This study evaluated the early management experience of these perforations. Lateral fall perforation occurred during attempted stone removal. Endoscopic retroperitoneal fatpexy of a large ercp related jejunal perforation by using a new overthescope clip device in billroth ii anatomy. The expected rate of ercpinduced pancreatitis is generally between 1% and 7%.
Perforation ercprelated perforations were previously classified into 34 types, regardless of the site of perforation12, table 1. Eus and mrcp are equivalent to ercp for the detection of some pancreaticobiliary disorders such as choledocholithiasis but lack the risk of pancreatitis associated with ercp. Infection cholangitis the rate of postercp cholangitis is 1% or less. Other complications of ercp are duodenal hemorrhage and cholangitis. Endoscopic retrograde cholangiopancreatography ercp. Effect of postercp pancreatitis on perioperative factors. Retroperitoneal air after ercp with sphincterotomy.
In 5 patients, duodenal perforation was immediately noticed during the ercp procedure, and in 1 patient the diagnosis was made after routine postercp abdominal radiography. Evidencebased strategies are lacking regarding the appropriate management of duodenal perforations complicating endoscopic retrograde cholangiopancreatography ercp combined with endoscopic sphincterotomy es. In 2011, kim et al14 proposed a new classification based on the instrument that caused the perforation. Perforation recognized or suspected at ercp periampullary perforation guidewire perforation duodenal perforation npo antibiotics clinical observation biliary stent or nasobiliary tube npo, antibiotics ct. Amylase and lipase elevations often occur after ercp even in asymptomatic patients 7. The diagnosis of a duodenal perforation is usually made at ercp by a limited contrast study through the endoscope.
During balloon sweepings the scope snapped and hit the duodenal wall opposite to the ampullary area. This has led some authors to recommended early operation in all duodenal perforations. Lavage and drainage in addition to suturing perforation site were performed immediately after diagnosis in all cases, and the postoperative course. Endoscopy shows a high sensitivity and specificity for diagnosis of iatrogenic perforation 11. Laparoscopicassisted spleen preserving distal pancreatectomy is a safe operation that should.
Ercp induced duodenal perforation successfully treated with endoscopic pursestring suture. Two perforations were incidentally diagnosed in an asymptomatic patient in. Postercp perforation is burdened by a high risk of mortality. Postercp pancreatitis is feared coma plication that is associated with substantial morbidity and occasional mortality 4 5.
Management of duodenopancreatobiliary perforations after. Perforation is a rare but serious adverse event of ercp. The abdominal radiographs of 4 patients 36% showed intraabdominal free air. Acute pancreatitis occurs in approximately 5% of diagnostic procedures and 10% of therapeutic procedures. Experience in the management of the complication surgical team 4. There is no consensus to guide the clinician on the management of ercprelated perforations, with particular controversy surrounding the immediate surgical management of postprocedurally detected duodenal perforation because of overextension of a sphincterotomy. The timing of diagnosis is critical for management and patient outcome 810. Iatrogenic duodenal perforations caused by endoscopic biliary stenting and stent migration.
During ercp, fluoroscopy revealed abnormal perinephric gas shadowing after breaking and extracting the stones. Major complications of ercp include pancreatitis, hemorrhage, cholangitis, and duodenal perforation4,5. M1660 management of ercprelated duodenal perforations. Between november 2003 and december 2011, a total of 8504 ercps were performed at our regional endoscopy center.
Acute iatrogenic perforation during endoscopy is defined as the presence of gas or luminal contents outside the gastrointestinal tract 7. There were 12 patients with duodenal perforation and 2 with biliary perforation. Perforation region were duodenal second portion in 2 patients and duodenal bulbus in 1. Ct of the abdomen demonstrated biliary and pancreatic duct. N2 iatrogenic duodenal and pancreaticobiliary perforations associated with endoscopic retrograde cholangiopancreatography ercp are rare but associated with a significant morbidity and mortality.
This is a pdf file of an unedited manuscript that has been accepted for publication. The occurrence of free air in the peritoneal cavity post ercp is usually the result of duodenal or ductal perforation related to therapeutic ercp and sphincterotomy4,68. Half of patients can be treated conservatively, but in case of sepsis or unstable general conditions, early surgical procedure is indicated as the. The most common complications are postercp pancreatitis 1. Endoscopic treatment of a large duodenal perforation. Ercp complications and challenges in their diagnosis and. Here, we report a case of ercpinduced duodenal perforation successfully treated with endoscopic pursestring suture. Postendoscopic retrograde cholangiopancreatography. The patient remained hospitalized with a diagnosis of postercp and sphincterotomy duodenal perforation. Some advocate a nonsurgical approach to management in certain select patients.
Surgical management of duodenal perforations after ercp. Sepsis may occur in patients with partial obstruction of common bile duct. Materials and methods between march 2003 and march 20, 2,071 ercps were performed in our hospital. Methods of reducing post ercp pancreatitis patient selection appropriate patient selectionis instrumental inreducing the incidence of pep. His medical history included heart failure, atrial fibrillation for which warfarin was prescribed, and a pacemaker. Computed tomography revealed localized collections in 9 64% patients.
The most frequent postercp perforation was stapfer type ii 177 patients, 58. Three cases of duodenal perforation following ercp keio. Early clinical and radiographic features have to be used to determine which type of surgical or conservative treatment is indicated. After successful medical management of a patient with a clinical picture suggestive of postsphincterotomy duodenal perforation, in which a computerized axial tomography cat scan of the abdomen revealed the presence of subcutaneous emphysema and retroperitoneal air, concern arose as to the frequency of pneumoretroperitoneum following. Management of perforation after endoscopic retrograde. It is generally agreed that some ercp related perforations can be successfully managed without surgery 8,9,10,11. The patient underwent emergency surgery after which she was admitted to the icu but her evolution was torpid, and she died. Pancreaticoduodenectomy pd is performed foralso patients with periampullary and pancreas head cancer. Management of ercprelated small bowel perforations. Perforation of the duodenum is a recognized complication of endoscopic retrograde cholangiopancreatography ercp.
Non surgical treatment is justified after polypectomy if there is a quick clinical improvement. Management of duodenal perforation after endoscopic. Algorithm for the management of ercprelated perforations. The incidence of perforation reported by recent series ranges from 0. The material includes 19 patients who underwent ercp in the years 20082011 and were subsequently diagnosed with duodenal perforation except for duodenal bulb and common bile duct cbd. Background and aims perforation is a rare but serious adverse event of ercp. In an attempt to classify post ercp duodenal perforation stapfer, et al. M1660 management of ercprelated duodenal perforations m1660 management of ercprelated duodenal perforations dubecz, attila. Case report of rescue terap for ile duct perforation using. Iatrogenic duodenal injuries ercp was first introduced in 1968 by mccune et al and has evolved over the decades currently, it is a valuable, widely used diagnostic and therapeutic tool in hepatobiliarypancreas diseases ercp has a relatively high complication rate of nearly 10% and a mortality rate of 0. Endoscopic retrograde cholangiopancreatography ercp is a procedure that should be performed by a skilled endoscopist to maximize the success rate and minimize complications, which occur in 5%10% of cases1,2. Perforation after endoscopic retrograde cholangiopancreatography ercp is a rare complication, but it is associated with significant mortality.
Endoscopic retrograde cholangiopancreatography ercp related perforations are a rare but serious complication. Endoscopic retrograde cholangiopancreatographyrelated perforation 18144 int j clin exp med 2016. Reattempt ercp cohort study at tertiary care in australia 51pts referred with failed ercp bile duct stones 45% malignant stricture 18% benign stricturebile leak 11% successful ercp 100% required needle knife for access 27% post ercp pancreatitis 3. Ercpinduced duodenal perforation successfully treated with endoscopic pursestring suture. A few perforations however result in lifethreatening retroperitoneal necrosis and require surgical intervention. An elevation in the serum amylase concentration is common after endoscopic retrograde cholangiopancreatography ercp, occurring in up to 75 percent of patients. Ercp in one case and, in the second case, perforation was evident during ercp and a biliary stent was inserted. An 83yearold man with an 18month history of a previously assumed benign duodenal stricture and relapsing pancreatitis was transferred from an outside hospital with newonset obstructive jaundice.
Endoscopic suturing of a large type i duodenal perforation. For example, epigastric abdominal pain after ercp can occur from other causes, such as duodenal perforation, excessive contrast injection, or air insufflation. Perforation ercprelated perforation occurs in 0 3%related perforation occurs in 0. Research article endoscopic closure for eus and ercp. Management of duodenal perforations after endoscopic retrograde cholangiopancreatography.
Eus and ercp related duodenal perforation occurred in cases. Duodenal perforation post ercp is rare, occurring in 1% range 0. Perforation of approximately 1 cm is evident in the duodenal wall contralateral to the papilla over a duodenal diverticulum. Early management experience of perforation after ercp. Endoscopic retroperitoneal fatpexy of a large ercprelated jejunal perforation by using a new overthescope clip device in billroth ii anatomy. Radiology ruled out the presence of subphrenic air, however, a cat scan of the abdomen revealed retroperitoneal air, but not collections or free fluid. To present the results of treatment of gastrointestinal perforation after ercp and indicate the correct procedure for such cases. Conservative management of duodenal perforation following. Treatment results of gastrointestinal perforation after.
Ercpinduced duodenal perforation successfully treated. In an attempt to classify postercp duodenal perforation stapfer, et al. The perforation is a rare but serious complication of the endoscopy of gastrointestinal tract, which can be healed. Vivek kumbhari, md, from the department of medicine, division of gastroenterology and hepatology, johns hopkins medical institutions, in baltimore, maryland, usa discusses this original article algorithm for the management of ercprelated perforations. Eleven of our fourteen perforations 79% were suspected at the time of ercp. Most are minor perforations that settle with conservative management. Due to the discrete nature of the symptoms and the absence of signs of peri. We report two cases of duodenal perforations following endoscopic sphincterotomy. Risk factors are sphincter of oddi dysfunction and young age.
Advanced endoscopic technology should be considered early diagnosis of postercp perforation, when performed during ercp, or. Surgical or endoscopic management for postercp large. Prevention and management of postercp pancreatitis. Management of duodenal perforations after endoscopic. Postercp duodenal perforation was diagnosed during the procedure in two patients and on the next day in one. Duodenal perforation is an uncommon complication of endoscopic retrograde cholangiopancreatography ercp and a rare complication of upper gastrointestinal endoscopy. Endoscopic retrograde cholangiopancreatographyrelated. 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. As a service to our customers we are providing this early version of the manuscript. Iatrogenic duodenal injuries suny downstate medical center. The focus of this study was to assess patient outcomes using a predetermined algorithm. The most common causes of postercp pain are acute pancreatitis and duodenal perforation.
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