Endoscopic treatments of endoscopic retrograde cholangiopancreatography-related duodenal perforations

Abstract

Iatrogenic duodenal perforation associated with endoscopic retrograde cholangiopancreatography (ERCP) is a very uncommon complication that is often lethal. Perforations during ERCP are caused by endoscopic sphincterotomy, placement of biliary or duodenal stents, guidewire-related causes, and endoscopy itself. In particular, perforation of the medial or lateral duodenal wall usually requires prompt diagnosis and surgical management. Perforation can follow various clinical courses, and management depends on the cause of the perforation. Cases resulting from sphincterotomy or guidewire-induced perforation can be managed by conservative treatment and biliary diversion. The current standard treatment for perforation of the duodenal free wall is early surgical repair. However, several reports of primary endoscopic closure techniques using endoclip, endoloop, or newly developed endoscopic devices have recently been described, even for use in direct perforation of the duodenal wall.

Keywords: Cholangiopancreatography, endoscopic retrograde; Duodenum; Perforation; Therapeutics.

Fig. 1

Classical types of iatrogenic duodenal perforations: type I, endoscope-related lateral or medial duodenal wall perforation; type II, sphincterotomy-related periampullary perforations; type III, ductal or duodenal perforations due to endoscopic instruments such as a guidewire; type IV, retroperitoneal micoperforation caused by compressed air during endoscopy.

Fig. 2

Primary endoscopic closure using endoclips through a cap-fitted endoscopy. (A) Direct duodenoscope-induced duodenal wall perforation. (B) Simple endoscopic closure using multiple hemoclips via cap-fitted endoscopy.

Fig. 3

Primary endoscopic closure using endoclips with glue injection in stent-induced duodenal wall perforation. (A) Cap-fitted endoscopy shows a circular perforated hole after removal of the stent. (B) The therapeutic attempt to generate primary closure using hemoclips and glue injection and spraying around the closed hole of the perforation.

Fig. 4

Endoscopic closure of a large defect using an endoloop with multiple endoclips through 2-channel endoscopy. (A) Placement of endoscope and endoloop-containing catheter around the perforated area. (B) The tip of the endoloop is caught by the endoclip from the distal margin. (C) Multiple clips are attached with the endoloop to the perforated area. (D) The endoloop is tightened, thus closing the perforated area completely.

Fig. 5

Modified endoscopic closure using multiple endoloops with endoclips. (A) An endoloop was anchored with a clip to normal mucosa near the proximal resection margin. (B) The maneuver was repeated to anchor the same endoloop at the distal resection margin. (C) The endoloop was tightened slightly, resulting in approximation of the borders of the defect. (D) Another endoloop was required to bring the margins together. Additional clips can be placed to obtain complete wound closure if necessary.

Fig. 6

Endoscopic band ligation (EBL) in an iatrogenic intestinal wall perforation. (A) Iatrogenic intestinal wall perforation after endoscopic mucosal resection or dissection. (B) Primary EBL was performed successfully in technical difficulty with endoclip closure. (C) Additional clips were applied around the band and surrounding mucosa.