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Classification of iatrogenic duodenal perforations: type I, duodenal perforation due to endoscopy; type II, sphincterotomyrelated perforation; type III, biliary perforations due to endoscopic instruments such as guidewires; type IV, microperforations at the retroperitoneum during endoscopy. Adapted from Lee et al. Clin Endosc 2013;46:522-528. 9
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Uneventful duodenal perforation during endoscopic retrograde cholangiopancreatography (ERCP) is an uncommon but occasionally fatal complication. ERCP-related perforations may occur during sphincterotomy and improper manipulation of the equipment and scope. Traditionally, duodenal perforation has been treated with early surgical repair. Recently, no...
Context in source publication
Context 1
... et al. 6 clinically classified perforations into four cate- gories according to the severity (Fig. 1). 9 Type I refers to per- foration of the lateral or medial duodenal wall, which can cause leakage of a large volume of digestive juice and may oc- cur as a result of tearing by the distal end of the endoscope or the migration of biliary stents. Type I perforations often cause large, persistent pancreatic juice leaks to the ...
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Background:
Use of electronic medical record systems has increased in the recent years. Epic is one such system gaining popularity in the USA. Epic is a private company, which invented the electronic documentation system adopted in our hospital. In spite of many presumed advantages, its use is not critically analyzed. Some of the perceived advanta...
Citations
... CT scan with a water-soluble oral contrast agent has the highest sensitivity to assess the presence of perforation. 21 The presence of extraluminal air is a hallmark of imaging of DP. Air may be present in the duodenal wall, retroperitoneum, or intraperitoneal compartment (►Fig. ...
Aim The aim of this study was to examine the imaging manifestations of post-endoscopic retrograde cholangiopancreatography (ERCP) specific complications by computed tomography to aid in its early and successful diagnosis and timely intervention.
Method Forty-one cases of imaging having post-ERCP were complications were retrospectively collected and the spectrum of complications and their key imaging features and methods to improve their detection were analyzed.
Result The most common complication detected in computed tomography (CT) post-ERCP was the presence of intra-abdominal collections seen in 21 patients (51.2%). Pancreatitis was seen in 20 of 41 patients (48.7%), while bowel perforation was present in 9 patients (21%). Pleural effusion was present in 8 patients (19.5%), liver abscess in 6 patients (14.6%), cholangitis in 4 patients (9.7%), gallbladder perforation in 4 patients (9.7%), displaced common bile duct stent in 3 patients (7.3%), possibility of main pancreatic duct cannulation in 2 patients (4.8%), vascular injury resulting in right hepatic artery pseudoaneurysm in 1 patient (2.4%), thrombosis of portal vein or its branches in 2 patients (4.8%), superior mesenteric vein thrombosis in 1 patient (2.4%), right hepatic vein thrombosis in 1 patient (2.4%), pulmonary thromboembolism in 2 patients (4.8%), duodenal inflammation in 1 patient (2.4%), bowel ileus in 4 patients (9.6%), and bowel obstruction in 1 patient (2.4%).
Conclusion Complications after ERCP can cause significant morbidity and mortality if not diagnosed early and treated appropriately. Familiarity with normal findings post-ERCP and knowledge of the imaging appearance of these complications are vital in the early management of these conditions.
... Procedural complexity was scored by both an established grading scale published by an American Society for Gastrointestinal Endoscopy (ASGE) working party and a novel grading scale (The HOUSE classification) proposed by Olsson et al. 14 15 Perforation was classified into four categories according to severity as previously described. 16 Analysis Categorical variables were analysed with a χ 2 test. Clinically relevant risk factors were examined by univariate analysis and calculated with ORs with 95% CIs. ...
Objective:
There is a lack of literature on postendoscopic retrograde cholangiopancreatography (ERCP) complications in predominantly black urban populations of low socioeconomic status. The aim of this study was to determine the incidence and predictors of post-ERCP complications in this patient population.
Design:
Retrospective review of ERCP cases performed at two hospitals from 2007 to 2017 was performed. The categories of complications evaluated were overall complications, severe or fatal complications, pancreatitis, bleeding, infection, perforation and cardiopulmonary events. Predictors of complications were determined by univariate analysis.
Results:
A total of 1079 ERCP procedures were reviewed. There were 106 complications (9.8%). Twenty-one were severe (1.9%) and 20 were fatal (1.9%). Both post-ERCP pancreatitis (PEP) and post-ERCP bleeding occurred in 18 patients (1.7%) each. Risk factors for overall complications were male sex (OR 1.54), ASA grade IV or V (OR 2.19), prior history of PEP (OR 6.98) and pancreatic duct stent placement (OR 2.75). Those who were ASA grade III or lower (OR 0.4) or who underwent biliary stone extraction (OR 0.62) had fewer complications. PEP was more likely in those with a prior history of PEP (OR 37.6). Those with a suspected or known biliary duct stone had less frequent pancreatitis (OR 0.32). Post-ERCP bleeding was more likely in the presence of cholangitis (OR 8.72).
Conclusion:
Outcomes of ERCP in a predominantly black urban population demonstrate a lower incidence of PEP and all-cause mortality compared with historical data reported in the general population. Potential risk factors for post-ERCP complications were identified but require larger studies for validation.
... Bizim olgumuz 79 yaşında ve bayan olarak perforasyon ile ilişkili risk faktörlerini taşımakta idi. Klinikte bu olgularda karın ve sırt ağrısı, subkutan dokuda amfizem ve ödem, ateş ve taşikardi yakınmaları saptanabilir (5). Olgumuzda da detaylı sorgulandığında karında huzursuzluk, distansiyon ve sırt ağrısı mevcuttu. ...
Endoskopik retrograd kolanjiyopankreatografi, pankreatobiliyer hastalıklarda tanı ve tedavi amaçlı çok sık kullanılan bir yöntemdir. Hastaya ve işleme bağlı olarak pankreatit, kanama ve perforasyon gibi birtakım komplikasyonlar görülebilir. Burada 79 yaşında bilinen kronik obstrüktif akciğer hastalığı öyküsü olan ve farklı bir merkezde koledokta taş nedenli uygulanan endoskopik retrograd kolanjiyopankreatografi işleminden yaklaşık 1,5 ay sonra genel durumunda ve beslenmesinde progresif bozulma yaşayan bir hasta sunuldu. Hastanın görüntüleme tetkiklerinde retroperitoneal perforasyon düşündüren bulgular ile birlikte karın ve sırtında cilt altında yaygın ve aynı zamanda alt ekstermitede ciddi ödem, eşlik eden sellülit mevcuttu. Takibinde hasta sepsis ve multiorgan yetmezliği ile kaybedildi. Endoskopik retrograd kolanjiyopankreatografi işlemi tanısal ve tedavi amaçlı sıklıkla uygulanan ve hayat kurtarıcı olarak da başvurulan bir yöntemdir. Bununla birlikte işlem sırasında, erken ve geç dönemde gelişebilecek komplikasyonlar açısından dikkatli olunmalı ve hastalar titizlikle takip edilmelidir.
... Post-ERCP duodenal perforation (DP) often mimics PEP and a delay in diagnosis could prove fatal. Therefore, there should be a low threshold to perform an abdominal CT scan (highest sensitivity) with water-soluble oral contrast material to assess for the presence of a perforation [47]. Presence of extra-luminal air is the imaging hallmark of DP. ...
Endoscopic retrograde cholangiopancreatography (ERCP) has currently become an inseparable tool in the gastroenterologist’s armamentarium for treatment of pancreaticobiliary disorders. Given the increase in number of therapeutic ERCP procedures today, the need for prompt and correct diagnosis of its complications is pivotal. This review discusses the mechanisms, risk factors, imaging findings and general management aspects of common and rare complications of ERCP. Furthermore, the review elaborates on imaging indications, recommended protocol and normal imaging findings post ERCP.
... For Type III perforations, nasobiliary drainage to divert the fluid and nonsurgical therapies usually provide ideal prognosis. 16,57,72 ...
Iatrogenic perforation (IP) is a rare but severe complication of endoscopy, and occurrences grow with the expansion of interventional endoscopy. Apart from symptoms and physical signs, CT scans provide an immediate and comprehensive diagnosis of IP and its severity. The general treatment is broad-spectrum antibiotics, intravenous nutrition, and close monitoring. Endoscopic treatments are considered as the first-line therapy. Endoclips are usually utilized for small perforations, while endoclips with endoloops and over the scope clip system are preferred for large ones. Covered self-expandable metal stents are effective for esophageal perforations. Fibrin glue and band ligation can be attempted, when the location of perforation is difficult for the clip placement. Close observation is required after the procedure. If endoscopic closure fails or deterioration occurs, surgical treatments should be requested. Keywords: Gastrointestinal perforation, Endoscopic treatment, Clip, Stent
... In the clinical setting, most cases of ESD-related perforation involving the esophagus, stomach, colon, or rectum can be managed using a short period of conservative therapy alone. On the other hand, endoscopic procedure-related duodenal perforation can sometimes cause severe peritonitis due to the leakage of pancreatic and bile juice [41]. Therefore, when conservative therapy is chosen, the patient will sometimes require long-term hospital treatment. ...
Background and aims:
Endoscopic submucosal dissection (ESD) is commonly used to treat early-stage digestive cancer because it results in a higher frequency of en-bloc resection and a lower frequency of local recurrence. However, the efficacy and safety of duodenal ESD remain unclear. Therefore, present study is aimed at evaluating clinical outcomes of duodenal ESD.
Methods:
To evaluate the efficacy and safety of duodenal ESD, electronic databases (MEDLINE, CENTRAL and EMBASE) were searched by two independent reviewers. The authors were contacted for additional information. A meta-analysis was performed to evaluate the efficacy and safety of duodenal ESD.
Results:
A total of 7 studies (203 patients) were included in the quantitative synthesis analysis. The pooled proportions of the frequencies of en-bloc resection, need for surgical intervention, bleeding, intraoperative perforation and delayed perforation were 87%, 4%, 2%, 15% and 2%, respectively. The quality of evidence regarding on surgical intervention outcomes was rated as moderate, whereas that of en-bloc resection was rated as low because of its marked inconsistency.
Conclusions:
Duodenal ESD produced acceptable outcomes in terms of the en-bloc R0 resection, but the incidence of procedure-related adverse events is high (PROSPERO register, CRD42017057110).
... Stapfer, et al. clinically classified perforations into four distinct categories according to severity [5]. The treatment option depends on the characteristics of the perforation and clinical status of the patient [6,7]. Our patient was diagnosed as Type II periampullary perforation with a large accumulation of digestive fluid into the retroperitoneal spaces. ...
... This may be secondary to a small papilla, a large sphincterotomy or a deviated cut, presence of juxtapapillary diverticula, and less commonly in patients with a Billroth II subtotal gastrectomy. [3] The management of Stapfer's Type II perforations after ERCP remains controversial as the clinical outcome can be variable. Conventionally, they are managed by surgical intervention in order to control the inflammation and prevent infection by draining the retroperitoneal and intraperitoneal fluid collection, as well as the diversion of the biliopancreatic system. ...
... Surgical closure of the perforation site will be performed if identified at operation, with or without a bypass procedure. [3] Recent development has led to a more selective approach based on the mechanism of injury, site of perforation, and degree of leakage as well as patient's condition and CT findings. [4] At present, nonoperative treatment is considered the first choice for Type II perforation. ...
... Although ERCP is an invasive procedure, it is still one of the Table 2. Demographics and diagnosis of patients who were not surgically treated most common procedures used for the diagnosis and treatment of biliary diseases (1). It has various complications, including gastrointestinal system perforation, which has significant morbidity and mortality rates (3)(4)(5)(6)(7)9). In this study, we evaluated the treatment approach to perforations and discovered that only some of these patients required surgical treatment. ...
Objective:
The best therapeutic approach for endoscopic retrograde cholangiopancreatography-related perforations remains controversial; while some authors suggest routine conservative management, others advocate mandatory surgical exploration. We aimed to evaluate our clinical experience of perforations during endoscopic sphincterotomy.
Material and methods:
A retrospective chart review from January 2010 to October 2015 identified 20 patients with endoscopic retrograde cholangiopancreatography-related perforations. Data collection included demographics, time to diagnosis, type of perforation, treatment strategy, surgical procedure, complications, hospital stay, and outcome. All patients were classified into two groups on the basis of radiological and operative findings.
Results:
Only five patients underwent surgical treatment, whereas 15 patients were managed conservatively. The mean time to diagnosis was 7.8 hrs (range: 1 to 36 hrs). In patients who underwent surgical treatment, the types of perforations included type I and III in one patient each and type II in three patients. Surgical procedures included laparoscopic and open cholecystectomy with t-tube drainage in two patients each and primary repair of duodenal injury with hepaticojejunostomy in one patient. Among conservatively managed patients, eight, four, and three had type II, type III, and type IV injuries, respectively. Of these 15 patients, 60% (n=9) underwent percutaneous procedures. The mean length of hospital stay was similar for conservatively and surgically treated patients (12 vs. 12.4 days, respectively, p=0.790). One patient (5%) with type I injury died of multiorgan deficiency.
Conclusion:
With close close clinical follow-up, medical treatment can be beneficial for most patients, and surgical procedures should be reserved for patients with type I (definite) and type II/III injuries; in patients with these clinical parameters, conservative management will likely be unsuccessful.
... Duodenal perforation is a rare but serious complication related to ERCP. ERCP-related perforations can occur during handling or manipulation of the endoscope, endoscopic sphincterotomy, or insertion of the guidewire [6]. The clinical outcome of duodenal perforations can be minimal to severe depending on the type and location of the perforation [7]. ...
... Type 3 injury is the perforation of the distal bile duct that occurs during guidewire or basket instrumentation. Usually, this kind of perforation is small, and medical management is sufficient in most of the cases [6,8]. Type 4 injury is the air leakage to retroperitoneum due to microperforations and is managed medically [6,8]. ...
... Usually, this kind of perforation is small, and medical management is sufficient in most of the cases [6,8]. Type 4 injury is the air leakage to retroperitoneum due to microperforations and is managed medically [6,8]. This classification is well correlated with the order of severity and helps in predicting early surgical intervention versus more conservative approach. ...
Duodenal perforation is a rare but life-threatening complication of endoscopic retrograde cholangiopancreatography (ERCP). Duodenal perforation can cause air leak into the extraperitoneal space. In rare instances, the air in the extraperitoneal space could dissect along the fascial planes of the abdomen to reach scrotum, leading to pneumoscrotum. We present the case of a 35-year-old male patient who developed scrotal pain and swelling following ERCP. He was found to have extensive pneumoscrotum, pneumoretroperitoneum, pneumomediastinum, and subcutaneous emphysema. The patient was diagnosed with retroperitoneal duodenal perforation. He was managed conservatively with close monitoring and supportive care.
