Endoscopic retrograde cholangiopancreatography-related perforation: Management and prevention

Abstract

Endoscopic retrograde cholangiopancreatography (ERCP) is a procedure that can result in serious complications, and thus should be handled by a skilled endoscopist to minimize the risk of complications and to enhance the success rate. The incidence of ERCP-related complications is 5%-10%, most commonly involving post-ERCP pancreatitis and clinically significant post-endoscopic sphincterotomy bleeding. Although ERCP-related perforation has a relatively lower incidence of 0.14%-1.6%, this complication is associated with a high mortality rate of 4.2%-29.6%. A classification of perforation type based on the instrument that caused the perforation was recently described that we postulated could affect the implementation of perforation management. In the present article, an algorithm for management and prevention of ERCP-related perforations is proposed that is based on the perforation type and delay of diagnosis. Available evidence demonstrates that a delayed diagnosis and/or treatment of perforation results in a poorer prognosis, and thus should be at the forefront of procedural consideration. Furthermore, this review provides steps and recommendations from the pre-procedural stage through the post-procedural evaluation with consideration of contributing factors in order to minimize ERCP-related complication risk and improve patient outcome. To avoid perforation, endoscopists must evaluate the risks related to the individual patient and the procedure and perform the procedure gently. Once a perforation occurs, immediate diagnosis and early management are key factors to minimize mortality.

Keywords: Classification; Endoscopic retrograde cholangiopancreatography; Management; Perforation; Prevention.

Figure 1

Classification of endoscopic retrograde cholangiopancreatography-related perforation (based on Kim et al[14]).

Figure 2

Endoscopic visualization of perforations. A: Image of yellowish tissue in the retroperitoneum; B and C: Bleeding from a lateral wall of the duodenum.

Figure 3

Fluoroscopy showing pneumoperitoneum (A), retroperitoneal air (B) and leakage of contrast media into the retroperitoneal cavity (C). The kidney outline (clear region on the right side of the image) showing retroperitoneal air.

Figure 4

Computed tomography showing retroperitoneal air.

Figure 5

Algorithm for prevention and management of endoscopic retrograde cholangiopancreatography-related perforations.