Clin Endosc.  2016 Jul;49(4):376-382. 10.5946/ce.2016.088.

Recent Advanced Endoscopic Management of Endoscopic Retrograde Cholangiopancreatography Related Duodenal Perforations

• Park SM

• KMID: 2348258
• DOI: http://doi.org/10.5946/ce.2016.088

Abstract

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.

Keyword

Cholangiopancreatography, endoscopic retrograde; Perforation; Endoscopic closure

MeSH Terms

Bile Ducts
Cholangiopancreatography, Endoscopic Retrograde*
Diagnosis
Drainage
Early Diagnosis
Fibrin Tissue Adhesive
Humans
Ligation
Phenobarbital
Stents
Fibrin Tissue Adhesive
Phenobarbital

Figure

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  Fig. 1. Classification of endoscopic retrograde cholangiopancreatography-related duodenal perforation. Type I, lateral or medial wall duodenal perforation; type II, periampullary perforation; type III, bile duct injuries; type IV, retroperitoneal air alone.

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  Fig. 2. Computed tomography (CT) findings indicating a duodenal perforation. (A) An abdominal CT image showing massive fluid and air collection at the retroperitoneal space (type II perforation). (B) An abdominal CT image showing massive air leakage without fluid accumulation in the retroperitoneal space (type IV perforation).

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  Fig. 3. Endoscopic closure of a duodenal wall perforation by using ligation band and endoclips. (A) A large duodenal perforation on the lateral wall. (B) Endoscopic closure with band ligation and endoclips. (C) Endoscopic band ligation.

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  Fig. 4. Endoscopic closure of an anastomotic perforation by using an over-the-scope clipping device (OTSC). (A) OTSCs. (B) Jejunum perforation caused by Billroth II anastomotic leak. (C) Using a twin grasping forceps, the edges of the perforation wall are pulled back into the lumen of the cap attached to the endoscope. (D) The perforation site is successfully sealed with an OTSC.

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  Fig. 5. Vacuum-assisted closure of the esophageal defect due to an anastomotic leak. (A) Device made of porous sponge and attached to a nasogastric tube. (B) Positioning of sponge device at the esophageal defect. (C) After 3 days of therapy, the sponge device is filled with extraluminal fluid and gastrointestinal secretions. (D) Esophageal wall perforation before treatment. (E) Improved luminal defect with the sponge changed once after 3 days. (F) Closed wound with the sponge changed twice every 3 days.

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  Fig. 6. Abdominal computed tomography scan showing air collection in the periductal space (arrow). To block further bile and pancreatic juice leakage, a self-expandable stent (arrowhead) is inserted at the distal common bile duct.

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