ERCP-Related Perforations: Risk Factors and Management

R. Enns; M. A. Eloubeidi; K. Mergener; P. S. Jowell; M. S. Branch; T. M. Pappas; J. Baillie

doi:10.1055/s-2002-23650

Endoscopy, Table of Contents

Endoscopy 2002; 34(4): 293-298
DOI: 10.1055/s-2002-23650

Original Article

ERCP-Related Perforations: Risk Factors and Management

R. Enns ¹ , M. A. Eloubeidi ² , K. Mergener ³ , P. S. Jowell ⁴ , M. S. Branch ⁴ , T. M. Pappas ², ⁵ , J. Baillie ⁴

¹Division of Gastroenterology, Department of Medicine, University of British Columbia, Vancouver, Canada
²Department of Gastroesterology and Hepatology, University of Alabama at Birmingham, Birmingham, Alabama, USA
³Gastroenterology Section, Virginia Mason Medical Center, Seattle, Washington, USA
⁴Division of Gastroenterology, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
⁵Division of Gastroenterology, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA

Abstract

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.

Full Text

References

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.

Division of Gastroenterology · Department of Medicine · University of British Columbia · St. Paul's Hospital

#300-1144 Burrard St. · Vancouver BC, V6K-2A5 · Canada

Fax: + 1-604-689-2004

Email: renns@interchange.ubc.ca