Management of duodenal perforation after endoscopic retrograde cholangiopancreatography and sphincterotomy

Abstract

Objective: To evaluate the authors' experience with periduodenal perforations to define a systematic management approach.

Summary background data: Traditionally, traumatic and atraumatic duodenal perforations have been managed surgically; however, in the last decade, management has shifted toward a more selective approach. Some authors advocate routine nonsurgical management, but the reported death rate of medical treatment failures is almost 50%. Others advocate mandatory surgical exploration. Those who favor a selective approach have not elaborated distinct management guidelines.

Methods: A retrospective chart review at the authors' medical center from June 1993 to June 1998 identified 14 instances of periduodenal perforation related to endoscopic retrograde cholangiopancreatography (ERCP), a rate of 1.0%. Charts were reviewed for the following parameters: ERCP findings, clinical presentation of perforation, diagnostic methods, time to diagnosis, radiographic extent and location of duodenal leak, methods of management, surgical procedures, complications, length of stay, and outcome.

Results: Fourteen patients had a periduodenal perforation. Eight patients were initially managed conservatively. Five of the eight patients recovered without incident. Three patients failed nonsurgical management and required extensive procedures with long hospital stays and one death. Six patients were managed initially by surgery, with one death. Each injury was evaluated for location and radiographic extent of leak and classified into types I through IV.

Conclusions: Clinical and radiographic features of ERCP-related periduodenal perforations can be used to stratify patients into surgical or nonsurgical cohorts. A selective management scheme is proposed based on the features of each type.

Figure 1. Classification of duodenal perforations into types I through IV based on anatomical location and mechanism of injury (type IV not shown).

Figure 2. Endoscopic view of a type I duodenal perforation (patient 10).

Figure 3. Plain film demonstrating a large leak (type I) after a duodenal perforation related to endoscopic retrograde cholangiopancreatography (patient 11).

Figure 4. Plain film demonstrating a minimal contrast leak (type III) with papillotomy caused by a wire perforation (patient 4).

Figure 5. Periduodenal fluid collection after a duodenal perforation related to endoscopic retrograde cholangiopancreatography (patient 6).