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© Georg Thieme Verlag Stuttgart · New York
ERCP-Related Perforations: Risk Factors and Management
14 May 2001
3 November 2001
03 April 2002 (online)
Background and Study Aims: Perforations during endoscopic retrograde cholangiopancreatography (ERCP) are rare, and the management of these perforations is variable, with some patients requiring immediate surgery and others only conservative management. We reviewed all ERCP-related perforations at our institution to determine: a) their incidence; b) clinical outcomes; c) which management approaches gave the best results; and d) which factors predict a perforation.
Patients and Methods: All patients who underwent ERCP and suffered perforation were reviewed. To compare the length of hospital stay of the perforation group with that of patients suffering a different complication, patients who developed post-ERCP pancreatitis were also reviewed. To evaluate predictors of ERCP-related perforations, three groups were compared: group 1 (n = 49), normal ERCP/no complications; group 2 (n = 52), ERCP complicated by pancreatitis; and group 3 (n = 33), ERCP with perforation.
Results: Of 33 patients with confirmed ERCP-related perforations, only seven patients required surgical intervention. The overall length of hospital stay (6.5 ± 3.5 days) was significantly longer (P = 0.003) than that of a random group of patients with the complication of post-ERCP pancreatitis (4.7 ± 2.6 days). According to univariate analysis, risk factors included: sphincterotomy (odds ratio [OR] 9.0, 95 % confidence interval [CI] 3.2 - 28.1); sphincter of Oddi dysfunction (OR 3.8, 95 % CI 1.4 - 11.0); and dilated common bile duct (OR 4.07, 95 % CI 1.63 - 10.18, P = 0.003). In the multivariate logistic regression analysis, additional predictive factors included the duration of procedure (OR 1.021, 95 % CI 1.006 - 1.036), and biliary stricture dilation (OR 7.2, 95 % CI 1.84 - 28.11).
Conclusions: (i) The incidence of ERCP-related perforations is very low (0.35 %). (ii) Esophageal, gastric and duodenal perforations usually require surgery, but sphincterotomy- and guide wire-related perforations rarely do so. (iii) Factors which carry increased risk of an ERCP-related perforation include suspected sphincter of Oddi dysfunction, greater age, a dilated bile duct, sphincterotomy, and longer duration of the procedure.
- 1 Freeman M L, Nelson D B, Sherman S. et al . Complications of endoscopic biliary sphincterotomy. N Engl J Med. 1996; 335 909-918
- 2 Aliperti G. Complications related to diagnostic and therapeutic endoscopic retrograde cholangiopancreatography. Gastrointest Endosc Clin N Am. 1996; 6 379-407
- 3 Baillie J. Complications of endoscopy. Endoscopy. 1994; 26 185-203
- 4 Loperfido S, Angelini G, Chilovi F. et al . Major complications from diagnostic and therapeutic ERCP. A prospective multicenter study (abstract). Gastroenterology. 1995; 108 A424
- 5 Sherman S RT, Ruffolo T A, Hawes R H, Lehman G A. Complications of endoscopic sphincterotomy. A prospective series with emphasis on the increased risk associated with sphincter of Oddi dysfunction and nondilated bile ducts. Gastroenterology. 1991; 101 1068-1075
- 6 Vaira D, D’Anna L, Ainley C. et al . Endoscopic sphincterotomy in 1000 consecutive patients. Lancet. 1989; 2 431-434
- 7 Loperfido S, Angelini G, Benedetti G. et al . Major early complications from diagnostic and therapeutic ERCP: a prospective multicenter study. Gastrointest Endosc. 1998; 48 1-10
- 8 Manbeck M A, Chang A C, McCracken J D, Chen Y K. Cystic duct perforation as a complication of endoscopic stone extraction. Am J Gastroenterol. 1996; 91 592-594
- 9 Martin D F, Tweedle D E. Retroperitoneal perforation during ERCP and endoscopic sphincterotomy: causes, clinical features and management. Endoscopy. 1990; 22 174-175
- 10 Mickisch O, Manegold B C. Esophageal perforation in attempted ERCP. (In German). Z Gastroenterol. 1992; 30 428-430
- 11 Cotton P B, Lehman G, Vennes J. et al . Endoscopic sphincterotomy complications and their management: an attempt at consensus. Gastrointest Endosc. 1991; 37 383-393
- 12 Osnes M, Rosseland A R, Aabakken L. Endoscopic retrograde cholangiography and endoscopic papillotomy in patients with a previous Billroth-II resection. Gut. 1986; 27 1193-1198
- 13 Safrany L, Neuhaus B, Porto-Carrero G, Krause S. Endoscopic sphincterotomy in patients with Billroth II gastrectomy. Endoscopy. 1980; 12 16-22
- 14 Bilbao M K, Dotter C T, Lee T G, Katon R M. Complications of endoscopic retrograde cholangiopancreatography (ERCP): a study of 10 000 cases. Gastroenterology. 1976; 70 314-320
- 15 Forbes A, Cotton P B. ERCP and sphincterotomy after Billroth II gastrectomy. Gut. 1984; 25 971-974
- 16 Onken J, Baillie J, Affronti J. ERCP in patients following Billroth II gastrectomy: is it tougher and riskier than “ordinary” ERCP (abstract)?. Gastrointest Endosc. 1992; 92 257
- 17 Wilkinson M L, Engelman J L, Hanson P JV. Intestinal perforation after ERCP in Billroth II partial gastrectomy. Gastrointest Endosc. 1994; 40 389-390
- 18 de Vriest H, Duijm L E, Dekker W. et al . CT before and after ERCP: detection of pancreatic pseudotumor, asymptomatic retroperitoneal perforation, and duodenal diverticulum (see comments). Gastrointest Endosc. 1997; 45 231-235
- 19 Husain S, Garmager K, McPhee M S. et al . The significance of retroperitoneal air following endoscopic sphincterotomy (abstract). Gastrointest Endosc. 1995; 41 400
- 20 Boender J, Nix G A, de Ridder M A. et al . Endoscopic papillotomy for common bile duct stones: factors influencing the complication rate. Endoscopy. 1994; 26 209-216
- 21 Baillie J. Needle-knife papillotomy revisited (editorial; comment). Gastrointest Endosc. 1997; 46 282-284
- 22 Cotton P B. Precut papillotomy - a risky technique for experts only (editorial; comment). Gastrointest Endosc. 1989; 35 578-579
- 23 Cotton P B. Needleknife precut sphincterotomy: the devil is in the indications (letter; comment). Endoscopy. 1997; 29 888
- 24 Deans G T, Sedman P, Martin D F. et al . Are complications of endoscopic sphincterotomy age related (see comments)?. Gut. 1997; 41 545-548
- 25 Chen Y K, Foliente R L, Santoro M J. et al . Endoscopic sphincterotomy-induced pancreatitis: Increased risk associated with non-dilated bile ducts and sphincter of Oddi dysfunction. Am J Gastroenterol. 1994; 89 327-333
- 26 Montes H, Ho K Y, Sossenheimer M J. et al . Multiple pancreatic injection is a risk factor for post-ERCP pancreatitis (abstract). Gastrointest Endosc . 1998; 47 AB 461
R. Enns, M.D.
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