Surgical Management of Duodenal Perforations After Ercp: the Crucial Role of a Retroperitoneal Approach.

Sergio Alfieri, MD, Fausto Rosa, MD, Caterina Cina, MD, Antonio P Tortorelli, MD, Vincenzo Perri, MD, Guido Costamagna, MD, Giovanni B Doglietto, MD. Department of Digestive Surgery, Catholic University, “A. Gemelli” Hospital

 

ABSTRACT

Introduction
Endoscopic retrograde cholangio-pancreatography (ERCP) combined with endoscopic sphincterotomy (ES) has become a common procedure worldwide in the era of minimally invasive management of biliary and pancreatic disorders. Although regarded widely as a safe procedure, ES carries a small but significant number of serious complications. Common complications include pancreatitis, bleeding, cholangitis, and perforation.
ERCP-related perforation occurs in 0.3% to 1% of patients, and the injury carries a mortality rate of 16% to 18%.
Evidence-based strategies are lacking regarding the appropriate management of duodenal perforations complicating endoscopic retrograde cholangiopancreatography (ERCP) combined with endoscopic sphincterotomy (ES). Some investigators advocate conservative management based on a clinical course, whereas others advocate operative repair in all cases because of the complications associated with delayed operative intervention.
The aim of this study was to investigate clinicoradiologic findings and treatment outcomes in patients with ERCP-related perforation and to suggest useful treatment modalities for the perforations.
Methods and procedures: A retrospective review of ERCP-related perforations to the duodenum observed at the Digestive Surgery Department of the Catholic University of Rome was conducted to identify their optimal management and clinical outcome. Charts were reviewed for the following data: ERCP indication, clinical presentation, diagnostic methods, time to diagnosis and treatment, type of injury, management, length of hospital stay, and clinical outcome.
Results: From January 1999 to December 2010, 18 duodenal perforations after ERCP were observed. Seven patients underwent ERCP/ES at another institution and eleven patients underwent an endoscopic procedure at the Digestive Endoscopy Unit of Gemelli Hospital, Catholic University of Rome.
Only one patient was treated conservatively just with aspirative naso-duodenal and naso-biliary tubes, two other patients received percutaneous drainages of retroperitoneal abscesses. Fifteen patients underwent surgery: ten received a posterior approach, three both an anterior and posterior approach and two an anterior approach. The overall mortality rate was 22.2% (4 of 18 patients).
Conclusion: Clinical and radiographic features can be used to determine which type of surgical or conservative treatment of ERCP-related duodenal perforations, whereas intraoperative findings can determine the final outcome and morbidity or mortality. The interval between the perforation and the operation is of great significance. The mortality rate increases dramatically with late surgical management.
Moreover, our data confirm that the technique of posterior laparostomy offers the advantage of creating a wide and open cavity, permitting continuous gravitational drainage and avoiding septic contamination of the peritoneal cavity. The direct access to the retroperitoneal spaces permits easier removal of infected collections in the operating theatre and repeated necrosectomy and washing during cleaning of the wound in the recovery unit. The good control of both retroperitoneal sepsis and duodenal secretions favours the spontaneous closure of duodenal leak, thus avoiding the need for more complex intraabdominal procedures. The possible risk of overtreatment is acceptable when the prospects of recovery are high and when delay in treatment may result in death.
In conclusion, this technique should always be considered as the first surgical step to drain retroperitoneal infections after endoscopic sphincterotomy.

 


Session Number: SS14 – Therapeutic Endoscopy
Program Number: S080

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