Management of duodenal perforation after endoscopic retrograde cholangiopancreatography and sphincterotomy

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Management of duodenal perforation after
endoscopic retrograde cholangiopancreatography
and sphincterotomy

• Annals of surgery 2000, Vol. 232, No.2, 191-198
• From the department of surgery, University of
  Southern California-Los Angeles County and the
  University of Southern California Medical Center,
  Los Angeles, California
• Presented by Ri ???

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Introductions

• ERCP with sphincterotomy commonly used in the
  treatment of common bile duct stones.
• Major complication rate10(pancreatitis,
  bleeding, cholangitis, and perforation).
• ERCP-related perforations occur in about 1 of
  patients, and the injury carries a death rate of
  16 to 18.
• Objective to define a management strategy for
  ERCP-related perforations.

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Methods(1)

• Patients Between June 1993 and June 1998, 14
  patients (1) had duodenal perforations during
  ERCP.
• 10 women and 4 men
• Median age 48.5 years.
• Diagnosis of Perforation ERCP, CXR(free air),
  clinical sepsis, gastrograffin UGI. (If there was
  doubt about a perforation at ERCP, an immediate
  contrast UGI was obtained)

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Methods(2)

• Medical management parameter
• 1. benign abdominal examination
• 2. absence of sepsis
• 3. minimal leak demonstrated on a follow-up
  UGI
• 4. absence of retroperitoneal fluid
  collections

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Methods(3)

• Surgical management parameter
• 1. extensive contrast extravasations on
  ERCP/UGI
• 2. extra- or intraperitoneal fluid collection
  on CT
• 3. retained hardware
• 4. documented perforation with retained
  stones
• 5. massive subcutaneous emphysema

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Results(1)

• Nonsurgical Management ( 8 patients)
• Five of the eight were successfully managed
  with antibiotics and observation.

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Results(2)

• Nonsurgical Management ( 8 patients)
• Three patients failed to respond to
  nonsurgical management and received delayed
  surgery.

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Results(3)

• Surgical management (6 patients)

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Results(4)

• Surgical Procedures and Outcomes
• 1. None of the six patients treated by primary
  surgical management required reoperation for
  duodenal leakage.
• 2. Two patients developed a retroperitoneal
  abscess it required open drainage in one
  patient.
• 3. Three patients underwent delayed surgical
  treatment and multiple reoperations (mean 3.6 per
  patient).

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Discussions(1)

• Leukocytosis and fever were often present early
  but were not useful to distinguish a management
  approach.
• Abdominal examination was not helpful in
  determining who should undergo surgery within the
  first few hours.
• Early peritonitis should dictate surgery, but the
  retroperitoneal nature of the injuries may mask
  the severity.

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Discussions(2)

• Classifications of duodenal injury (Type I IV)

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Discussions(3)

• Type I (Lateral or medial wall perforations)
• 1. caused by the endoscope, tend to be large
  and remote from the ampulla, and require
  immediate surgery.
• 2. cause large, persistent contrast leaks in
  the retroperitoneal or intraperitoneal space.
• Type II (Peri-Vaterian injuries)
• varied in severity but usually were more
  discrete and less likely (43 of patients in our
  series) to require surgery.

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Discussions(4)

• Type III injuries
• 1. distal bile duct injuries related to wire
  or basket instrumentation near an obstructing
  entity and are often small.
• 2. tend to seal spontaneously.
• Type IV (Retroperitoneal air alone)
• 1. probably related to the use of compressed
  air to maintain patency of a lumen (not a true
  perforation).

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Discussions(5)

• Revision of surgical indications

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Discussions(6)

• If an initial study demonstrates minimal contrast
  extravasation and a conservative approach is
  chosen, a UGI study should be repeated within 8
  hours to confirm the initial impression.
• In addition, a double-contrast CT scan should be
  performed at 8 hours and at 48 hours to confirm
  that the leak remains sealed and to exclude the
  development of fluid collections.