Dubecz, Attila, Ottmann, Jurgen, Schweigert, Michael, Stadlhuber, Rudolf J., Feith, Marcus, Wiessner, Volkmar, Muschweck, Herbert, and Stein, Hubert J.
Background: Management of endoscopic retrograde cholangiopancreatography (ERCP)-associated duodenal perforation remains controversial. Some recommend surgery, while others recommend conservative treatment. Methods: A retrospective chart review was conducted to identify patients treated at our institution for ERCP-related duodenal perforations. Study variables included indication for ERCP, clinical presentation, diagnostic procedures, time to diagnosis and treatment, location of injury, management, length of stay in hospital and survival. Results: Between January 2000 and October 2009, 12 232 ERCP procedures were performed at our centre, and perforation occured in 11 patients (0.08%; 5 men, 6 women, mean age 71 yr). Six of the perforations were discovered during ERCP; 5 required radiologic imaging for diagnosis. Three perforations were diagnosed incidentally by follow-up ERCP. In 1 patient, perforation occurred 3 years after the procedure owing to a dislocated stent. Four of 11 perforations were stent-related; in 2 patients ERCP was performed in a nonanatomic situation (Billroth II gastroenterostomy). Free peritoneal perforation occurred in 4 patients; 1 was successfully managed conservatively. Four patients (36%) were treated surgically and none died. Five patients were managed conservatively with a successful outcome, and 2 patients died after conservative treatment (18%). Operative treatment included hepaticojejunostomy and duodenostomy (1 patient), suture of the perforation with T-drain (1 patient) and suture only (2 patients). The mean length of stay in hospital for all patients was 20 days. Conclusion: Post-ERCP duodenal perforations are associated with significant morbidity and mortality. Immediate surgical evaluation and close monitoring is needed. Management should be individually tailored based on clinical findings only. Contexte: La prise en charge de la perforation duodenale associee a la cholangiopancreatographie endoscopique retrograde (CPER) demeure controversee. Certains recommandent la chirurgie, tandis que d'autres optent pour un traitement conservateur. Methodes: Une analyse retrospective des dossiers a permis de recenser les patients qui ont ete traites dans notre etablissement pour une perforation duodenale liee a une CPER. Parmi les parametres de l'etude, mentionnons l'indication de la CPER, le tableau clinique, les interventions diagnostiques, le delai avant le diagnostic et le traitement, la localisation de la lesion, le type de traitement, la duree du sejour hospitalier et la survie. Resultats: Entre janvier 2000 et octobre 2009, 12 232 CPER ont ete effectuees dans notre etablissement et 11 patients ont subi une perforation (0,08 %; 5 hommes, 6 femmes; age moyen 71 ans). Six des perforations ont ete decouvertes durant la CPER; 5 ont necessite une epreuve d'imagerie radiologique pour etre diagnostiquees; 3 ont ete reconnues de maniere fortuite lors du suivi de la CPER. Chez 1 patient, la perforation est survenue 3 ans apres l'intervention en raison d'une dislocation de l'endoprothese. Sur 11 perforations, 4 ont ete causees par l'endoprothese; chez 2 patients, la CPER a ete realisee dans un contexte non anatomique (gastroenterostomie Billroth II). Une perforation en peritoine libre a affecte 4 patients; 1 patient a bien repondu a un traitement conservateur. Quatre (36 %) patients ont ete traites chirurgicalement et aucun patient n'est decede. Cinq patients ont ete traites avec succes de maniere conservatrice et 2 sont decedes apres un traitement conservateur (18 %). Les chirurgies correctrices ont ete hepatojejunostomie et duodenostomie (1 patient), suture de la perforation avec pose de drain en T (1 patient) et suture seulement (2 patients). La duree moyenne de l'hospitalisation pour l'ensemble des patients a ete de 20 jours. Conclusion: Les perforations duodenales post-CPER sont associees a une morbidite et a une mortalite significatives. Il faut proceder a des evaluations chirurgicales immediates et une surveillance etroite s'impose. La prise en charge doit etre individualisee en fonction des observations cliniques seulement., Endoscopic retrograde cholangiopancreatography (ERCP) is widely regarded as a safe procedure, but the associated rate of major adverse events approaches 6%-7%. Although the incidence of duodenal perforations after ERCP has [...]