Eus and ercp related duodenal perforation occurred in cases. Case discussion perforation of the duodenum is a recognized complication of endoscopic retrograde cholangiopancreatography ercp. Diagnosis of perforation was both clinical and instrumental. Endoscopic retroperitoneal fatpexy of a large ercp related jejunal perforation by using a new overthescope clip device in billroth ii anatomy. Early management experience of perforation after ercp hindawi. It is generally agreed that some ercp related perforations can be successfully managed without surgery 8,9,10,11. Management of duodenopancreatobiliary perforations after. This has led some authors to recommended early operation in all duodenal perforations. It is rare for mesenteric fibromatosis to present with intestinal perforation and only one case been reported in the. From january 1999 to december 2011, 30 perforations after ercp were observed. Evidencebased strategies are lacking regarding the appropriate management of duodenal perforations complicating endoscopic retrograde cholangiopancreatography ercp combined with endoscopic sphincterotomy es. Duodenal perforation is an uncommon complication of endoscopic retrograde cholangiopancreatography ercp and a very rare complication of upper gastrointestinal endoscopy. Iatrogenic duodenal injuries suny downstate medical center. Acute iatrogenic perforation during endoscopy is defined as the presence of gas or luminal contents outside the gastrointestinal tract 7.
Temporary duodenal stenting as a bridge to ercp for. Research article endoscopic closure for eus and ercp. Perforation is another risk associated with ercp and occurs in approximately 1 in 1,000 ercps. Endoscopic retrograde cholangiopancreatography ercp related perforations are a rare but serious complication.
Septic complications of ercp include ascending cholangitis, liver abscess, acute cholecystitis, infected pancreatic pseudocyst, infection following perforation of a viscus, and less commonly, endocarditis. Duodenum perforation an overview sciencedirect topics. The etiology of the perforations were related to sphincterotomy in. However, if there is doubt about perforation at ercp, an immediate contrast upper gastrointestinal study or computed tomography scan should be obtained 7. Postercp duodenal perforation was diagnosed during the procedure in two patients and on the next day in one. Advanced endoscopic technology should be considered early diagnosis of postercp perforation, when performed during ercp, or in the recovery room. The diagnosis of a duodenal perforation is usually made at ercp by a limited contrast study through the endoscope. A case report john menachery yogesh chawla ajay duseja radha k. We report two cases of duodenal perforations following endoscopic sphincterotomy. Duodenal perforations are a rare complication during interventional endoscopy. This study evaluated the early management experience of these perforations. Pdf management of duodenal perforation postendoscopic.
Endoscopic cholangiopancreatography related perforation. Management of duodenal perforation after endoscopic. The mortality rate increases dramatically with late surgical. Early management experience of perforation after ercp article pdf available in gastroenterology research and practice 201212. The management of perforation after endoscopic retrograde. Perforation ercprelated perforations were previously classified into 34 types, regardless of the site of perforation12, table 1. The incidence of perforation reported by recent series ranges from 0. Postendoscopic retrograde cholangiopancreatography. Duodenal perforation is an ercprelated complication that. Perforation injuries, or injuries that cause a hole in the esophagus or stomach during this procedure, are rare. With the improvement of the endoscopic and surgical treatments of duodenal perforation, the outcomes have improved 3,4. Percutaneous retrieval of a biliary stent after migration. Endoscopic retrograde cholangiopancreatographyrelated perforation 18144 int j clin exp med 2016.
Uneventful duodenal perforation during endoscopic retrograde. Endoscopic retrograde cholangiopancreatographyrelated. Duodenal perforations after endoscopic retrograde cholangiopancreatography ercp are an uncommon complication. Perforation of approximately 1 cm is evident in the duodenal wall contralateral to the papilla over a duodenal diverticulum. Duodenal perforation post ercp is rare, occurring in 1% range 0. Perforation region were duodenal second portion in 2 patients and duodenal bulbus in 1. Endoscopic retrograde cholangiopancreatography ercprelated duodenal perforation develops in 0.
Materials and methods between march 2003 and march 20, 2,071 ercps were performed in our hospital. Some advocate a nonsurgical approach to management in certain select patients. The diagnosis of postercp perforations are difficult and localization of the. The initial procedure, urgent surgery or conservative. All patients underwent a lowradiation abdominal ct after a median time of 48 minutes range. Managing perforations related to endoscopic retrograde. Endoscopic retrograde cholangiopancreatography ercp is an invasive. Endoscopy shows a high sensitivity and specificity for diagnosis of iatrogenic perforation 11. Seven patients underwent ercp at another institution, and 23 patients underwent an endoscopic procedure at our hospital.
Ercpinduced duodenal perforation successfully treated with endoscopic pursestring suture. We performed a percutaneous drainage of the abscess followed by percutaneous retrieval of the stent. Duodenal perforation is an uncommon complication of endoscopic retrograde cholangiopancreatography ercp and a rare complication of upper gastrointestinal endoscopy. Ercp induced duodenal perforation successfully treated with endoscopic pursestring suture. To investigate the therapeutic safety, feasibility, and efficacy of endoclips for closing the endoscopic ultrasound eus and endoscopic retrograde cholangiopancreatography ercp related duodenal perforation in a retrospective study from a single center. However, an increased risk of perforation is seen in patients with sphincter of oddi dysfunction, patients who are undergoing extensions of prior sphincterotomies, and. Duodenal perforation during endoscopic sphincterotomy is usually the result of a poorly. We present a case of a migrated biliary stent that resulted in a distal small bowel perforation, abscess formation and high grade partial small bowel obstruction in a medically stable patient without signs of sepsis or diffuse peritonitis. Management of duodenal perforation postendoscopic retrograde cholangiopancreatography. Complications can also arise from bleeding due to sphincterotomy which can occur in approximately 1 in patients. In case of suspected postercp perforation, the patient was studied by the general surgery oncall team.
The expected rate of ercpinduced pancreatitis is generally between 1% and 7%. In an attempt to classify post ercp duodenal perforation stapfer, et al. Conservative management of duodenal perforation following. Early management experience of perforation after ercp. Sphincterotomy related perforations diagnosed by ct. The management of this kind of perforation is controversial. Endoscopic retrograde cholangiopancreatography ercp.
The presentation of peritoneal perforation showed free gas shadow under. During ercp, fluoroscopy revealed abnormal perinephric gas shadowing after breaking and extracting the stones. The interval between the perforation and the operation is of great significance. Download citation duodenal perforations after endoscopic retrograde cholangiopancreatography introduction. Duodenal perforation occurring during endoscopic retrograde. Pdf early management experience of perforation after ercp. Free bowel wall perforation is rare and is associated with ercp undertaken in patients with altered anatomy, such as billroth ii. In the endoscopic group there were 5 peritoneal 41. The perforation of the digestive tract after endoscopic retrograde cholangiopancreatography ercp is a rare complication.
Endoscopic fibrin sealant closure of duodenal perforation after endoscopic retrograde cholangiopancreatography. Most are minor perforations that settle with conservative management. Endoscopic retrograde cholangiopancreatography ercprelated perforation, is a rare complication with a high morbidity and mortality. Management of ercprelated small bowel perforations. The patient underwent emergency surgery after which she was admitted to the icu but her evolution was torpid, and she died. There were 12 patients with duodenal perforation and 2 with biliary perforation. N2 iatrogenic duodenal and pancreaticobiliary perforations associated with endoscopic retrograde cholangiopancreatography ercp are rare but. Surgical or endoscopic management for post ercp large transmural duodenal perforations van argasmatos, et al rev gastroenterol peru. Patients who developed eus and ercp related duodenal perforation between january 2012 and january 2015 were. We analyzed data pertaining to clinical details, management, and outcome. Provisional deployment of sems to overcome duodenal strictures may be a therapeutic option to allow an ercp procedure after a few days. 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. When the ercp images shown above are inverted, free air in the right retroperitoneal compartment is more easily identified as bubbly lucency adjacent to the vertebral column.
During balloon sweepings the scope snapped and hit the duodenal wall opposite to the ampullary area. Given that the overall incidence of duodenal and common bile duct perforations is about 1% and most of these cases 80% have retroperitoneal perforations causing. Closure of a persistent sphincterotomyrelated duodenal perforation by placement of a covered selfexpandable metallic biliary stent. Lavage and drainage in addition to suturing perforation site were performed immediately after diagnosis in all cases, and the postoperative course. Ercp medical malpractice lawsuits baltimore, maryland.
Free retroperitoneal air that is associated with a duodenal perforation will always be immediately adjacent to the duodenum and associated with. The timing of diagnosis is critical for management and patient outcome 810. An immediate diagnosis and early management of ercprelated perforation are key factors to minimize mortality. Surgical management of duodenal perforations after ercp. Computed tomography revealed localized collections in 9 64% patients. Perforation after endoscopic retrograde cholangiopancreatography ercp is a rare. Ercp in one case and, in the second case, perforation was evident during ercp and a biliary stent was inserted. Duodenal perforations after endoscopic retrograde cholangiopancreatography ercp are. Experience in the management of the complication surgical team 4. Mild intraluminal bleeding postfna is not uncommon and is usually selflimited. On the other hand, infection is one of the most morbid complications of ercp and among the most common causes of ercp related death. Endoscopic closure of duodenal perforation with an over.
Endoscopic retroperitoneal fatpexy of a large ercprelated jejunal perforation by using a new overthescope clip device in billroth ii anatomy. An algorithm for the management of ercprelated perforations. Early diagnosis of perforation was based on figure 1. A few perforations however result in lifethreatening retroperitoneal necrosis and require surgical intervention. Sems removal, usually after 7 days, does not represent a problem and, in most cases, allows an. The size, location and seriousness of such a perforation or hole can vary along with the treatment choices for such an injury. The reasons of perforation include patientrelated factors such as post. The diagnosis of duodenal perforation is usually made during the procedure.
Here, we report a case of ercpinduced duodenal perforation successfully treated with endoscopic pursestring suture. 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. Clinical and radiographic features can be used to determine the surgical or conservative treatment of ercprelated duodenal perforations, whereas patient age and intraoperative findings can determine the final outcome and morbidity or mortality. Ercpinduced duodenal perforation successfully treated. Their mortality is high, and the treatment in most cases is surgical. In 2011, kim et al14 proposed a new classification based on the instrument that caused the perforation. Perforation can result in abscess formation, pancreatitis, peritonitis, and death. Fifteen patients 50 % were successfully treated conservatively. The clinical outcomes depend on the timing of the diagnosis and the efficacy of the. Perforation is one of the most feared complications of ercp and endoscopic. Three cases of duodenal perforation following ercp keio. Between november 2003 and december 2011, a total of 8504 ercps were performed at our regional endoscopy center. Perforation ercp related perforation occurs in 0 3%related perforation occurs in 0.
Surgical or endoscopic management for postercp large. Perforation after endoscopic retrograde cholangiopancreatography ercp is a rare complication, but it is associated with significant mortality. Most series report a majority of nonlifethreatening perforations which settle with conservative management 1, 2. One patient with duodenal perforation and three patients with afferent limb perforation. Kumbhari and colleagues describes a predetermined algorithm for managing type i lateral or medial duodenal wall perforation, endoscope related and type ii periampullary perforations, sphincterotomy related ercprelated perforations based on their experience of 61 such patients over a 14year period. Sepsis may occur in patients with partial obstruction of common bile duct. The chart showing full article pdf series, full article word series. Pdf endoscopic retrograde cholangiopancreatography ercp has evolved from a diagnostic tool to. Endoscopic closure for eus and ercp related duodenal. Eleven of our fourteen perforations 79% were suspected at the time of ercp. Management of perforation after endoscopic retrograde.
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