatment of iatrogenic gastrointestinal perforations was limited to surgical management or to medical observation. Natural Orifice Transluminal Endoscopic Surgery (NOTES) has paved the way towards the development of reliable endoscopic closure techniques, which can be applicable in accidental perforations of the gastrointestinal tract. When endoscopic treatment is feasible, hemoclips are preferred in smaller perforations, while over-the-scope-clips or a combination of hemoclips, endoloops, and glue are used in larger ones. Endoscopic stitching is rarely utilized, and endoscopic stapling has been practically abandoned. The use of self-expandable covered stents can be considered in the esophagus and duodenum. Broad spectrum antibiotics are recommended in most cases. Clinical follow-up in a medico-surgical unit is mandatory and surgical intervention should not be delayed more than 24h if clinical or biological worsening occurs. Imaging with oral contrast medium is advisable before resumption of oral feeding in the case of large perforations.

Emergencies after endoscopic procedures

Endoscopy adverse events (AEs), or complications, are a rising concern on the quality of endoscopic care, given the technical advances and the crescent complexity of therapeutic procedures, over the entire gastrointestinal and bilio-pancreatic tract. In a small percentage, not established, there can be real emergency conditions, as perforation, severe bleeding, embolization or infection. Distinct variables interfere in its occurrence, although, the awareness of the operator for their potential, early recognition, and local organized facilities for immediate handling, makes all the difference in the subsequent outcome. This review outlines general AEs' frequencies, important predisposing factors and putative prophylactic measures for specific procedures (from conventional endoscopy to endoscopic cholangio-pancreatography and ultrasonography), with comprehensive approaches to the management of emergent bleeding and perforation.

Endoscopic treatments of endoscopic retrograde cholangiopancreatography-related duodenal perforations

Iatrogenic duodenal perforation associated with endoscopic retrograde cholangiopancreatography (ERCP) is a very uncommon complication that is often lethal. Perforations during ERCP are caused by endoscopic sphincterotomy, placement of biliary or duodenal stents, guidewire-related causes, and endoscopy itself. In particular, perforation of the medial or lateral duodenal wall usually requires prompt diagnosis and surgical management. Perforation can follow various clinical courses, and management depends on the cause of the perforation. Cases resulting from sphincterotomy or guidewire-induced perforation can be managed by conservative treatment and biliary diversion. The current standard treatment for perforation of the duodenal free wall is early surgical repair. However, several reports of primary endoscopic closure techniques using endoclip, endoloop, or newly developed endoscopic devices have recently been described, even for use in direct perforation of the duodenal wall.

Perforations following endoscopic retrograde cholangiopancreatography: a single institution experience and surgical recommendations

BACKGROUND

Perforation after endoscopic retrograde cholangiopancreatography (ERCP) is uncommon, and its management is dependent on the mechanism and the graded classification of injury.

METHODS

Records of patients undergoing ERCP were analyzed over a 16-year period, patterning the types of injuries, diagnosis, management, and patient outcome. Type I injuries damage the medial or lateral duodenal wall before sphincter cannulation. Type II injuries are periampullary and occur as a result of a precut or a papillotomy. Type III injuries occur secondary to guidewire insertion or stone extraction from the common bile duct. Type IV injuries are probably microperforations that are noted on excessive insufflation during and after ERCP withdrawal.

RESULTS

Between 1995 and 2011, 27 perforations were identified from 1,638 ERCP procedures (1.6%). Nearly half of the procedures were regarded as difficult by the endoscopist, with 70% of the ERCPs (19 of 27) being for therapeutic indications. There were 5 type I, 12 type II, 5 type III, and 5 type IV perforations, of which 18 cases were diagnosed at the time of ERCP. Delayed diagnosis of type I perforations that were associated with free intraperitoneal air and contrast leakage proved fatal. Most type II perforations required immediate surgery with pyloric exclusion; delayed surgery with simple drainage had a high mortality rate. Most type III and type IV injuries can successfully be managed conservatively without delayed sepsis.

CONCLUSIONS

In perforation, the mechanism of injury during ERCP predicts the need for surgical management. Type I and type II injuries require early diagnosis and aggressive surgery, whereas type III and type IV injuries may be managed conservatively.

Unusual complications related to endoscopic retrograde cholangiopancreatography and its endoscopic treatment

Endoscopic retrograde cholangiopancreatography (ERCP)-induced complications, once occurred, can lead to significant morbidity. Commonly 5% to 10% of patients experience procedure related complications such as post-ERCP pancreatitis, biliary hemorrhage, and cholangitis, in descending order. However, complications such as perforation, pneumothorax, air embolism, splenic injury, and basket impaction are rare but are associated with high mortality if occurred. Such unexpected unusual complications might extend the length of hospitalization, require urgent surgical intervention, and put the patient in miserable condition leading to permanent disability or mortality. Although these ERCP-induced complications can be minimized by a skilled operator using advanced techniques and devices, the occurrence of unusual complications are hard to expect and induce very difficult management condition. In this review, we will focus on the uncommon complications related to ERCP. This review is also aimed at suggesting optimal endoscopic treatment strategies for several complications based on our institutional experiences.

Efficacy of cap-assisted endoscopy for routine examining the ampulla of Vater

AIM: To determine the efficacy of a cap-assisted endoscopy (CAE) to completely visualize the ampulla of Vater (AV) in patients failed by conventional endoscopy.

METHODS: A prospective study was conducted on 120 patients > 20 years of ages who visited the Health Promotion Center of Chungbuk National University Hospital for conscious sedation esophagogastroduodenoscopy (EGD) as a screening test from July to October, 2011. First, forward-viewing endoscopy was performed with reasonable effort using a push and pull method. We considered complete visualization of the AV when we could observe the entire AV including the orifice clearly, and reported the observation as complete or incomplete (partial or not found at all). Second, in cases of complete failure of the observation, an additional AV examination was conducted by attaching a short cap (D-201-10704, Olympus Medical Systems, Tokyo, Japan) to the tip of a forward-viewing endoscope. Third, if the second method failed, we replaced the short cap with a long cap (MH-593, Olympus Medical Systems) and performed a re-examination of the AV.

RESULTS: Conventional endoscopy achieved complete visualization of the AV in 97 of the 120 patients (80.8%) but was not achieved in 23 patients (19.2%). Age (mean ± SD) and gender [male (%)] were not significantly different between the complete observation and the incomplete observation groups. Additional short CAE was performed in patients in whom we could not completely visualize the AV. This group included 13 patients (10.9%) with partial observation of the AV and 10 (8.3%) in which the AV was not found. Short CAE permitted a complete observation of the AV in 21 of the 23 patients (91.3%). Patients in whom visualization of the AV failed with short CAE had satisfactory outcomes by replacing the short cap with a long cap. The additional time for CAE took an average of 141 ± 88 s. There were no complications and no significant mucosal trauma.

CONCLUSION: CAE is safe to use as a salvage method to achieve complete visualization of the AV when a regular EGD examination fails.

Early management experience of perforation after ERCP

Background and Aim. Perforation after endoscopic retrograde cholangiopancreatography (ERCP) is a rare complication, but it is associated with significant mortality. This study evaluated the early management experience of these perforations. Patients and Methods. Between November 2003 and December 2011, a total of 8504 ERCPs were performed at our regional endoscopy center. Sixteen perforations (0.45%) were identified and retrospectively reviewed. Results. Nine of these 16 patients with perforations were periampullary, 3 duodenal, 1 gastric fundus, and 3 patients had a perforation of an afferent limb of a Billroth II anastomosis. All patients with perforations were recognized during ERCP by X-ray and managed immediately. One patient with duodenal perforation and three patients with afferent limb perforation received surgery, others received medical conservative treatment which included suturing lesion, endoscopic nasobiliary drainage (ENBD), endoscopic retrograde pancreatic duct drainage (ERPD), gastrointestinal decompression, fasting, broad-spectrum antibiotics, and so on. All patients with perforation recovered successfully. Conclusions. We found that: (1) the diagnosis of perforation during ERCP may be easy, but you must pay attention to it. (2) Most retroperitoneal perforations can recover with only medical conservative treatment in early phase. (3) Most peritoneal perforations need surgery unless you can close the lesion up under endoscopy in early phase.

ERCP-related upper gastrointestinal perforation: an analysis of 11 cases

AIM: To analyze the causes and treatments of upper gastrointestinal perforation associated with endoscopic retrograde cholangiopancreatography (ERCP).

METHODS: The clinical data for 2 399 patients who underwent ERCP in Nanjing Drum Tower Hospital from August 31, 2008 to August 31, 2011 were analyzed retrospectively.

RESULTS: Of 2 399 patients, 11 (0.46%) developed upper gastrointestinal perforation. Of these 11 patients, 1 developed esophageal perforation, 1 had cardia perforation, 2 had duodenal bulb perforation, 5 had perforation in the descending duodenum and duodenal papilla; 2 underwent Birroth Ⅱ gastrectomy; 7 received conservative treatment, and 4 underwent surgical treatment.

CONCLUSION: ERCP-related upper gastrointestinal perforations are mainly iatrogenic. Early diagnosis and conservative treatment are essential for optimal outcome in patients with ERCP-related upper gastrointestinal perforations.

Bacterial peritonitis due to duodenal perforation by a fish bone in an elderly peritoneal dialysis patient

The patient, a 77-year-old-man, began peritoneal dialysis (PD) in August 2005. In January 2009, he developed lower abdominal pain and cloudy PD effluent. A diagnosis of peritonitis was made and Escherichia coli was detected in cultures of the PD effluent. An abdominal computed tomography scan showed a fish bone in the duodenal wall. An upper gastrointestinal endoscopy was performed, and a 3-cm fish bone was removed. We thus recommend careful investigation with the possibility of enteric peritonitis from the intestinal tract when E. coli is detected in effluent cultures during PD.

Triple-tube-ostomy: a novel technique for the surgical treatment of iatrogenic duodenal perforation

Although duodenal perforation is currently an infrequent complication of medical procedures, its incidence in the future predictably will increase as endoscopic treatment of duodenal neoplasms becomes more frequently used. In some cases, duodenal perforation is difficult to treat even surgically. We report here a novel technique called ‘triple-tube-ostomy’ for the treatment of iatrogenic duodenal perforation. Since November 2009, there have been three cases of iatrogenic perforation of the duodenum, due to various causes, which we have treated with our novel technique. The main principles of the technique are biliary diversion, decompression of the duodenum, and early enteral nutrition. All patients who underwent the triple-tube-ostomy procedure had good postoperative courses, with few complications. The novel surgical technique we describe in this report is safe, reliable, easy to learn and perform, and led to a good postoperative course in all cases where we performed it.

Closure of a persistent sphincterotomy-related duodenal perforation by placement of a covered self-expandable metallic biliary stent

Retroperitoneal duodenal perforation as a result of endoscopic biliary sphincterotomy is a rare complication, but it is associated with a relatively high mortality risk, if left untreated. Recently, several endoscopic techniques have been described to close a variety of perforations. In this case report, we describe the closure of a persistent sphincterotomy-related duodenal perforation by using a covered self-expandable metallic biliary (CEMB) stent. A 61-year-old Greek woman underwent an endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy for suspected choledocholithiasis, and a retroperitoneal duodenal perforation (sphincterotomy-related) occurred. Despite initial conservative management, the patient underwent a laparotomy and drainage of the retroperitoneal space. After that, a high volume duodenal fistula developed. Six weeks after the initial ERCP, the patient underwent a repeat endoscopy and placement of a CEMB stent with an indwelling nasobiliary drain. The fistula healed completely and the stent was removed two weeks later. We suggest the transient use of CEMB stents for the closure of sphincterotomy-related duodenal perforations. They can be placed either during the initial ERCP or even later if there is radiographic or clinical evidence that the leakage persists.