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Management of perforation after endoscopic retrograde cholangiopancreatography (ERCP): a population-based review.

ABSTRACT: BACKGROUND: Perforation related to endoscopic retrograde cholangiopancreatography (ERCP) is a rare complication associated with significant morbidity and mortality. This study evaluated the management and outcomes of these perforations. PATIENTS AND METHODS: Between July 1996 and December 2002, a total of 6620 ERCPs were performed at our regional endoscopy unit serving the 1.5 million population of Southern Alberta. Thirty perforations (0.45%) were identified and retrospectively reviewed. Results. Seven of these 30 patients were found to have guidewire perforations of the bile duct, 11 perforations were peri-ampullary, 3 duodenal, 1 esophageal, and 1 patient had a perforation of an afferent limb of a Billroth II anastomosis. In seven patients the location of the perforation could not be determined (unknown). All patients with guidewire perforations were recognized during ERCP, and all were managed medically. Of the 11 peri-ampullary perforations, 7 of these patients had a pre-cut sphincterotomy, 5 underwent surgery and 4 patients died. Delay in diagnosis occurred in all patients that died. Of the three duodenal perforations, all required operation and one patient died. Of the seven 'unknown' retroperitoneal perforations, two patients required surgery and there was no mortality. The patients with esophageal and afferent limb perforations both recovered uneventfully after surgery. Most patients who required surgery had retroperitoneal fluid seen on CT scanning. CONCLUSIONS: We found that most guidewire perforations can be managed medically with little morbidity. Pre-cut sphincterotomy is a risk factor for perforation. Peri-ampullary and duodenal perforations have a high morbidity and mortality rate. In particular, retroperitoneal fluid collections on CT scans, delay in diagnosis and failure of medical therapy requiring salvage surgery are associated with poor outcomes. Early aggressive surgery may improve patient care.

SUBMITTER: Wu HM

PROVIDER: S-EPMC2020744 | biostudies-other | 2006

REPOSITORIES: biostudies-other

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Project description:Background and study aims Endoscopic retrograde cholangiopancreatography (ERCP) is technically challenging in patients with Roux-en-Y gastric bypass (RYGB) anatomy, which is increasing in frequency given the rise of obesity. Laparoscopy-assisted ERCP (LA-ERCP) and enteroscopy-assisted ERCP (EA-ERCP) are distinct approaches with their respective strengths and weaknesses. We conducted a meta-analysis comparing the procedural time, rates of success and adverse events of each method. Patients and methods A search of PubMed, EMBASE and the Cochrane library was performed from inception to October 2018 for studies reporting outcomes of LA or EA-ERCP in patients with RYGB anatomy. Studies using single, double, 'short' double-balloon or spiral enteroscopy were included in the EA-ERCP arm. Outcomes of interest included procedural time, papilla identification, papilla cannulation, therapeutic success and adverse events. Therapeutic success was defined as successful completion of the originally intended diagnostic or therapeutic indication for ERCP. Results A total of 3859 studies were initially identified using our search strategy, of which 26 studies met the inclusion criteria. The pooled rate of therapeutic success was significantly higher in LA-ERCP (97.9 %; 95 % CI: 96.7-98.7 %) with little heterogeneity (I 2 = 0.0 %) when compared to EA-ERCP (73.2 %; 95 % CI: 62.5-82.6 %) with significant heterogeneity (I 2 : 80.2 %). Conversely, the pooled rate of adverse events was significantly higher in LA-ERCP (19.0 %; 95 % CI: 12.6-26.4 %) when compared to EA-ERCP (6.5 %; 95% CI: 3.9-9.6 %). The pooled mean procedure time for LA-ERCP was 158.4 minutes (SD ± 20) which was also higher than the mean pooled procedure time for EA-ERCP at 100.5 minutes (SD ± 19.2). Conclusions LA-ERCP is significantly more effective than EA-ERCP in patients with RYGB but is associated with a higher rate of adverse events and longer procedural time.

Project description:GoalsWe aimed to assess outcomes of patients with liver cirrhosis who underwent therapeutic or diagnostic endoscopic retrograde cholangiopancreatography (ERCP) to determine whether these patients had different outcomes relative to patients without cirrhosis.BackgroundERCP is an important procedure for treatment of biliary and pancreatic disease. However, ERCP is relatively technically difficult to perform when compared with procedures such as esophagogastroduodenoscopy or colonoscopy. Little is known about how ERCP use affects patients with liver cirrhosis.StudyUsing patient records from the National Inpatient Sample (NIS) database, we identified adult patients who underwent ERCP between 2009 and 2014 using International Classification of Disease, Ninth Revision coding and stratified data into 2 groups: patients with liver cirrhosis and those without liver cirrhosis. We compared baseline characteristics and multiple outcomes between groups and compared outcomes of diagnostic versus therapeutic ERCP in patients with cirrhosis. A multivariate regression model was used to estimate the association of cirrhosis with ERCP outcomes.ResultsA total of 1,038,258 hospitalizations of patients who underwent ERCP between 2009 and 2014 were identified, of which 31,294 had cirrhosis and 994,681 did not have cirrhosis. Of the patients with cirrhosis, 21,835 (69.8%) received therapeutic ERCP and 9459 (30.2%) received diagnostic ERCP. Patients with cirrhosis had more ERCP-associated hemorrhages (2.5% vs. 1.2%; P <0.0001) compared with noncirrhosis patients but had lower incidence of perforations (0.1% vs. 0.2%; P <0.0001) and post-ERCP pancreatitis (8.6% vs. 7%; P <0.0001). Cholecystitis was the same between groups (2.3% vs. 2.3%; P <0.0001). In patients with cirrhosis, those who received therapeutic ERCP had higher post-ERCP pancreatitis (7.9% vs. 5.1%; P <0.0001) and ERCP-associated hemorrhage (2.7% vs. 2.1%; P <0.0001) but lower incidences of perforation and cholecystitis (0.1% vs. 0.3%; P <0.0001) and cholecystitis (1.9 vs. 3.1%; P <0.0001) compared with those who received diagnostic ERCP.ConclusionsUse of therapeutic ERCP in patients with liver cirrhosis may lead to higher risk of complications such as pancreatitis and postprocedure hemorrhage, whereas diagnostic ERCP may increase the risk of pancreatitis and cholecystitis in patients with cirrhosis. Comorbidities in cirrhosis patients may increase the risk of post-ERCP complications and mortality; therefore, use of ERCP in cirrhosis patients should be carefully considered, and further studies on this patient population are needed.

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Management of perforation after endoscopic retrograde cholangiopancreatography (ERCP): a population-based review.

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