J Korean Surg Soc.  2012 Oct;83(4):218-226. 10.4174/jkss.2012.83.4.218.

Proposal of an endoscopic retrograde cholangiopancreatography-related perforation management guideline based on perforation type

• Kwon W
• Jang JY
• Ryu JK
• Kim YT
• Yoon YB
• Kang MJ
• Kim SW

• KMID: 2212310
• DOI: http://doi.org/10.4174/jkss.2012.83.4.218

Abstract

PURPOSE
Consensus for endoscopic retrograde cholangiopancreatography (ERCP) related perforation management is lacking. We aimed to identify candidate patients for conservative management by examining treatment results and to introduce a simple, algorithm-based management guideline.
METHODS
A retrospective review of 53 patients with ERCP-related perforation between 2000 and 2010 was conducted. Data on perforation site (duodenum lateral wall or jejunum, type I; para-Vaterian, type II), management method, complication, mortality, hospital stay, and hospital cost were reviewed. Comparative analysis was done according to the injury types and management methods.
RESULTS
The outcome was greater in the conservative group than the operative group with shorter hospital stay (20.6 days vs. 29.8 days, P = 0.092), less cost (10.6 thousand United States Dollars [USD] vs. 19.9 thousand USD, P = 0.095), and lower morbidity rate (22.9% vs. 55.6%, P = 0.017). Eighty-one percent (17/21) of type I injuries were operatively managed and 96.9% (31/32) of type II injuries were conservatively managed. Between the types, type II showed better results over type I with shorter hospital stay (19.3 days vs. 30.6 days, P = 0.010), less cost (9.5 thousand USD vs. 20.1 thousand USD, P = 0.028), and lower complication rate (18.8% vs. 57.1%, P = 0.004). There was no difference in mortality.
CONCLUSION
Type II injuries were conservatively manageable and demonstrated better outcomes than type I injuries. The management algorithm suggests conservative management in type II injuries without severe peritonitis or unsolved problem requires immediate surgical correction, including operative management in type I injuries unless endoscopic intervention is possible. Conservative management offers socio-medical benefits. Conservative management is recommended in well-selected patients.

Keyword

Endoscopic retrograde cholangiopancreatography; Intestinal perforation; Guideline; Algorithms

MeSH Terms

Cholangiopancreatography, Endoscopic Retrograde
Consensus
Hospital Costs
Hospital Mortality
Humans
Intestinal Perforation
Jejunum
Length of Stay
Peritonitis
Retrospective Studies
United States

Figure

• 

  Fig. 1 Radiologic findings of endoscopic retrograde cholangiopancreatography perforations are demonstrated. (A) Computed tomography shows pneumoperitoneum, pneumoretroperitoneum, and fluid collection adjacent to duodenum. (B) Massive bilateral subdiaphragmatic pneumoperitoneum is detected on simple radiography.

• 

  Fig. 2 Perforation site endoclipping is presented. The patient was conservatively managed and discharged uneventfully. (A) The perforation site at posterior wall of duodenal bulb is identified. (B) Perforation site is successfully sealed with endoclips.

• 

  Fig. 3 Simple, easy-to-remember management algorithm is proposed based on the findings of current study.

Reference

1. McCune WS, Shorb PE, Moscovitz H. Endoscopic cannulation of the ampulla of vater: a preliminary report. Ann Surg. 1968. 167:752–756.

2. Cotton PB, Lehman G, Vennes J, Geenen JE, Russell RC, Meyers WC, et al. Endoscopic sphincterotomy complications and their management: an attempt at consensus. Gastrointest Endosc. 1991. 37:383–393.

3. Freeman ML, Nelson DB, Sherman S, Haber GB, Herman ME, Dorsher PJ, et al. Complications of endoscopic biliary sphincterotomy. N Engl J Med. 1996. 335:909–918.

4. Loperfido S, Angelini G, Benedetti G, Chilovi F, Costan F, De Berardinis F, et al. Major early complications from diagnostic and therapeutic ERCP: a prospective multicenter study. Gastrointest Endosc. 1998. 48:1–10.

5. Wu HM, Dixon E, May GR, Sutherland FR. Management of perforation after endoscopic retrograde cholangiopancreatography (ERCP): a population-based review. HPB (Oxford). 2006. 8:393–399.

6. Masci E, Toti G, Mariani A, Curioni S, Lomazzi A, Dinelli M, et al. Complications of diagnostic and therapeutic ERCP: a prospective multicenter study. Am J Gastroenterol. 2001. 96:417–423.

7. Christensen M, Matzen P, Schulze S, Rosenberg J. Complications of ERCP: a prospective study. Gastrointest Endosc. 2004. 60:721–731.

8. Sarr MG, Fishman EK, Milligan FD, Siegelman SS, Cameron JL. Pancreatitis or duodenal perforation after peri-Vaterian therapeutic endoscopic procedures: diagnosis, differentiation, and management. Surgery. 1986. 100:461–466.

9. Bell RC, Van Stiegmann G, Goff J, Reveille M, Norton L, Pearlman NW. Decision for surgical management of perforation following endoscopic sphincterotomy. Am Surg. 1991. 57:237–240.

10. Stapfer M, Selby RR, Stain SC, Katkhouda N, Parekh D, Jabbour N, et al. Management of duodenal perforation after endoscopic retrograde cholangiopancreatography and sphincterotomy. Ann Surg. 2000. 232:191–198.

11. Avgerinos DV, Llaguna OH, Lo AY, Voli J, Leitman IM. Management of endoscopic retrograde cholangiopancreatography: related duodenal perforations. Surg Endosc. 2009. 23:833–838.

12. Booth FV, Doerr RJ, Khalafi RS, Luchette FA, Flint LM Jr. Surgical management of complications of endoscopic sphincterotomy with precut papillotomy. Am J Surg. 1990. 159:132–135.

13. Martin DF, Tweedle DE. Retroperitoneal perforation during ERCP and endoscopic sphincterotomy: causes, clinical features and management. Endoscopy. 1990. 22:174–175.

14. Scarlett PY, Falk GL. The management of perforation of the duodenum following endoscopic sphincterotomy: a proposal for selective therapy. Aust N Z J Surg. 1994. 64:843–846.

15. Enns R, Eloubeidi MA, Mergener K, Jowell PS, Branch MS, Pappas TM, et al. ERCP-related perforations: risk factors and management. Endoscopy. 2002. 34:293–298.

16. Assalia A, Suissa A, Ilivitzki A, Mahajna A, Yassin K, Hashmonai M, et al. Validity of clinical criteria in the management of endoscopic retrograde cholangiopancreatography related duodenal perforations. Arch Surg. 2007. 142:1059–1064.

17. Fatima J, Baron TH, Topazian MD, Houghton SG, Iqbal CW, Ott BJ, et al. Pancreaticobiliary and duodenal perforations after periampullary endoscopic procedures: diagnosis and management. Arch Surg. 2007. 142:448–454.

18. Kim BS, Kim IG, Ryu BY, Kim JH, Yoo KS, Baik GH, et al. Management of endoscopic retrograde cholangiopancreatography-related perforations. J Korean Surg Soc. 2011. 81:195–204.

19. Chaudhary A, Aranya RC. Surgery in perforation after endoscopic sphincterotomy: sooner, later or not at all? Ann R Coll Surg Engl. 1996. 78(3 Pt 1):206–208.

20. Knudson K, Raeburn CD, McIntyre RC Jr, Shah RJ, Chen YK, Brown WR, et al. Management of duodenal and pancreaticobiliary perforations associated with periampullary endoscopic procedures. Am J Surg. 2008. 196:975–981.

21. Howard TJ, Tan T, Lehman GA, Sherman S, Madura JA, Fogel E, et al. Classification and management of perforations complicating endoscopic sphincterotomy. Surgery. 1999. 126:658–663.

22. Dunham F, Bourgeois N, Gelin M, Jeanmart J, Toussaint J, Cremer M. Retroperitoneal perforations following endoscopic sphincterotomy; clinical course and management. Endoscopy. 1982. 14:92–96.

23. Kaneko T, Akamatsu T, Shimodaira K, Ueno T, Gotoh A, Mukawa K, et al. Nonsurgical treatment of duodenal perforation by endoscopic repair using a clipping device. Gastrointest Endosc. 1999. 50:410–413.

24. Jeong G, Lee JH, Yu MK, Moon W, Rhee PL, Paik SW, et al. Non-surgical management of microperforation induced by EMR of the stomach. Dig Liver Dis. 2006. 38:605–608.

25. Charabaty-Pishvaian A, Al-Kawas F. Endoscopic treatment of duodenal perforation using a clipping device: case report and review of the literature. South Med J. 2004. 97:190–193.