Post-ERCP perforation

Authors:: Andrea Tringali, MD, PhD; Guido Costamagna, MD, FACG
Section Editor:: John R Saltzman, MD, FACP, FACG, FASGE, AGAF
Deputy Editor:: Kristen M Robson, MD, MBA, FACG

Literature review current through: Jan 2024.

This topic last updated: Nov 17, 2022.

INTRODUCTION — Perforation is one of the most serious complications of endoscopic retrograde cholangiopancreatography (ERCP). This topic will focus on the risk factors, diagnosis, and treatment of post-ERCP perforation. An overview of ERCP and detailed discussions of other complications are presented separately:

●(See "Overview of endoscopic retrograde cholangiopancreatography (ERCP) in adults".)

●(See "Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis".)

●(See "Post-endoscopic retrograde cholangiopancreatography (ERCP) bleeding".)

CLASSIFICATION — Four types of perforation complicating ERCP have been recognized [1,2]. The Stapfer classification is most commonly used and is based on the mechanism, anatomical location, and severity of the injury that may predict the need for surgical intervention (figure 1) [2]:

●Type I: Free duodenal wall perforation

●Type II: Retroperitoneal duodenal perforation secondary to periampullary injury

●Type III: Perforation of the pancreatic or bile duct

●Type IV: Retroperitoneal air alone

Of these, type II retroperitoneal duodenal perforations are the most common. In a case series of 44 post-ERCP perforations, 30 (68 percent) were retroperitoneal duodenal perforations, which usually occur as a result of a sphincterotomy or large balloon dilation that extends beyond the intramural portion of bile duct [3]. Perforation of the pancreatic or bile duct usually occurs following dilation of strictures, forceful cannulation, guidewire manipulation, stent migration, or difficult stone extraction [4-12]. Liver and pancreatic parenchymal perforation by the guidewire during ERCP is an under-appreciated complication, and subcapsular liver hematoma and subcapsular biloma can occur in this context [13,14]. (See "Adverse events related to endoscopic retrograde cholangiopancreatography (ERCP) in adults".)

Type I free perforation of the duodenum (ie, lateral or medial wall, remote from the ampulla) or the jejunum is caused by the endoscope, is rare, and usually occurs in patients with a stricture or altered anatomy, such as Billroth II gastrectomy [15-18]. (See "Endoscopic retrograde cholangiopancreatography (ERCP) after Billroth II reconstruction" and "ERCP in patients with Roux-en-Y anatomy".)

In a single-center series, 79 post-ERCP perforations were diagnosed: seven perforations were type I, 54 were type II, nine were type III, six were type IV, and three were hypopharyngeal or esophageal [18]. While most patients with Type II perforations were medically managed, four patients from this group (7 percent) required surgical intervention.

Gastric and esophageal perforation [4,19,20] and pneumomediastinum without evidence of perforation [21] have also been described after ERCP and sphincterotomy and in patients with altered anatomy, such as an esophageal diverticulum or stricture. Intestinal perforation related to biliary stents is uncommon. (See "Endoscopic stenting for malignant biliary obstruction", section on 'Stent-related'.)

INCIDENCE — Retroduodenal perforation was reported in 0.5 to 2.1 percent of patients who had ERCP with sphincterotomy in older series [22]. The incidence of perforation has appeared to decrease to less than 0.5 percent, probably because of improvement in instruments, accessories, and experience and skill of endoscopists [23]. However, severe and fatal cases continue to occur [24,25]. In a summary of 21 prospective studies involving 16,855 patients undergoing ERCP, procedure-related perforation was reported in 101 patients (0.60 percent), with 10 deaths (0.06 percent) [26].

Multiple observational studies have described perforation rates following ERCP [1-4,11,12,27-53]. According to these series including nearly 210,000 ERCPs, 830 procedures were complicated by perforation (approximately 0.4 percent), with a mortality rate among patients with perforation of approximately 7 to 8 percent. Type I perforations accounted for 25 percent of perforations, type II for 46 percent, type III for 22 percent, and type IV for 3 percent [50]. (See 'Classification' above.)

RISK FACTORS — A number of patient- and procedure-related risk factors for perforation have been identified in individual reports and in large series. A difficulty with interpreting the risk factors identified in these reports is that many of the studies combined free bowel wall perforation at a site remote from the papilla (endoscope-related) and periampullary retroperitoneal perforation (sphincterotomy-related). The mechanisms leading to the different types of perforations vary substantially. Furthermore, the absolute number of patients studied is small, reflecting the infrequent occurrence of these complications.

All perforations — The following risk factors for free abdominal or retroperitoneal perforation have been identified [54,55]:

●Patient-related risk factors – Surgically altered anatomy, female sex, older age, dilated common bile duct, and the presence of a papillary lesion. Sphincter of Oddi dysfunction was a risk factor for perforation in older studies, but ERCP is not typically performed for this indication.

●Procedure-related risk factors – Sphincterotomy, use of precut needle-knife methods for bile duct access, endoscopic papillary large-balloon dilatation, biliary stricture dilation, difficult cannulation, intramural injection of contrast material, longer duration of the procedure, and less experienced endoscopists.

Bowel wall perforation — The risk of bowel wall perforation is increased in patients who have stenosis in the upper gastrointestinal tract, and in patients with altered anatomy, such as gastrectomy, pancreaticoduodenectomy, situs inversus, or periampullary diverticula [15,16,18,28,56,57]. Particular caution is required with the use of a side-viewing duodenoscope (the endoscope typically used for ERCP) in patients with a Billroth II gastrectomy [56,58]. (See "Endoscopic retrograde cholangiopancreatography (ERCP) after Billroth II reconstruction".)

Retroperitoneal perforation — The risk of retroperitoneal perforation is increased with precut sphincterotomy and larger sphincterotomies, particularly those that are created outside of the usually recommended landmarks (11 to 1 o'clock) [59-62]. In one report, 7 of 13 sphincterotomy perforations were related to precutting [4]. (See "Management of difficult biliary access during ERCP in adults".)

Use of endoscopic papillary large-balloon dilation is a risk factor for perforation [54], especially when performed in combination with a large sphincterotomy during the same procedure [63].

ERCP with endoscopic snare papillectomy (ESP) is a risk factor for retroperitoneal perforation. In a study of 104 patients who underwent ESP, the perforation rate was 8 percent [64]. In a retrospective study, ESP had been performed in 7 out of 30 cases (23 percent) of duodeno-pancreato-biliary perforations reported after ERCP [65]. (See "Ampullary adenomas: Management".)

Other risk factors identified in individual reports include a small caliber bile duct [66], the presence of a peripapillary diverticulum [61,67], and intramural injection of contrast [59].

Biliopancreatic ductal perforation — Biliary stricture dilation increases the risk of biliopancreatic perforation [4].

CLINICAL MANIFESTATIONS AND DIAGNOSIS — Free abdominal perforation (type I perforation) is almost always recognized immediately based upon clinical symptoms, physical signs, and fluoroscopic findings. By contrast, retroduodenal perforation (type II) is usually determined by radiologic evidence of air (image 1) or by contrast material in the retroperitoneal space outside the confines of the bile duct and duodenum during ERCP (image 2) or computed tomographic (CT) evaluation for post-ERCP pain. However, type II perforations may be evident endoscopically (picture 1).

A retrospective series of ERCPs that included 61 type I or II duodenal perforations found that the diagnosis was made during the procedure in six patients (10 percent) and after the procedure in 54 patients (90 percent). The mean time to diagnosis was 24 (+/-13) hours [18]. However, other studies suggest that the rate of detection during ERCP may be higher [50,51]. For example, in a review of 18 studies with a total of 437 perforations, the diagnosis of perforation was made during ERCP in 321 cases (73 percent) [50].

Patients with undetected leaks can present hours after the procedure with pain, fever, and leukocytosis. Pneumomediastinum and subcutaneous emphysema can occur [21,68-72]. Pneumothorax [73] and gas in the portal system [74] have also been rarely described. Case reports have documented patients who developed pneumoretroperitoneum, pneumoperitoneum, pneumomediastinum, pneumothorax, and subcutaneous emphysema following ERCP [75-78]. Indeed, an anatomic continuum exists between the retroperitoneum, pneumoperitoneum, mediastinum, pneumothorax, and subcutaneous tissues. As a result, ectopic air in one of these compartments can extend to distant communicating spaces [79].

An abdominal CT scan should be obtained in patients who are suspected of having a perforation, even if they do not have evidence of retroperitoneal air on plain films, since CT scan is the most sensitive means for detecting and localizing the site of perforation [80,81]. The clinical or radiographic amount of air does not always indicate the size of the perforation or correlate with the severity of the complication, but rather reflects the degree of manipulation after the perforation occurred [80,82].

Retroperitoneal air in asymptomatic patients — As discussed above, perforation is typically associated with the presence of retroperitoneal air, which can be detected by plain radiographs or CT. However, retroperitoneal air may also develop following sphincterotomy in patients who are clinically asymptomatic [81,83]. Such patients may not require intervention. This was illustrated in a series of 21 patients studied prospectively who underwent an abdominal CT scan following sphincterotomy. Retroperitoneal air was observed in six (29 percent) patients, all of whom were asymptomatic and had an uneventful postprocedural course [83]. No clinical or procedure-related characteristics predicted the presence of air.

The origin of retroperitoneal air in such patients is presumably related to dissection through an injured or macroscopically intact bowel, which has also been described after colonoscopy [84,85], although sealed microperforations are also possible. These findings suggest that retroperitoneal air in the absence of symptoms should warrant careful observation but may not require intervention.

Retroperitoneal perforation associated with pancreatitis — The finding of retroperitoneal air may be challenging in patients who are symptomatic following sphincterotomy in whom a distinction needs to be made between perforation, clinically insignificant retroperitoneal air, and pancreatitis, particularly since pancreatitis and perforation can have a similar clinical presentation or occur simultaneously [74,80,86]. This was illustrated in a study that included 36 patients who developed prolonged abdominal pain following sphincterotomy and underwent a diagnostic CT scan. Complications included acute pancreatitis in 23 patients (64 percent), duodenal perforation in 11 (31 percent), and both pancreatitis and duodenal perforation in six patients (17 percent) [80]. In a series that included 61 type I or II duodenal perforations, concurrent post-ERCP pancreatitis was diagnosed in 26 patients (43 percent) and was associated with increased mean length of stay [18]. In another series, two of three perforations in patients with Billroth II anatomy were associated with acute pancreatitis [87]. The diagnosis of retroperitoneal duodenal perforation associated with pancreatitis should be based upon the detection of retroperitoneal air or contrast in a symptomatic patient meeting criteria for post-ERCP pancreatitis (see "Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis").

A retroperitoneal abscess should be suspected in patients with post-ERCP pancreatitis who develop back pain and persistent fever [88].

GRADING — Post-ERCP retroperitoneal perforation can be graded as mild, moderate, or severe based upon a consensus definition [55,89]:

●Mild – Either of the following:

•Procedure aborted because of adverse event

•Unplanned hospital admission less than four nights in duration

●Moderate – Any of the following:

•Unplanned hospital admission for four to 10 nights

•Admission requiring intensive care for at least one night

•Need for blood transfusion

•Need for repeat endoscopy or interventional radiology

•Intervention for integument injuries

●Severe – Any of the following:

•Unplanned hospital admission >10 nights

•Admission requiring intensive care for >1 night

•Need for surgery

•Permanent disability

MANAGEMENT

General principles — All patients should be kept fasting while receiving hydration, nasogastric or nasoduodenal suction, and intravenous antibiotics, with the possible exception of asymptomatic patients with small type III perforations of the pancreatic or bile duct. If immediately diagnosed, type I perforations (free bowel wall perforations) can sometimes be successfully treated endoscopically with the use of endoscopic clips, an over-the-scope clip device, or endoscopic suturing device [18,90]. However, most patients with esophageal and free abdominal gastric, jejunal, or duodenal perforation usually require surgery [4,91].

By contrast, a less invasive approach to retroperitoneal perforation following sphincterotomy has been adopted, and this includes medical management and, for some patients, placement of a fully covered metal stent to seal the perforation [2,11,12,28,31]. However, early surgical consultation and careful observation is mandatory since the outcome may be poor in patients who do not receive prompt intervention if their condition worsens [1,92-95]. For example, in a retrospective study of 380 patients with ERCP-related perforation, 330 patients (87 percent) were managed nonoperatively, while 50 patients (13 percent) required surgical intervention [93]. For 20 of 50 surgical patients, surgery was performed 24 hours after ERCP, and delayed surgery was associated with higher rates of mortality and postoperative duodenal leak compared with early surgery (50 versus 20 percent, and 75 versus 23 percent, respectively).

Medical management — Patients with a post-ERCP perforation should be kept fasting while receiving intravenous hydration, nasogastric or nasoduodenal suction, and intravenous antibiotics. Patients who are expected to require bowel rest for at least one week should receive parenteral nutrition.

Surgery — Overall, surgery was required in 20 to 50 percent of patients with a perforation in most reports, although mostly for type I free bowel perforations [3,4,11,12,18,22,32-36,50,52,59,65,91,96-98]. Surgery should be performed for patients with a major contrast leak, persistent biliary obstruction, or cholangitis, and for those whose symptoms do not improve after a brief period of nonoperative management [99]. Surgical options include choledochotomy with stone extraction and T-tube drainage, repair of the perforation, drainage of an abscess or phlegmon, choledochojejunostomy, or pancreatoduodenectomy [65,99-102]. (See "Repair of common bile duct injuries".)

The location of the perforation in cases of ERCP-associated injury may not be identified at laparotomy, especially in patients with type II or III perforations [11]. For patients with perforation complicated by a retroperitoneal fluid collection, a surgical approach using a retroperitoneal laparostomy has been reported [65].

Surgical repair is associated with a higher mortality rate than medical management. In a review that included 11 studies, surgery was required in 29 of 137 patients with type II perforations (21 percent), with an overall mortality rate of 9 percent. However, the mortality rate in patients who required surgery was 38 percent (11 of 29 patients) [50].

Endoscopic therapy — Endoscopic interventions to manage ERCP-related perforations include:

●First-line techniques – Placement of either a fully covered self-expandable metal stent (SEMS) or an over-the-scope clip are first-line endoscopic interventions for managing ERCP-related perforation:

•Fully covered SEMS – Temporary placement of a biliary, fully covered SEMS is effective for treating ERCP-related retroperitoneal perforation. When the perforation is diagnosed during the index procedure, it can be treated immediately with stenting (image 2 and picture 2) [18,103-108]. In a case series including 19 patients with type II perforation who were managed with a fully covered SEMS either during the index procedure or up to 48 hours later, none of the patients required further intervention (ie, surgical or percutaneous intervention) [109]. (See 'Classification' above.)

•Over-the-scope clip – Data from case reports suggest that post-ERCP perforation can be effectively managed with placement of an over-the-scope clip. As examples, an over-the scope clip device was used to close a post-ERCP jejunal perforation in a patient with Billroth II anatomy [110] and a large post-ERCP retroperitoneal duodenal perforation (picture 3 and picture 4 and image 3) [111]. Endoscopic therapy with over-the-scope clip closure is typically used for patients who are not surgical candidates, do not have sepsis, and have minimal or no peritoneal fluid collection [112]. Use of an over-the-scope clip device is discussed in more detail separately. (See "Endoscopic clip therapy in the gastrointestinal tract: Bleeding lesions and beyond", section on 'Uses for over-the-scope endoscopic clips'.)

●Other techniques

•Through-the-scope endoscopic clips – Effective and safe placement of metallic endoscopic clips in the treatment of duodenal perforation secondary to sphincterotomy has been reported [37,113,114]. Effective endoscopic closure of duodenal perforations caused by the tip of the endoscope during ERCP using endoscopic clips has also been reported [98,115,116]. However, endoscopic therapy of a duodenal perforation is more technically difficult than that of a colonic or gastric perforation.

•Endoscopic purse-string suture – The endoscopic purse-string suture uses endoscopically placed loops and clips to repair perforations of the gastrointestinal tract. It has been reported that this technique was successfully employed with a double-lumen endoscope for closing a large perforation on the lateral duodenal wall [117].

•Fibrin glue – In a case report, the injection of fibrin glue proved effective in sealing a perforation located in the posterior wall of the duodenal bulb [118]. Fibrin sealant injection successfully occluded a retroperitoneal perforation after sphincterotomy in a case report where previously a CT-guided abscess drainage had been performed and the biliary orifice had been protected by a stent [119]. Additional study of the use of fibrin glue for perforations is needed.

•Endoscopic vacuum therapy – A case of successful drainage of an iatrogenic retroperitoneal duodenal perforation following ERCP with papillotomy that used a vacuum technique has been reported [120]. The distal end of a drainage tube, wrapped in a very thin, open-pore, double-layered drainage film and secured using a suture was inserted nasally and then advanced into the duodenal lumen under endoscopic view. A vacuum was applied, resulting in collapse of the stomach and duodenum around the tube. Gastric, biliary, and pancreatic secretions were drained via the open-pore tube. Once the perforation healed (after six days in the report), the tube was removed.

•If a fully covered SEMS is not available when perforation is diagnosed during the procedure, an alternative is placement of a nasobiliary drain to divert biliary secretions from the site of perforation [59]. A nasobiliary tube can be placed in an attempt to aspirate bile and minimize retroperitoneal contamination.

Percutaneous drainage — Percutaneous transhepatic drainage is an alternative to surgery for patients who develop localized retroperitoneal fluid collections [97,102]. Percutaneous transhepatic cholangiography and associated interventions are discussed separately. (See "Percutaneous transhepatic cholangiography in adults".)

PROGNOSIS — The prognosis of patients with an ERCP-related perforation depends upon the rapidity with which it is recognized, the clinical setting, and patient comorbidities. The overall mortality was 16 percent in an older report that summarized the outcomes of 153 perforations following endoscopic sphincterotomy [22]. Overall mortality was 6 percent (seven out of 115 patients) in five large series [4,38,59,96,121], and a mortality rate of 8 percent (20 out of 251 patients) was demonstrated in a subsequent review [122]. An overall mortality of 13 percent (four deaths among 30 cases) and a postoperative mortality of 27 percent (four deaths among 15 cases) were reported in a retrospective study [65]. The overall need for surgery after perforation was approximately 35 percent and the mortality was approximately 7 percent according to results from observational studies [1-4,11,12,27-48,51,52]. The lower mortality seen in many of the subsequent studies may reflect the benefits related to a conservative team approach for the management of small retroperitoneal perforations and the use of biliary fully covered SEMS [109].

PREVENTION — Endoscopic strategies for reducing the risk of ERCP- and sphincterotomy-related perforation include [90]:

●Orientation of the sphincterotome between 11 and 1 o'clock.

●Step-by-step incision.

●Avoiding a "zipper" cut.

●Sphincterotomy length tailored to the size of papilla, length of the infundibulum, bile duct diameter, and eventual stone size.

●Selective use of precut (access) papillotomy by endoscopists with expertise in difficult biliary access. (See "Management of difficult biliary access during ERCP in adults".)

●Appropriate technique in cases of altered anatomy such as peripapillary diverticulum and Billroth II gastrectomy. (See "Endoscopic retrograde cholangiopancreatography (ERCP) after Billroth II reconstruction" and "ERCP in patients with Roux-en-Y anatomy".)

●Use of balloon dilation in conjunction with sphincterotomy in patients with large bile duct stones rather than relying on sphincterotomy alone [123-125], although severe perforations have been noted with this technique as well [124]. In a retrospective study comparing small sphincterotomy combined with endoscopic papillary large balloon dilation (group A) versus sphincterotomy alone (group B) for removal of large common bile duct stones involving a total of 153 patients, there were no perforations in either group and the rate of bleeding was significantly lower in group A (1.6 versus 5.6 percent) [126]. (See "Endoscopic balloon dilation for removal of bile duct stones".)

●Use of carbon dioxide for insufflation during ERCP is common and can theoretically minimize retroperitoneal gas in the event of ERCP-related perforation [54,127]. Carbon dioxide is rapidly absorbed from the gastrointestinal tract, and benefits of carbon dioxide for insufflation during endoscopy are discussed separately. (See "Overview of endoscopic retrograde cholangiopancreatography (ERCP) in adults", section on 'Gas insufflation' and "Overview of colonoscopy in adults", section on 'Colonoscope advancement and mucosal inspection'.)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Endoscopic retrograde cholangiopancreatography (ERCP)" and "Society guideline links: Gastrointestinal perforation".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Beyond the Basics topics (see "Patient education: ERCP (endoscopic retrograde cholangiopancreatography) (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●Classification – Four types of perforation complicating endoscopic retrograde cholangiopancreatography (ERCP) have been recognized. (See 'Classification' above.):

•Type I: Free duodenal wall perforation

•Type II: Retroperitoneal duodenal perforation secondary to periampullary injury

•Type III: Perforation of the pancreatic or bile duct

•Type IV: Retroperitoneal air alone

●Incidence – Retroduodenal perforation was reported in 0.5 to 2.1 percent of patients who had ERCP with sphincterotomy in older series. Over time, the incidence of perforation has appeared to decrease to less than 0.5 percent, probably because of improvements in instruments, accessories, and endoscopist experience and skill. (See 'Incidence' above.)

●Clinical features and diagnosis – Free abdominal, intraperitoneal perforation is almost always recognized immediately based on endoscopic and fluoroscopic findings, clinical symptoms, and physical signs. In contrast, retroduodenal perforation is usually determined by radiologic evidence of air or contrast in the retroperitoneal space outside the confines of the bile duct and duodenum during computed tomographic (CT) evaluation for post-ERCP abdominal pain. Retroperitoneal perforation is rarely evident endoscopically. (See 'Clinical manifestations and diagnosis' above.)

Retroperitoneal air may also develop following sphincterotomy in patients who are clinically asymptomatic. Such patients may not require treatment. (See 'Retroperitoneal air in asymptomatic patients' above.)

●Management – Most patients with esophageal and free abdominal gastric, jejunal, or duodenal perforation require surgery. For some patients, in whom ERCP-related perforation is diagnosed during the procedure, an endoscopic intervention to seal the perforation (eg, placement of a fully covered self-expandable metal stent or over-the-scope clip) may be used when expertise in endoscopic closure methods is available.

For patients with a small retroperitoneal perforation related to sphincterotomy, medical management may be appropriate. However, careful observation along with surgical consultation is mandatory since the outcome may be poor in patients who do not receive prompt treatment if their condition worsens. (See 'Management' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledge Francesco Ferrara, MD, and Silvano Loperfido, MD, who contributed to earlier versions of this topic review.

Howard TJ, Tan T, Lehman GA, et al. Classification and management of perforations complicating endoscopic sphincterotomy. Surgery 1999; 126:658.
Stapfer M, Selby RR, Stain SC, et al. Management of duodenal perforation after endoscopic retrograde cholangiopancreatography and sphincterotomy. Ann Surg 2000; 232:191.
Polydorou A, Vezakis A, Fragulidis G, et al. A tailored approach to the management of perforations following endoscopic retrograde cholangiopancreatography and sphincterotomy. J Gastrointest Surg 2011; 15:2211.
Enns R, Eloubeidi MA, Mergener K, et al. ERCP-related perforations: risk factors and management. Endoscopy 2002; 34:293.
Jayaprakash B, Wright R. Common bile duct perforation--an unusual complication of ERCP. Gastrointest Endosc 1986; 32:246.
Lambiase RE, Cronan JJ, Ridlen M. Perforation of the common bile duct during endoscopic sphincterotomy: recognition on computed tomography and successful percutaneous treatment. Gastrointest Radiol 1989; 14:133.
Coelho JC, Campos AC, Pisani JC, et al. Common hepatic duct perforation: a rare complication associated with ERCP. Gastrointest Endosc 1990; 36:427.
Martin DF, Tweedle DE. Retroperitoneal perforation during ERCP and endoscopic sphincterotomy: causes, clinical features and management. Endoscopy 1990; 22:174.
Siragusa G, Gelarda E, Epifanio E, et al. [Video laparoscopy in abdominal emergencies]. Minerva Chir 1999; 54:199.
Freeman ML. Adverse outcomes of ERCP. Gastrointest Endosc 2002; 56:S273.
Wu HM, Dixon E, May GR, Sutherland FR. Management of perforation after endoscopic retrograde cholangiopancreatography (ERCP): a population-based review. HPB (Oxford) 2006; 8:393.
Fatima J, Baron TH, Topazian MD, et al. Pancreaticobiliary and duodenal perforations after periampullary endoscopic procedures: diagnosis and management. Arch Surg 2007; 142:448.
Rabie ME, Al Faris S, Nasser A, et al. Parenchymal Guidewire Perforation during ERCP: An Unappreciated Injury. Case Rep Surg 2015; 2015:670323.
Takano Y, Nagahama M, Yamamura E, et al. Perforation of the Papilla of Vater in Wire-Guided Cannulation. Can J Gastroenterol Hepatol 2016; 2016:5825230.
Wilkinson ML, Engelman JL, Hanson PJ. Intestinal perforation after ERCP in Billroth II partial gastrectomy. Gastrointest Endosc 1994; 40:389.
Lin LF, Siauw CP, Ho KS, Tung JC. ERCP in post-Billroth II gastrectomy patients: emphasis on technique. Am J Gastroenterol 1999; 94:144.
Feitoza AB, Baron TH. Endoscopy and ERCP in the setting of previous upper GI tract surgery. Part I: reconstruction without alteration of pancreaticobiliary anatomy. Gastrointest Endosc 2001; 54:743.
Kumbhari V, Sinha A, Reddy A, et al. Algorithm for the management of ERCP-related perforations. Gastrointest Endosc 2016; 83:934.
Stermer E, Levy N. Esophageal perforation during ERCP. Gastrointest Endosc 1993; 39:603.
Fireman Z, Kyzer S, Michalevicz D, et al. Esophageal perforation after endoscopic sphincterotomy during stone extraction from the common bile duct. J Clin Gastroenterol 1994; 19:173.
Ciaccia D, Branch MS, Baillie J. Pneumomediastinum after endoscopic sphincterotomy. Am J Gastroenterol 1995; 90:475.
Cotton PB, Lehman G, Vennes J, et al. Endoscopic sphincterotomy complications and their management: an attempt at consensus. Gastrointest Endosc 1991; 37:383.
Rabenstein T, Schneider HT, Hahn EG, Ell C. 25 years of endoscopic sphincterotomy in Erlangen: assessment of the experience in 3498 patients. Endoscopy 1998; 30:A194.
Pierie JP, van Vroonhoven TJ. [Obstructive cholangiopathy: are endoscopic retrograde cholangiopancreatography and papillotomy always really necessary?]. Ned Tijdschr Geneeskd 1999; 143:1497.
Vandervoort J, Soetikno RM, Tham TC, et al. Risk factors for complications after performance of ERCP. Gastrointest Endosc 2002; 56:652.
Andriulli A, Loperfido S, Napolitano G, et al. Incidence rates of post-ERCP complications: a systematic survey of prospective studies. Am J Gastroenterol 2007; 102:1781.
Kayhan B, Akdoğan M, Sahin B. ERCP subsequent to retroperitoneal perforation caused by endoscopic sphincterotomy. Gastrointest Endosc 2004; 60:833.
Morgan KA, Fontenot BB, Ruddy JM, et al. Endoscopic retrograde cholangiopancreatography gut perforations: when to wait! When to operate! Am Surg 2009; 75:477.
Li G, Chen Y, Zhou X, Lv N. Early management experience of perforation after ERCP. Gastroenterol Res Pract 2012; 2012:657418.
Preetha M, Chung YF, Chan WH, et al. Surgical management of endoscopic retrograde cholangiopancreatography-related perforations. ANZ J Surg 2003; 73:1011.
Assalia A, Suissa A, Ilivitzki A, et al. Validity of clinical criteria in the management of endoscopic retrograde cholangiopancreatography related duodenal perforations. Arch Surg 2007; 142:1059.
Kim JH, Yoo BM, Kim JH, et al. Management of ERCP-related perforations: outcomes of single institution in Korea. J Gastrointest Surg 2009; 13:728.
Knudson K, Raeburn CD, McIntyre RC Jr, et al. Management of duodenal and pancreaticobiliary perforations associated with periampullary endoscopic procedures. Am J Surg 2008; 196:975.
Ercan M, Bostanci EB, Dalgic T, et al. Surgical outcome of patients with perforation after endoscopic retrograde cholangiopancreatography. J Laparoendosc Adv Surg Tech A 2012; 22:371.
Dubecz A, Ottmann J, Schweigert M, et al. Management of ERCP-related small bowel perforations: the pivotal role of physical investigation. Can J Surg 2012; 55:99.
Kim J, Lee SH, Paik WH, et al. Clinical outcomes of patients who experienced perforation associated with endoscopic retrograde cholangiopancreatography. Surg Endosc 2012; 26:3293.
Katsinelos P, Paroutoglou G, Papaziogas B, et al. Treatment of a duodenal perforation secondary to an endoscopic sphincterotomy with clips. World J Gastroenterol 2005; 11:6232.
Avgerinos DV, Llaguna OH, Lo AY, et al. Management of endoscopic retrograde cholangiopancreatography: related duodenal perforations. Surg Endosc 2009; 23:833.
Kim BS, Kim IG, Ryu BY, et al. Management of endoscopic retrograde cholangiopancreatography-related perforations. J Korean Surg Soc 2011; 81:195.
Kwon W, Jang JY, Ryu JK, et al. Proposal of an endoscopic retrograde cholangiopancreatography-related perforation management guideline based on perforation type. J Korean Surg Soc 2012; 83:218.
Mao Z, Zhu Q, Wu W, et al. Duodenal perforations after endoscopic retrograde cholangiopancreatography: experience and management. J Laparoendosc Adv Surg Tech A 2008; 18:691.
Miller R, Zbar A, Klein Y, et al. Perforations following endoscopic retrograde cholangiopancreatography: a single institution experience and surgical recommendations. Am J Surg 2013; 206:180.
Rabie ME, Mir NH, Al Skaini MS, et al. Operative and non-operative management of endoscopic retrograde cholangiopancreatography-associated duodenal injuries. Ann R Coll Surg Engl 2013; 95:285.
Kodali S, Mönkemüller K, Kim H, et al. ERCP-related perforations in the new millennium: A large tertiary referral center 10-year experience. United European Gastroenterol J 2015; 3:25.
Koc B, Bircan HY, Adas G, et al. Complications following endoscopic retrograde cholangiopancreatography: minimal invasive surgical recommendations. PLoS One 2014; 9:e113073.
Turner RC, Steffen CM, Boyd P. Endoscopic duodenal perforation: surgical strategies in a regional centre. World J Emerg Surg 2014; 9:11.
Motomura Y, Akahoshi K, Gibo J, et al. Immediate detection of endoscopic retrograde cholangiopancreatography-related periampullary perforation: fluoroscopy or endoscopy? World J Gastroenterol 2014; 20:15797.
Prachayakul V, Aswakul P. Endoscopic retrograde cholangiopancreatography-related perforation: Management and prevention. World J Clin Cases 2014; 2:522.
Jin YJ, Jeong S, Kim JH, et al. Clinical course and proposed treatment strategy for ERCP-related duodenal perforation: a multicenter analysis. Endoscopy 2013; 45:806.
Vezakis A, Fragulidis G, Polydorou A. Endoscopic retrograde cholangiopancreatography-related perforations: Diagnosis and management. World J Gastrointest Endosc 2015; 7:1135.
Bill JG, Smith Z, Brancheck J, et al. The importance of early recognition in management of ERCP-related perforations. Surg Endosc 2018; 32:4841.
Weiser R, Pencovich N, Mlynarsky L, et al. Management of endoscopic retrograde cholangiopancreatography-related perforations: Experience of a tertiary center. Surgery 2017; 161:920.
Langerth A, Isaksson B, Karlson BM, et al. ERCP-related perforations: a population-based study of incidence, mortality, and risk factors. Surg Endosc 2020; 34:1939.
ASGE Standards of Practice Committee, Chandrasekhara V, Khashab MA, et al. Adverse events associated with ERCP. Gastrointest Endosc 2017; 85:32.
Dumonceau JM, Kapral C, Aabakken L, et al. ERCP-related adverse events: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2020; 52:127.
Faylona JM, Qadir A, Chan AC, et al. Small-bowel perforations related to endoscopic retrograde cholangiopancreatography (ERCP) in patients with Billroth II gastrectomy. Endoscopy 1999; 31:546.
Bray MS, Borgert AJ, Folkers ME, Kothari SN. Outcome and management of endoscopic retrograde cholangiopancreatography perforations: A community perspective. Am J Surg 2017; 214:69.
Kim MH, Lee SK, Lee MH, et al. Endoscopic retrograde cholangiopancreatography and needle-knife sphincterotomy in patients with Billroth II gastrectomy: a comparative study of the forward-viewing endoscope and the side-viewing duodenoscope. Endoscopy 1997; 29:82.
Loperfido S, Angelini G, Benedetti G, et al. Major early complications from diagnostic and therapeutic ERCP: a prospective multicenter study. Gastrointest Endosc 1998; 48:1.
Cotton PB, Williams C. Technique of biliary sphincterotomy. In: Practical Gastrointestinal Endoscopy, Fourth edition, Blackwell Science Ltd, Oxford 1996. p.142.
Boender J, Nix GA, de Ridder MA, et al. Endoscopic papillotomy for common bile duct stones: factors influencing the complication rate. Endoscopy 1994; 26:209.
Trap R, Adamsen S, Hart-Hansen O, Henriksen M. Severe and fatal complications after diagnostic and therapeutic ERCP: a prospective series of claims to insurance covering public hospitals. Endoscopy 1999; 31:125.
Dumonceau JM, Delhaye M, Tringali A, et al. Endoscopic treatment of chronic pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Updated August 2018. Endoscopy 2019; 51:179.
Kang SH, Kim KH, Kim TN, et al. Therapeutic outcomes of endoscopic papillectomy for ampullary neoplasms: retrospective analysis of a multicenter study. BMC Gastroenterol 2017; 17:69.
Alfieri S, Rosa F, Cina C, et al. Management of duodeno-pancreato-biliary perforations after ERCP: outcomes from an Italian tertiary referral center. Surg Endosc 2013; 27:2005.
Kaw M. Complications of diagnostic and therapeutic ERCP (abstract). Gastrointest Endosc 2000; 51:AB70.
Ruiz-Tovar J, Lobo E, Sanjuanbenito A, Martínez-Molina E. Case series: pneumoretroperitoneum secondary to duodenal perforation after endoscopic retrograde cholangiopancreatography. Can J Surg 2009; 52:68.
Colemont LJ, Pelckmans PA, Moorkens GH, Van Maercke YM. Unilateral periorbital emphysema: an unusual complication of endoscopic papillotomy. Gastrointest Endosc 1988; 34:473.
Tam F, Prindiville T, Wolfe B. Subcutaneous emphysema as a complication of endoscopic sphincterotomy of the ampulla of Vater. Gastrointest Endosc 1989; 35:447.
Scarlett PY, Falk GL. The management of perforation of the duodenum following endoscopic sphincterotomy: a proposal for selective therapy. Aust N Z J Surg 1994; 64:843.
Doerr RJ, Kulaylat MN, Booth FV, Corasanti J. Barotrauma complicating duodenal perforation during ERCP. Surg Endosc 1996; 10:349.
Alexiou K, Sakellaridis T, Sikalias N, et al. Subcutaneous emphysema, pneumomediastinum and pneumoperitoneum after unsuccessful ERCP: a case report. Cases J 2009; 2:120.
Savides T, Sherman S, Kadell B, et al. Bilateral pneumothoraces and subcutaneous emphysema after endoscopic sphincterotomy. Gastrointest Endosc 1993; 39:814.
Merine D, Fishman EK. Uncomplicated portal venous gas associated with duodenal perforation following ERCP: CT features. J Comput Assist Tomogr 1989; 13:138.
Ferrara F, Luigiano C, Billi P, et al. Pneumothorax, pneumomediastinum, pneumoperitoneum, pneumoretroperitoneum, and subcutaneous emphysema after ERCP. Gastrointest Endosc 2009; 69:1398.
Song SY, Lee KS, Na KJ, Ahn BH. Tension pneumothorax after endoscopic retrograde pancreatocholangiogram. J Korean Med Sci 2009; 24:173.
Sampaziotis F, Wiles A, Shaukat S, Dickinson RJ. Bilateral Pneumothorax and Subcutaneous Emphysema following Endoscopic Retrograde Cholangiopancreatography: A Rare Complication. Diagn Ther Endosc 2010; 2010.
Garmon EH, Contreras E, Conley J. Tension pneumothorax and widespread pneumatosis after endoscopic retrograde cholangiopancreatography. Anesthesiology 2013; 119:699.
Guerra F, Giuliani G, Coletti M. Images in Emergency Medicine. Elderly Female With Abdominal Pain. Palpebral Emphysema From Endoscopic Retrograde Cholangiopancreatography-Related Retroperitoneal Perforation. Ann Emerg Med 2015; 66:89, 95.
Kuhlman JE, Fishman EK, Milligan FD, Siegelman SS. Complications of endoscopic retrograde sphincterotomy: computed tomographic evaluation. Gastrointest Radiol 1989; 14:127.
de Vries JH, Duijm LE, Dekker W, et al. CT before and after ERCP: detection of pancreatic pseudotumor, asymptomatic retroperitoneal perforation, and duodenal diverticulum. Gastrointest Endosc 1997; 45:231.
Evrard S, Mendoza L, Mutter D, et al. Massive gas spread through a duodenal perforation after endoscopic sphincterotomy. Gastrointest Endosc 1993; 39:817.
Genzlinger JL, McPhee MS, Fisher JK, et al. Significance of retroperitoneal air after endoscopic retrograde cholangiopancreatography with sphincterotomy. Am J Gastroenterol 1999; 94:1267.
Heer M, Altorfer J, Pirovino M, Schmid M. Pneumatosis cystoides coli: a rare complication of colonoscopy. Endoscopy 1983; 15:119.
Meyers MA, Ghahremani GG, Clements JL Jr, Goodman K. Pneumatosis intestinalis. Gastrointest Radiol 1977; 2:91.
Humar A, Barron PT, Sekar AS, Lum A. Pancreatitis and duodenal perforation as complications of an endoscopically placed biliary stent. Gastrointest Endosc 1994; 40:365.
Jang JS, Lee S, Lee HS, et al. Efficacy and Safety of Endoscopic Papillary Balloon Dilation Using Cap-Fitted Forward-Viewing Endoscope in Patients Who Underwent Billroth II Gastrectomy. Clin Endosc 2015; 48:421.
Riahi S, Hansen J, Bjerre J, Kragsbjerg P. ERCP complicated by a retroperitoneal abscess caused by Haemophilus influenzae and Haemophilus parainfluenzae. Gastrointest Endosc 1998; 47:417.
Cotton PB, Eisen GM, Aabakken L, et al. A lexicon for endoscopic adverse events: report of an ASGE workshop. Gastrointest Endosc 2010; 71:446.
Paspatis GA, Arvanitakis M, Dumonceau JM, et al. Diagnosis and management of iatrogenic endoscopic perforations: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement - Update 2020. Endoscopy 2020; 52:792.
Masci E, Toti G, Mariani A, et al. Complications of diagnostic and therapeutic ERCP: a prospective multicenter study. Am J Gastroenterol 2001; 96:417.
Guerra F, Giuliani G, Coletta D, et al. Clinical outcomes of ERCP-related retroperitoneal perforations. Hepatobiliary Pancreat Dis Int 2017; 16:160.
Patil NS, Solanki N, Mishra PK, et al. ERCP-related perforation: an analysis of operative outcomes in a large series over 12 years. Surg Endosc 2020; 34:77.
Chaudhary A, Aranya RC. Surgery in perforation after endoscopic sphincterotomy: sooner, later or not at all? Ann R Coll Surg Engl 1996; 78:206.
Samara AA, Diamantis A, Perivoliotis K, et al. Surgical versus non-operative initial management of post-endoscopic retrograde cholangiopancreatography perforation: a systematic review and meta-analysis. Ann Gastroenterol 2022; 35:95.
Freeman ML, Nelson DB, Sherman S, et al. Complications of endoscopic biliary sphincterotomy. N Engl J Med 1996; 335:909.
Krishna RP, Singh RK, Behari A, et al. Post-endoscopic retrograde cholangiopancreatography perforation managed by surgery or percutaneous drainage. Surg Today 2011; 41:660.
Yang JF, Zhang X, Zhang XF. [Diagnosis and management of duodenal perforation after endoscopic retrograde cholangio-pancreatography: clinical analysis of 15 cases]. Zhonghua Wei Chang Wai Ke Za Zhi 2012; 15:682.
Chung RS, Sivak MV, Ferguson DR. Surgical decisions in the management of duodenal perforation complicating endoscopic sphincterotomy. Am J Surg 1993; 165:700.
Isozaki H, Okajima K, Mizutani H, Takeda Y. The successful surgical management of perforation after endoscopic sphincterotomy: report of two cases. Surg Today 1993; 23:1018.
Doglietto GB, Pacelli F, Caprino P, et al. Posterior laparostomy through the bed of the 12th rib to drain retroperitoneal infection after endoscopic sphincterotomy. Br J Surg 2004; 91:730.
McCarthy CJ, Butros SR, Dawson SL, Arellano RS. Image-guided percutaneous management of duodenal perforation following endoscopic retrograde cholangiopancreatography (ERCP): assessment of efficacy and safety. Clin Radiol 2018; 73:319.e9.
Vezakis A, Fragulidis G, Nastos C, et al. Closure of a persistent sphincterotomy-related duodenal perforation by placement of a covered self-expandable metallic biliary stent. World J Gastroenterol 2011; 17:4539.
Jeon HJ, Han JH, Park S, et al. Endoscopic sphincterotomy-related perforation in the common bile duct successfully treated by placement of a covered metal stent. Endoscopy 2011; 43 Suppl 2 UCTN:E295.
Canena J, Liberato M, Horta D, et al. Short-term stenting using fully covered self-expandable metal stents for treatment of refractory biliary leaks, postsphincterotomy bleeding, and perforations. Surg Endosc 2013; 27:313.
Park WY, Cho KB, Kim ES, Park KS. A case of ampullary perforation treated with a temporally covered metal stent. Clin Endosc 2012; 45:177.
Lee SM, Cho KB. Value of temporary stents for the management of perivaterian perforation during endoscopic retrograde cholangiopancreatography. World J Clin Cases 2014; 2:689.
Odemis B, Oztas E, Kuzu UB, et al. Can a Fully Covered Self-Expandable Metallic Stent be Used Temporarily for the Management of Duodenal Retroperitoneal Perforation During ERCP as a Part of Conservative Therapy? Surg Laparosc Endosc Percutan Tech 2016; 26:e9.
Bozbiyik O, Cetin B, Gumus T, et al. Fully covered self-expandable metal stent for intraprocedural or late-diagnosed Type-II endoscopic retrograde cholangiopancreatography-related perforations. BMC Gastroenterol 2022; 22:385.
Buffoli F, Grassia R, Iiritano E, et al. Endoscopic "retroperitoneal fatpexy" of a large ERCP-related jejunal perforation by using a new over-the-scope clip device in Billroth II anatomy (with video). Gastrointest Endosc 2012; 75:1115.
Donatelli G, Dumont JL, Vergeau BM, et al. Colic and gastric over-the-scope clip (Ovesco) for the treatment of a large duodenal perforation during endoscopic retrograde cholangiopancreatography. Therap Adv Gastroenterol 2014; 7:282.
Tribonias G, Voudoukis E, Vardas E, et al. Endoscopic Retrograde Cholangiopancreatography-Related Large Jejunal Perforation: Operate or Apply Over-the-Scope Clip Device? Clin Endosc 2014; 47:281.
Baron TH, Gostout CJ, Herman L. Hemoclip repair of a sphincterotomy-induced duodenal perforation. Gastrointest Endosc 2000; 52:566.
Amodio PM, Faggiani R, Pastorelli A, et al. Selected treatments for duodenal perforation after ERCP. A report of three cases. Chir Ital 2007; 59:343.
Lee TH, Bang BW, Jeong JI, et al. Primary endoscopic approximation suture under cap-assisted endoscopy of an ERCP-induced duodenal perforation. World J Gastroenterol 2010; 16:2305.
Solomon M, Schlachterman A, Morgenstern R. Iatrogenic duodenal perforation treated with endoscopic placement of metallic clips: a case report. Case Rep Med 2012; 2012:609750.
Li Q, Ji J, Wang F, et al. ERCP-induced duodenal perforation successfully treated with endoscopic purse-string suture: a case report. Oncotarget 2015; 6:17847.
Mutignani M, Iacopini F, Dokas S, et al. Successful endoscopic closure of a lateral duodenal perforation at ERCP with fibrin glue. Gastrointest Endosc 2006; 63:725.
Yang HY, Chen JH. Endoscopic fibrin sealant closure of duodenal perforation after endoscopic retrograde cholangiopancreatography. World J Gastroenterol 2015; 21:12976.
Loske G, Rucktäschel F, Schorsch T, et al. Successful endoscopic vacuum therapy with new open-pore film drainage in a case of iatrogenic duodenal perforation during ERCP. Endoscopy 2015; 47:E577.
Christensen M, Matzen P, Schulze S, Rosenberg J. Complications of ERCP: a prospective study. Gastrointest Endosc 2004; 60:721.
Machado NO. Management of duodenal perforation post-endoscopic retrograde cholangiopancreatography. When and whom to operate and what factors determine the outcome? A review article. JOP 2012; 13:18.
Heo JH, Kang DH, Jung HJ, et al. Endoscopic sphincterotomy plus large-balloon dilation versus endoscopic sphincterotomy for removal of bile-duct stones. Gastrointest Endosc 2007; 66:720.
Attasaranya S, Cheon YK, Vittal H, et al. Large-diameter biliary orifice balloon dilation to aid in endoscopic bile duct stone removal: a multicenter series. Gastrointest Endosc 2008; 67:1046.
Draganov PV, Evans W, Fazel A, Forsmark CE. Large size balloon dilation of the ampulla after biliary sphincterotomy can facilitate endoscopic extraction of difficult bile duct stones. J Clin Gastroenterol 2009; 43:782.
Guo SB, Meng H, Duan ZJ, Li CY. Small sphincterotomy combined with endoscopic papillary large balloon dilation vs sphincterotomy alone for removal of common bile duct stones. World J Gastroenterol 2014; 20:17962.
Cheng Y, Xiong XZ, Wu SJ, et al. Carbon dioxide insufflation for endoscopic retrograde cholangiopancreatography: A meta-analysis and systematic review. World J Gastroenterol 2012; 18:5622.

Topic 634 Version 34.0

خرید پکیج

Post-ERCP perforation

References