ERCP associated duodenal injuries: to operate or not to operate?

M E Ezzedien, MD, Najeeb H Mir, M S Alskaini, MD, Ismail El Hakeem, MD, Ahmad Haddad, MD, Mahmoud Obeid, MD, Hussein Ageely, MD, Abdulelah M Hummadi, MD, FRCSC, MBA

Armed Forces Hospital – Southern Region, Saudi Arabia

Background: endoscopic retrograde cholangiopancreatography (ERCP) is indispensable in every day surgical practice. Yet, as an invasive procedure, it has its own mortality and morbidity, the most feared of which is periduodenal perforations.

Aims: to present our experience with ERCP related periduodenal perforations and its treatment strategies. Additionally, a rarely encountered subtype is highlighted.
Patients and methods: we reviewed patients who underwent ERCP and sustained a periduodenal perforation, in the period from August 2008 to October 2011.

Results: we were able to identify 10 patients, 3 males and 7 females, with a mean age of 56.6 years. During the procedure, injury was suspected in 4 patients and it passed unnoticed in the remaining 6. The decision to operate or follow a conservative policy was based on a combination of clinical and radiological findings. Operative intervention was required in three patients with one mortality, while conservative treatment was followed in the remaining seven. Laparotomy was performed early in two patients, whereas it was performed after an initial period of conservative treatment in one. The presence of periduodenal fluid collection, contrast extravasation or free intraperitoneal air were decisive factors for performing laparotomy.

Conclusion: ERCP related periduodenal perforations include different categories. Certain types require operative repair, while others should be treated conservatively. The choice of the management approach should be individualized, depending on the clinical picture and radiological findings. Although rare, these are potentially serious complications which may end fatally. Early recognition and appropriate intervention is the only way to avert a fatal outcome.

Session: Poster Presentation

Program Number: P254

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