REVIEW
MANAGEMENT OF
ENDOSCOPIC RETROGRADE
CHOLANGIOPANCREATOGRAPHY-
RELATED PERFORATION
Endoscopic retrograde cholangiopancreatography (ERCP)-related perforation occurs in 0.1–1.8% of
patients after therapeutic ERCP. It is a serious complication with a high mortality. However, little
evidence exists in the medical literature and the optimal management remains unclear. This review
aims to critically evaluate the optimal management of therapeutic ERCP-related perforation.
Keywords: ERCP, sphincterotomy, duodenal perforation, retroperitoneal
perforation, complication
Surgeon, 1 February 2008 45-48
INTRODUCTION
With the emergence of newer diagnostic
imaging technologies, endoscopic retrograde
cholangiopancreatography (ERCP) is evolving into
a predominantly therapeutic procedure. ERCP
with sphincterotomy and stone removal is a
valuable therapeutic modality in choledocholithiasis
presenting with jaundice, dilated common bile
duct, acute pancreatitis or cholangitis. ERCP with
stenting is also a common procedure for unresectable
malignant biliary obstruction. Major complication
and mortality rates range from 5.4% to 11.2% and
0.1% to 1%, respectively.1-9 Common complications
include pancreatitis, bleeding, sepsis and duodenal
perforation. Duodenal perforation occurs in
0.1–1.8% of patients after therapeutic ERCP.1-9
While some types of ERCP-related perfora-
tion can be managed conservatively, duodenal
perforation is a serious complication with a high
mortality rate of 8–23%.10-12 Delayed diagnosis and
intervention are associated with a high mortality.13,14
Death following ERCP-related perforation is usually
related to sepsis and multi-organ dysfunction. The
presence of duodenal perforation in a patient with
coexisting sepsis due to cholangitis or pancreatitis
further increases the management difficulty. It is
very difficult to evaluate the efficacy of different
modalities of treatment as few patients with such
complications can be found in a single centre. As a
consequence, there is little evidence in the medical
literature and the optimal management remains
unclear.
This review aims to critically evaluate the
optimal management of therapeutic ERCP
-related perforation.
© 2008 Surgeon 6; 1: 45-48
C. H. Eric Lai
W. Y. Lau
Department of Surgery,
Chinese University of
Hong Kong, Shatin,
New Territories, Hong Kong
SAR, China
Correspondence to:
Professor W.Y. Lau,
Department of Surgery, The
Chinese University of Hong
Kong, Prince of Wales
Hospital, Shatin, New
Territories, Hong Kong SAR,
China
Tel: +852 2632 2626
Fax: +852 2637 7974
Email: josephlau@cuhk.
edu.hk
METHOD
A Medline, Pubmed database search was performed
to identify articles from 1986 to 2007, using the
keywords ‘duodenal perforation’, ‘retroperitoneal
perforation’, ‘ERCP’ and ‘endoscopic sphinc-
terotomy’. All articles, except case reports, were
reviewed. No randomised controlled trial could be
identifed during this search.
RISK FACTORS
Factors which carry an increased risk of an ERCP-
related perforation include suspected sphincter of
Oddi dysfunction, age, dilated bile duct, papil-
lary stenosis, sphincterotomy and long duration
of the procedure.15-18 In some series, the rate of
perforation increased following pre-cut papillotomy,
when compared with standard papillotomy only.19,20
Perforation is more likely to occur if the incision
strays beyond the usual recommended sector (11
to 1 o’clock position), particularly beyond the 2
o’clock position.21
CLASSIFICATION
With the increasing use of therapeutic ERCP, a
classification of ERCP-related perforation bearing
therapeutic and prognostic implications is needed.
In 1999, Howard et al. classified ERCP-related
perforations into three distinct types: Group I:
guidewire perforations, Group II: Periampullary
perforations and Group III: duodenal perforations
remote from the papilla.12 In 2000, Stapfer et al.
classified the perforations in relation to the mecha-
nism, anatomical location and severity of injury,
which may predict the need for surgery.11 They
classified ERCP-related perforation, in descending
the royal colleges of surgeons of edinburgh and ireland | 45
 Figure 1. X-ray showing retroperitoneal perforation after ERCP with sphincterotomy. The retroperitoneal air
outlines bilateral kidneys and psoas muscles
order of severity, into four types: Type I: lateral or medial wall
duodenal perforation, Type II: peri-Vaterian injuries, Type III: distal
bile duct injuries related to wire/basket instrumentation and Type IV:
retroperitoneal air alone. Type IV is probably related to the use of
compressed air to maintain patency of the duodenal lumen, which can
result in the air going within the layers of the duodenal lumen wall
or outside the lumen, as in pneumatosis cystoides.11,22 This is not a
true perforation and therefore does not require surgical intervention.
Howard et al. commented that the additional category of Type IV
is questionable, as there is a general agreement that post-procedural
retroperitoneal air is a common benign finding after endoscopic
sphincterotomy and it has no predictive value in identifying patients
who require intervention.23 In the prospective study of Genzlinger et
al. 21 consecutive patients who had ERCP with sphincterotomy had
abdominal CT examinations within 24 hours after completion of the
procedure.22 Six (29%) of the 21 patients exhibited CT findings of
retroperitoneal air. All six patients had uneventful post-procedural
courses, and none had abnormal clinical signs or symptoms. In the
prospective study of Hans de Vries et al. 58 patients underwent CT
46 | the royal colleges of surgeons of edinburgh and ireland
before and after ERCP, and asymptomatic retroperitoneal perforation
after sphincterotomy was diagnosed in three patients (13%).24
DIAGNOSIS
Early diagnosis is very important. Perforation can usually be recognised
at the time of ERCP. Contrast or air is seen outside the biliary tree,
duodenum or retroperitoneal space. When a patient experiences severe
abdominal pain after ERCP, the differential diagnosis of ERCP-related
perforation or acute pancreatitis should be made.
Patients with ERCP-related perforation may present with localised
peritonitis, fever, tachycardia, leucocytosis or mildly elevated serum
amylase level. However, retroperitoneal injuries may not be evident in
the physical examination. In the majority of retroperitoneal perfora-
tions, there is at first only mild epigastric tenderness with a progres-
sive rise in temperature, and tachycardia. Signs of peritonitis usually
develop after several hours when the duodenal contents extravasate
into the peritoneal cavity. Free or retroperitoneal air can usually
be recognised radiologically by a plain abdominal x-ray (Figure 1).
© 2008 Surgeon 6; 1: 45-48
The abdominal x-ray may reveal the presence of air outlining the right
kidney in the retroperitoneum along the psoas. Other less specific
signs include obliteration of the psoas margin, and segmental ileus in
or near the duodenum. In doubtful cases, contrast CT scan or upper
gastrointestinal oral contrast study will help.
MANAGEMENT
Historically, ERCP-related perforation was managed surgically. The
goals in the surgical management of ERCP-related perforation include:
1: control of sepsis (drainage of the retroperitoneal collection/intra-
abdominal collection and drainage of the biliary system/removal of
bile duct stones) and 2: repair of the perforation with or without
diversion. In the last decade, the management has shifted toward
a selective approach.21 The site and mechanism of injury guide the
management approach.
Duodenal perforations (Howard Group III or Stapfer Type I) are
caused by the endoscope, and the perforations tend to be large and
remote from the ampulla. All these duodenal perforations should be
treated by an operation immediately after diagnosis.11,12,16
When researching the available literature, there was no prospective
comparative study to find out the optimal procedure for ERCP-related
duodenal perforation.25,26 Most of the clinical experience was derived
from duodenal trauma. Duodenal perforations can be closed primarily
in one or two layers and devitalised tissue should be debrided. The
closure should also be oriented transversely to prevent compromising
the duodenal lumen. For large duodenal perforation, jejunal serosal
patch is an option which can be used to close the duodenal wound.
Possible duodenal fistula/suture line dehiscence is a major concern
as more than 6L of fluid, including saliva, gastric fluid, bile and
pancreatic enzymes, traverse the duodenum daily. For this, duodenal
diversions are usually reserved for high risk patients with a delay
in diagnosis or large defects in the duodenal wall. The rationale is
to divert the gastrointestinal contents and the proteolytic enzymes
from the duodenal repair site and, in case of duodenal fistula, to
facilitate management. Duodenal diversion techniques include tube
decompression, duodenal diverticulation and pyloric exclusion. The
use of tube decompression in the management of duodenal repair
is controversial. Its drawbacks include new perforations being made
in the gastrointestinal tract and the inefficiency of the duodeno-
stomy/jejunostomy tube in decompressing the duodenum properly.
Duodenal diverticulation includes a distal Billroth II gastrectomy,
closure of the duodenal wound, placement of a decompressive catheter
into the duodenum and generous drainage of the duodenal repair.
Truncal vagotomy and biliary drainage may also be added. The major
shortcoming of duodenal diverticulation is that it is an extensive
procedure which is inappropriate for haemodynamically unstable
patients. Pyloric exclusion is an alternative to the above extensive
procedure. This procedure consists of repair of the duodenal wound,
closure of the pylorus through a gastrotomy with running suture or by
stapling, and side-to-side gastrojejunostomy at the site of gastrotomy.
In the majority of patients, the closure of the pylorus breaks down
after several weeks and gastrointestinal continuity re-establishes. The
advantage is that the procedure is less extensive, less time consuming
and causes less physiological disturbance. Most clinicians advocate a
pyloric exclusion procedure, if duodenal diversion is needed.10-12,25,26
Howard Group I or Stapfer Type III injury is caused by guidewire
or basket instrumentation, and these perforations tend to be small.
These perforations will usually seal off spontaneously. Most patients
© 2008 Surgeon 6; 1: 45-48 the royal colleges of surgeons of edinburgh and ireland |
recover with non-operative treatment.11,12,16,27 There is not much
controversy for the management of these two types of ERCP-related
perforation injuries.
However, the management of periampullary perforation (Howard
Group II/Stapfer Type II) remains controversial. These perforations
occur mainly due to endoscopic sphincterotomy. Recommendations
vary from early operation to conservative treatment.11,12,19,21,27-32 The
major challenge for the conservative approach is that it is difficult
to predict who will respond to treatment. The conservative approach
was reported to be successful in 50% to 90% of patients.11,12,27,31,32
Based on the results of the published series, patients with early
diagnosis benefit most from conservative treatment.10-13 Conservative
treatment includes nothing by mouth, nasogastric or nasoduodenal
tube decompression, antibiotics and frequent re-evaluation. Other
authors advocate the use of immediate endoscopic treatment once the
retroperitoneal perforation is identified.12,21,29 This consists of diversion
of the bile and pancreatic secretion away from the site of perfora-
tion using either an internal biliary stent or a nasobiliary stent. The
alternative is biliary decompression with percutaneous transhepatic
biliary drainage. Follow-up contrast CT scan helps to detect the devel-
opment and progress of retroperitoneal/intra-abdominal collection,
which may require percutaneous or surgical drainage. Indications for
surgery include: 1: failure of non-surgical treatment, 2: documented
ERCP perforation with retained stones or instruments, 3: large free
or retroperitoneal fluid collections/ongoing leakage, 4: prominent
peritoneal signs and 5: suspected suppuration.11,12,29-33
In conclusion, early diagnosis and careful management are important
for the management of ERCP-related perforation. A management guide-
line has been proposed, based on the available evidence in the medical
literature. However, the clinician managing an ERCP-related perforation
should remain flexible in the management approach, as the severity and
consequence of an individual perforation may vary greatly.
Copyright © 25 June 2007
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© 2008 Surgeon 6; 1: 47-48