Left hepatic artery pseudoaneurysm complicating endoscopic retrograde cholangiopancreatography: A case report

BACKGROUND

Pseudoaneurysms of the hepatic artery or its branches have been reported following abdominal trauma, iatrogenic injury at the time of many operations such as percutaneous transhepatic biliary drainage and cholecystectomy. Hepatic artery pseudoaneurysms after endoscopic retrograde cholangiopancreatography (ERCP) are uncommon and potentially life threatening and should be identified and treated rapidly.

CASE SUMMARY

We report a case of intra-abdominal hemorrhage secondary to a left hepatic artery pseudoaneurysm resulting from guide wire injury at ERCP. The patient primary diagnosis was acute biliary pancreatitis with cholangitis, he underwent ERCP on the third day of admission. During ERCP, the left intrahepatic bile duct was cannulated three times. Over the sixth day, Contrast enhanced computed tomography scan demonstrated left hepatic lobe contusion and a pseudoaneurysm formation. The patient was successfully treated with the embolization of a small branch of left hepatic artery angiographically.

CONCLUSION

The common complications of ERCP are pancreatitis, bleeding and perforation. False aneurysms occur as a result of damage to the wall of an artery. As far as we know, it is rare complication has been reported following ERCP. We advise urgent referral for angiographic embolization in this situation to avoid aneurysm rupture.

Management of difficult or failed biliary access in initial ERCP: A review of current literature

Selective bile duct cannulation is the prerequisite for all endoscopic biliary therapeutic interventions, but this cannot always be achieved easily. Despite advances and new developments in endoscopic accessories, selective biliary access fails in 5%-15% of cases, even in expert high volume centers. Various techniques - such as double-guidewire induced cannulation, pre-cut papillotomy or transpancreatic sphincterotomy with or without placement of a pancreatic stent - have been used to improve cannulation success rates. Repeated and prolonged attempts at cannulation increase the risk of pancreatitis. Repeating the ERCP within a few days after initial failed pre-cut is a successful strategy and should be tried before contemplating more invasive, alternative interventions such as percutaneous-endoscopic or endoscopic ultrasound guided rendezvous procedure, percutaneous transhepatic or surgical intervention. However, standard guidelines or sequential protocol has not been existed up to now. In certain circumstances, there are unique clinical indications for which invasive, alternative interventions should be preferred. We present and discuss the methods that can be used in difficult or failed initial ERCP, therefore to provide practical advice for endoscopists, especially those who are inexperienced.

Risk Factors for the Development of Stent-Associated Cholangitis Following Endoscopic Biliary Stent Placement

BACKGROUND AND AIM

To elucidate the overall risk and risk factors for developing cholangitis following biliary stent placement by endoscopic retrograde cholangiopancreatography (ERCP) and to determine the clinical outcomes of these individuals.

METHODS

We performed a retrospective review of 796 patients who had undergone 1127 ERCPs with biliary stent placement between 2007 and 2015 at a single tertiary care center. There were 91 episodes of stent-associated cholangitis (SAC) during the study period. Data obtained through the medical records included ERCP indication, patient factors (biliary anatomy, demographics, and comorbidities), stent characteristics (material, length, and design), change in serum bilirubin, stent indwelling time, rates and etiologies of bacteremia, and the mortality rate.

RESULTS

Those with SAC were more likely to have an anatomic biliary stricture (13.1% vs. 2.3%, p < .0001), with hilar and multiple strictures having the highest risk (19.1% vs. 11.6%, p = .04). The ERCP indication of malignant biliary obstruction was associated with higher rates of SAC (15.6% vs. 3.4%, p = < .0001). Rates of SAC were higher in those who failed to normalize total bilirubin (16.9% vs. 7.8%, p = .0005), and these episodes occurred earlier compared to those who normalized total bilirubin (median 30.5 days vs. 140.5 days, p < .0001).

CONCLUSIONS

Patients at increased risk of SAC include those with an anatomic stricture, malignant biliary obstruction, and those who fail to normalize total bilirubin after biliary stent placement. Future protocols should be designed to reduce the risk of cholangitis in these populations.

Retroperitoneal Perforation Caused by Migration of a Pancreatic Spontaneous Dislodgement Stent into Periampullary Diverticula

An 85-year-old woman underwent endoscopic retrograde cholangiopancreatography (ERCP) for obstructive jaundice. Selective bile duct cannulation was unsuccessful because of periampullary diverticula (PAD). A pancreatic spontaneous dislodgement stent (PSDS) (5F diameter, 3 cm, straight type) was inserted to prevent post-ERCP pancreatitis. Three days after ERCP, she complained of abdominal pain, and computed tomography revealed retroperitoneal perforation because of PSDS migration to the PAD. If the papillary orifice is observed at the diverticular rim or in the diverticula, a pigtailed PSDS on the duodenal side or flanged stent on the pancreatic ductal side should be inserted in order to prevent this rare adverse event.

ERCP-related perforations in the new millennium: A large tertiary referral center 10-year experience

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.