Surgical management of post endoscopic retrograde cholangiopancreatography [ERCP] duodenal perforation

ABSTRACT

Traditionally post ERCP duodenal perforations have been managed surgically; however, in the last decade, management has shifted toward a more selective approach. Those who favor a selective approach have not elaborated distinct management guidelines. To evaluate the authors experiences in management of post ERCP duodenal perforations to define the criteria for operative management and a systematic management approach. A retrospective review of consecutive cases of ERCP related perforation [from May 2000 to May 2004] was carried out. Seventy-four out of 3050 ERCP performed [2.4%] were complicated by duodenal perforations and were included in the study. Forty-two perforations [56.8%] were discovered at ERCP while 32 cases [43.2%] required additional radiological assistance. Twenty-nine patients [39.2%] were operated early within 6 hours whereas 45 patients [60.8%] were initially treated conservatively. Fifteen patients had surgery after failure of medical treatment. Four cases [8.9%] died under conservative treatment and 14 cases [31.8%] died after surgical intervention. Pyloric exclusion procedure [PE] was done for 33 patients [75%]. Early diagnosis is important but difficult especially for retroperitoneal perforations. Clinical and radiographic features of ERCP - related duodenal perforations can be used to stratify patients into surgical or non-surgical cohorts. A selective management scheme is proposed based on the features of each type. Pyloric exclusion procedure is the operation of choice when the diagnosis is delayed and when the perforation is not detected or can't be repaired