Management of endoscopic retrograde cholangiopancreatography: related duodenal perforations

As the performance of upper gastrointestinal endoscopy, especially endoscopic retrograde cholangiopancreatography (ERCP), has increased since 1968, so has the incidence of duodenal perforations. The frequency of ERCP use varies among hospitals and depends on the availability of trained endocopists, equipment, and facilities. A retrospective review of ERCP-related perforations to the duodenum was conducted to identify their incidence, 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. From April 1999 to February 2008, 4,358 ERCP were performed, 15 of which (0.34%) resulted in perforation to the duodenum. Only four of the perforations were discovered during ERCP, with another eight requiring computed tomography or abdominal radiography for diagnosis. Surgery was performed for 13 of the patients (87%), and 2 patients died (15%). One patient was managed conservatively with a successful outcome. Nine patients underwent surgery within 24 h after the ERCP, with only one patient undergoing surgery after 24 h. The overall mortality rate was 20% (3 of 15 patients). Clinical and radiographic features can be used to determine the surgical or conservative treatment of ERCP-related duodenal perforations, whereas patient age and 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 (> 24 h). An algorithm for the selective management of ERCP-induced duodenal perforations is proposed.