Elsevier

Surgery

Volume 126, Issue 4, October 1999, Pages 658-665
Surgery

Central Surgical Association
Classification and management of perforations complicating endoscopic sphincterotomy

Presented at the 56th Annual Meeting of the Central Surgical Association, St Louis, Mo, Mar 4-6, 1999.
https://doi.org/10.1016/S0039-6060(99)70119-4Get rights and content

Abstract

Background: The management of perforations after endoscopic sphincterotomy (ES) is controversial. The purpose of this study was to analyze the treatments and outcome of patients with ES perforations. Methods: Between January 1994 and July 1998, in a series of 6040 endoscopic retrograde cholangiopancreatographies, 2874 (48%) ESs were performed: 40 patients (0.6%) with perforation were identified and retrospectively reviewed. Results: All patients (n = 14) with guidewire perforation (group I) were recognized early, managed medically, and discharged after a mean hospital stay of 3.5 days. Twenty of 22 patients with periampullary perforation (group II) were identified early; 18 patients (90%) had aggressive endoscopic drainage, and none required operation. Of the 2 patients identified late, 1 patient required operation and subsequently died. Mean hospital stay for this group was 8.5 days. Only 1 of 4 patients with duodenal perforations (group III) was identified early; all required operation; 1 patient died, and the mean hospital stay was 19.5 days. Conclusions: ES perforation has 3 distinct types: guidewire, periampullary, and duodenal. Guidewire perforations are recognized early and resolve with medical treatment. Periampullary perforations diagnosed early respond to aggressive endoscopic drainage and medical treatment. Postsphincterotomy perforations diagnosed late (particularly duodenal) require surgical drainage, which carries a high morbidity and mortality rate. (Surgery 1999:126:658-65.)

Section snippets

Methods

Consecutive patients with ERCP/ES perforations between January 1994 and July 1998 were retrospectively reviewed. In a series of 6040 ERCPs, 2874 ESs were performed. In this population, 39 perforations (0.6%) were identified from the Indiana University ERCP complication database. This database was cross-referenced through our medical records data system by querying using the ICD9 code 998.2 (accidental puncture or laceration during a procedure) as both the primary or secondary diagnosis and

Results

Patients were categorized into 3 groups on the basis of the type of injury: guidewire perforation of the duct (group I), periampullary perforation (group II), or duodenal perforation remote from the papilla (group III). Patient demographics and associated illnesses are listed in Table I. The indications for ES and the type of procedure performed are reported in Table II. All patients (n = 14 patients) with guidewire perforation (group I) were identified immediately during the procedure by the

Discussion

Perforations during ERCP/ES may occur either during cutting of the Vaterian sphincter, cannulation of the bile or pancreatic duct with a guidewire or sharp tip catheter, or by the endoscope during positioning and manipulation (Fig 1).

. Mechanisms of perforation during the performance of ES: (I ) guidewire perforation, (II ) periampullary retroperitoneal perforation, and (III ) duodenal perforation.

Some of the ambiguity surrounding the appropriate treatment of ES perforations is in not

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Reprint requests: Thomas J. Howard, MD, Associate Professor of Surgery, Emerson Hall #523, 545 Barnhill Dr, Indianapolis, IN 46202.

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