Validity of clinical criteria in the management of endoscopic retrograde cholangiopancreatography-related duodenal perforations

Objective: To assess the validity of predetermined clinical and radiologic criteria in the management of endoscopic retrograde cholangiopancreatography (ERCP)related duodenal perforations (DPs). Design: Prospective case series. Setting: Tertiary medical facility. Patients: Twenty-two individuals with ERCP-related DPs Interventions: The guidelines advocated operative management for patients with free contrast leak and those with positive peritoneal signs or other indicators suggesting sepsis irrespective of the mechanism or location of injury. Main Outcome Measures: Thirty-day mortality rates, success of nonoperative management, and complications related to nonoperative and operative policies. Results: Diagnosis of DP was accomplished early (within 6 hours of ERCP) in 20 of 22 patients (91%). Three patients with early positive peritoneal signs were treated surgically; 2 of them sustained injury from the endoscope, and the third by papillotomy. All 3 patients had significant findings justifying immediate surgery. Nineteen patients with retroperitoneal DPs due to papillotomy or guidewire insertion were treated nonoperatively. In patients diagnosed early (n = 17), only I failure (6%) occurred. In the 2 patients with delayed diagnosis, there was 1 failure, which culminated in death. Conclusions: Our results might validate the role of clinical criteria for the selective management of ERCP-related DPs. These criteria were found to correlate well with radiologic findings and the mechanism of injury.