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Management of duodenal perforation after endoscopic retrograde cholangiopancreatography and sphincterotomy

Introductions. ERCP with sphincterotomy: commonly used in the treatment of common bile duct stones. Major complication rate:10%(pancreatitis, bleeding, cholangitis, and perforation).ERCP-related perforations occur in about 1% of patients, and the injury carries a death rate of 16% to 18%. Objective: to define a management strategy for ERCP-related perforations..

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Management of duodenal perforation after endoscopic retrograde cholangiopancreatography and sphincterotomy

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    1. Management of duodenal perforation after endoscopic retrograde cholangiopancreatography and sphincterotomy Annals of surgery 2000, Vol. 232, No.2, 191-198 From the department of surgery, University of Southern California-Los Angeles County and the University of Southern California Medical Center, Los Angeles, California Presented by Ri ???

    2. Introductions ERCP with sphincterotomy: commonly used in the treatment of common bile duct stones. Major complication rate:10%(pancreatitis, bleeding, cholangitis, and perforation). ERCP-related perforations occur in about 1% of patients, and the injury carries a death rate of 16% to 18%. Objective: to define a management strategy for ERCP-related perforations.

    3. Methods(1) Patients: Between June 1993 and June 1998, 14 patients (1%) had duodenal perforations during ERCP. 10 women and 4 men Median age: 48.5 years. Diagnosis of Perforation: ERCP, CXR(free air), clinical sepsis, gastrograffin UGI. (If there was doubt about a perforation at ERCP, an immediate contrast UGI was obtained)

    4. Methods(2) Medical management parameter: 1. benign abdominal examination 2. absence of sepsis 3. minimal leak demonstrated on a follow-up UGI 4. absence of retroperitoneal fluid collections

    5. Methods(3) Surgical management parameter: 1. extensive contrast extravasations on ERCP/UGI 2. extra- or intraperitoneal fluid collection on CT 3. retained hardware 4. documented perforation with retained stones 5. massive subcutaneous emphysema

    6. Results(1) Nonsurgical Management ( 8 patients) Five of the eight were successfully managed with antibiotics and observation.

    7. Results(2) Nonsurgical Management ( 8 patients) Three patients failed to respond to nonsurgical management and received delayed surgery.

    8. Results(3) Surgical management (6 patients)

    9. Results(4) Surgical Procedures and Outcomes 1. None of the six patients treated by primary surgical management required reoperation for duodenal leakage. 2. Two patients developed a retroperitoneal abscess; it required open drainage in one patient. 3. Three patients underwent delayed surgical treatment and multiple reoperations (mean 3.6 per patient).

    10. Discussions(1) Leukocytosis and fever were often present early but were not useful to distinguish a management approach. Abdominal examination was not helpful in determining who should undergo surgery within the first few hours. Early peritonitis should dictate surgery, but the retroperitoneal nature of the injuries may mask the severity.

    11. Discussions(2) Classifications of duodenal injury (Type I ~IV)

    12. Discussions(3) Type I (Lateral or medial wall perforations) 1. caused by the endoscope, tend to be large and remote from the ampulla, and require immediate surgery. 2. cause large, persistent contrast leaks in the retroperitoneal or intraperitoneal space. Type II (Peri-Vaterian injuries) varied in severity but usually were more discrete and less likely (43% of patients in our series) to require surgery.

    13. Discussions(4) Type III injuries 1. distal bile duct injuries related to wire or basket instrumentation near an obstructing entity and are often small. 2. tend to seal spontaneously. Type IV (Retroperitoneal air alone) 1. probably related to the use of compressed air to maintain patency of a lumen (not a true perforation).

    14. Discussions(5) Revision of surgical indications

    15. Discussions(6) If an initial study demonstrates minimal contrast extravasation and a conservative approach is chosen, a UGI study should be repeated within 8 hours to confirm the initial impression. In addition, a double-contrast CT scan should be performed at 8 hours and at 48 hours to confirm that the leak remains sealed and to exclude the development of fluid collections.

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