Operative and non-operative management of endoscopic retrograde cholangiopancreatography-associated duodenal injuries

Abstract

Introduction: Endoscopic retrograde cholangiopancreatography (ERCP) is indispensable in everyday surgical practice. Despite this, as an invasive procedure, it has its own mortality and morbidity, the most feared of which is periduodenal perforations. Our experience with ERCP related periduodenal perforations and its treatment strategies are presented. Additionally, a rarely encountered subtype is highlighted.

Methods: Patients who underwent ERCP and sustained a periduodenal perforation between August 2008 and October 2011 were reviewed.

Results: During the period from August 2008 to October 2011, 597 ERCP procedures were performed in our hospital. Ten of these patients (3 male, 7 female) had a perforation. The mean patient age was 56.6 years. During the procedure, injury was suspected in four patients; it passed unnoticed in the remaining six. The decision to operate or follow a conservative policy was based on a combination of clinical and radiological findings. Operative intervention was required in three patients, with one mortality, while conservative treatment was followed in the remaining seven. A laparotomy was performed early in two patients whereas it was performed after an initial period of conservative treatment in one. The presence of periduodenal fluid collection, contrast extravasation or free intraperitoneal air were decisive factors for performing laparotomy.

Conclusions: ERCP-related periduodenal perforations include different categories. Certain types require operative repair while others should be treated conservatively. The choice of the management approach should be individualised, depending on the clinical picture and radiological findings. Although rare, these are potentially serious complications that may end fatally. Early recognition and appropriate intervention is the only way to avert a fatal outcome.

Figure 1

Computed tomography of Patient 2 following endoscopic retrograde cholangiopancreatography, showing air and contrast extravasation around the right kidney

Figure 2

Retroperitoneal air in Patient 6 with periampullary cancer and liver metastasis. Owing to the lack of marked signs, no operative intervention was needed. Percutaneous cholecystostomy was performed and patient was discharged with the draining catheter in situ.

Figure 3

Massive retroperitoneal air extending from the neck (A) down to the groin (B) and thigh (C) in Patient 10, who had a periampullary adenocarcinoma. Laparotomy was not performed; only percutaneous drainage of the collection was required.

Figure 4

Retroperitoneal lateral duodenal wall perforation (red arrow) in Patient 3. Common bile duct was explored (white arrow) and stone extracted.

Figure 5

Guidewire penetrating the pancreatic duct (white circle) of Patient 4

Figure 6

Peripancreatic air collection (white arrows) in Patient 4