The use of fully-covered self-expanding metallic stents for intraprocedural management of post-sphincterotomy perforations: a single-center study (with video)

Abstract

Background and study aims Management of post-sphincterotomy perforations is variable, with some patients managed conservatively and other requiring surgery. Fully-covered self-expanding metal stents (FCSEMs) have been used in the past, but data is limited. The aim of this study was to report the clinical characteristics and outcomes following placement of anchored FCSEMSs for the immediate management of post-sphincterotomy perforation.

Patients and methods All patients undergoing an ERCP procedure between June 2011 and December 2015 at our institution were reviewed for post-sphincterotomy perforation. All intra-procedurally recognized perforations underwent placement of FCSEMs with flexible anchoring fins and were included in this study. Data extracted included patient demographics, indication, peri-procedural details, clinical course and long-term outcome following anchored FCSEMS placement.

Results A total of 15 patients (12 females, median age-66 years) with post-sphincterotomy perforation were included. Major indications included choledocholithiasis in 9 (60 %), and 5 (33.3 %) patients had intra-ampullary or periampullary diverticula. All patients underwent placement of FCSEMS without any complication and had immediate resolution of perforation as evidenced by decrease in fluoroscopic gas and lack of contrast extravasation. None of the patients became symptomatic or needed surgery with a median 2 days of hospitalization following the procedure. Stents were removed after a median of 30.5 days and no complications were noted during follow-up after stent removal.

Conclusions Anchored FCSEMs are safe and effective for management of intra-procedurally recognized post-sphincterotomy perforations and obviates need for surgery.

• References

• 1 Freeman ML, Nelson DB, Sherman S. et al. Complications of endoscopic biliary sphincterotomy. N Engl J Med 1996; 335: 909-918
• 2 Christensen M, Matzen P, Schulze S. et al. Complications of ERCP: a prospective study. Gastrointest Endosc 2004; 60: 721-731
• 3 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
• 4 Masci E, Toti G, Mariani A. et al. Complications of diagnostic and therapeutic ERCP: a prospective multicenter study. Am J Gastroenterol 2001; 96: 417-423
• 5 Stapfer M, Selby RR, Stain SC. et al. Management of duodenal perforation after endoscopic retrograde cholangiopancreatography and sphincterotomy. Ann Surg 2000; 232: 191-198
• 6 Enns R, Eloubeidi MA, Mergener K. et al. ERCP-related perforations: risk factors and management. Endoscopy 2002; 34: 293-298
• 7 Odemis B, Oztas E, Kuzu UB. et al. Can a Fully Covered Self-Expandable Metallic Stent be Used Temporarily for the Management of Duodenal Retroperitoneal Perforation During ERCP as a Part of Conservative Therapy?. Surg Laparosc Endosc Percutan Tech 2016; 26: e9-e17
• 8 Fatima J, Baron TH, Topazian MD. et al. Pancreaticobiliary and duodenal perforations after periampullary endoscopic procedures: diagnosis and management. Arch Surg Chi Ill 1960 2007; 142: 448-454 ; discussion 454-455
• 9 Vezakis A, Fragulidis G, Nastos C. et al. Closure of a persistent sphincterotomy-related duodenal perforation by placement of a covered self-expandable metallic biliary stent. World J Gastroenterol 2011; 17: 4539-4541
• 10 Katsinelos P, Paroutoglou G, Papaziogas B. et al. Treatment of a duodenal perforation secondary to an endoscopic sphincterotomy with clips. World J Gastroenterol 2005; 11: 6232-6234
• 11 Chaudhary A, Aranya RC. Surgery in perforation after endoscopic sphincterotomy: sooner, later or not at all?. Ann R Coll Surg Engl 1996; 78: 206-208
• 12 Baron TH, Gostout CJ, Herman L. Hemoclip repair of a sphincterotomy-induced duodenal perforation. Gastrointest Endosc 2000; 52: 566-568
• 13 Amodio PM, Faggiani R, Pastorelli A. et al. Selected treatments for duodenal perforation after ERCP. A report of three cases. Chir Ital 2007; 59: 343-346
• 14 Irani S, Baron TH, Law R. et al. Endoscopic treatment of nonstricture-related benign biliary diseases using covered self-expandable metal stents. Endoscopy 2015; 47: 315-321
• 15 Canena J, Liberato M, Horta D. et al. Short-term stenting using fully covered self-expandable metal stents for treatment of refractory biliary leaks, postsphincterotomy bleeding, and perforations. Surg Endosc 2013; 27: 313-324
• 16 Cotton PB, Lehman G, Vennes J. et al. Endoscopic sphincterotomy complications and their management: an attempt at consensus. Gastrointest Endosc 1991; 37: 383-393
• 17 Vezakis A, Fragulidis G, Polydorou A. Endoscopic retrograde cholangiopancreatography-related perforations: Diagnosis and management. World J Gastrointest Endosc 2015; 7: 1135-1141
• 18 Bell RC, Van Stiegmann G, Goff J. et al. Decision for surgical management of perforation following endoscopic sphincterotomy. Am Surg 1991; 57: 237-240
• 19 Balmadrid B, Kozarek R. Prevention and management of adverse events of endoscopic retrograde cholangiopancreatography. Gastrointest Endosc Clin N Am 2013; 23: 385-403
• 20 Baron TH, Wong KeeSong LM, Zielinski MD. et al. A comprehensive approach to the management of acute endoscopic perforations (with videos). Gastrointest Endosc 2012; 76: 838-859
• 21 Kumbhari V, Sinha A, Reddy A. et al. Algorithm for the management of ERCP-related perforations. Gastrointest Endosc 2015; 83: 934-43