Unusual complications related to endoscopic retrograde cholangiopancreatography and its endoscopic treatment

Abstract

Endoscopic retrograde cholangiopancreatography (ERCP)-induced complications, once occurred, can lead to significant morbidity. Commonly 5% to 10% of patients experience procedure related complications such as post-ERCP pancreatitis, biliary hemorrhage, and cholangitis, in descending order. However, complications such as perforation, pneumothorax, air embolism, splenic injury, and basket impaction are rare but are associated with high mortality if occurred. Such unexpected unusual complications might extend the length of hospitalization, require urgent surgical intervention, and put the patient in miserable condition leading to permanent disability or mortality. Although these ERCP-induced complications can be minimized by a skilled operator using advanced techniques and devices, the occurrence of unusual complications are hard to expect and induce very difficult management condition. In this review, we will focus on the uncommon complications related to ERCP. This review is also aimed at suggesting optimal endoscopic treatment strategies for several complications based on our institutional experiences.

Keywords: Cholangiopancreatography, endoscopic retrograde; Complication; Endoscopy.

Fig. 1

The illustration of the classification of endoscopic retrograde cholangiopancreatography-related perforations.

Fig. 2

Endoscopic images of a case with type I perforation. (A) A large perforation on lateral duodenal wall. (B) Duodenal serosa and omentum is revealed. (C) Successful primary endoscopic closure using multiple clips and endoloop.

Fig. 3

(A, B) Abdominal computed tomography of a case with successful primary endoscopic closure for type I perforation. It shows a pneumoretroperitoneum at the right side abdomen, due to perforation at the second portion of the duodenum. Free airs are revealed at the right perirenal, anterior pararenal and posterior pararenal spaces. Several clips are noted at the second portion of the duodenum without visible definite defect and soiling or fluid collection at the periduodenal area.

Fig. 4

Endoscopic images and cholangiograms of a case with type II perforation. (A) Endoscopic view of ampulla. (B) Cholangiogram shows mild biliary dilatation with several round filling defecs in the common bile duct. (C) Endoscopic view shows active bleeding and edematous change at the postsphincterotomy's area. (D) Cholangiogram shows unsuspected large amount of air in the retroperitoneal area.

Fig. 5

Illustration of cap-assisted endoscope and instruments before endoscopic combination therapy. An alligator forceps are inserted into the working channel of the endoscope and the alligator forceps caught the tip of an endoloop.

Fig. 6

Illustration of cap-assisted, endoscopic combination therapy with multiple clips and endoloop for type I perforation. (A) Placement of endoscope and endoloop containing catheter around the perforated area. (B) The alligator forceps are opened for detaching the endoloop containing the catheter. (C) The endoloop containing the catheter is properly released around the perforated area. (D) Insertion of the clipping catheter through the working channel. (E) The tip of the endoloop is caught with the clip and clipping is started from the distal margin. (F) Multiple clips are attached with the endoloop to the perforated area and vice versa (a bunch-like clip formation is caught and fixed with the endoloop). (G) The endoloop is tightened and this closes the perforated area.

Fig. 7

Endoscopic images of a case with type I perforation (arrow) and successful endoscopic management. (A) A perforation is noted on lateral duodenal wall. (B) Placement of endoscope and endoloop containing catheter around the perforated area. (C) The alligator forceps are opened for detaching the endoloop containing the catheter and the endoloop containing the catheter is properly released around the perforated area. (D, E) The tip of the endoloop is caught with the clip and clipping is started from the distal margin. (F, G) Multiple clips are attached with the endoloop to the perforated area and vice versa (a bunch-like clip formation is caught and fixed with the endoloop). (H) The endoloop is tightened and this closes the perforated area, successfully.

Fig. 8

Basket impaction occurs during removal of stone in case with distal biliary stricture.

Fig. 9

Illustration of rescue lithotripsy for basket impaction. (A) Basket catheter is cut near the catheter handle. (B-D) The endoscope and outer sheath of basket catheter are removed. (E) The traction wire is passed through the metal sheath using the snare catheter without outer sheath. (F) The metal sheath is approached at the impacted area over the traction wire. (G) Rescue lithotripsy can crush the impacted stone.