ENDOSCOPIC TREATMENT OF TYPE I AND II PERFORATIONS RELATED WITH ERCP. PRESENTATION OF THREE CLINICAL CASES

Aims:

Perforation is a feared complication of ERCP, uncommon but potentially deadly. We present three cases of perforation type I-II with a successfully endoscopic treatment

Methods:

Clinical cases

Results:

PERFORATION TYPE-I

Patient-A 41y-o male, with a cholecystectomy and a history of recurrent choledocholithiasis, was admitted for cholangitis. An ERCP was performed. During the duodenoscope insertion a side duodenal wall perforation occurred.

Patient-B 74-yo male with Child B8 cirrhosis was admitted for a biliary obstructive jaundice. ERCP was performed with an incomplete bile duct cleaning and placement of a plastic stent. A second ERCP was performed some weeks after, and during the duodenoscope intubation a perforation was seen at the medial duodenal wall of the bottom of a diverticulum

Both patients were endoscopically managed, the first one with an OVESCO™ device placed with a 5 hours delay since the perforation, and the second one with a Padlock Clip™ together with three haemostatic clips, without any medical complication. Related with the delay Patient-A developed a retroperitoneal abscess that was medically managed with no further intervention

PERFORATION TYPE-II

Patient-A 83-year-old male, with history of recurrent choledocholithiasis was admitted for obstructive jaundice and cholangitys. A new ERCP was performed with a “CRE 15 mm” dilation of the distal coledocus and papilla (CRE) to complete bile duct cleaning. Pneumoperitoneum was detected on the control x-ray, so an immediate endoscopy was performed that objectified perforation on the upper edge of the ampulla (image-6); a fully covered metal stent was placed (Image-7). The evolution was satisfactory, without infectious complications and complete radiological resolution. The metal stent was removed after 6 weeks.

Conclusions:

Through over-the-scope clips for type-I perforations or the use of fully covered metal stents for type-II ERCP's duodenal perforations are easy, accessible and reduce morbi-mortality when these devices are placed immediately after the perforation.