Reply to Matsushita et al.

I appreciate the interest of Dr. Matsushita and colleagues in our report [1]. Nowadays, 40 years after the first endoscopic retrograde cholangiopancreatography (ERCP) procedure [2], biliary endoscopy is usually the technique of choice to drain the bile duct [3]. By the same token, it is also very well known that complications cannot be completely avoided in ERCP, despite extensive operator experience and refinement in devices and techniques. This is what we have also experienced over the years [4] [5].

First of all, we fully agree with Matsushita et al. that ERCP-related retroperitoneal perforation should be initially treated with conservative measures, with an attempt to avoid surgical intervention. As in other digestive endoscopy complications, a team approach (including surgeons) is suitable.

Our patient suffered a retroperitoneal perforation in the papillary area following a precut sphincterotomy to gain access to the bile duct. The perforation was recognized immediately after the procedure once the endoscope had been removed. Probably, with conservative management, the outcome would have been as good as it was with surgery. As the patient had undergone a Billroth II operation and the papillary area remained in a sort of cul-de-sac (afferent limb), where the bile could stagnate and leak through the perforation, perhaps a nasogastric tube would not have been as useful as in a patient with normal anatomy. Therefore, a naso-afferent limb drainage would have been the easiest conservative method. The same drainage that was achieved with the surgical T-tube could have been accomplished with a nasobiliary drainage. Use of a biliary stent (either plastic or covered metal) could have been another option, perhaps with the addition of naso-afferent limb drainage.

Another problem would have been reaching the papillary area again in this Billroth II anatomy, a well known risk factor for bowel perforation, although in recent years we have had a high success rate using a guide wire that marks the path to the papilla [6].

In addition, it is necessary that biliary endoscopists, surgeons, and the doctors responsible for the patient “speak the same language” that is, they are confident that such a complication, with an impressive CT image of large quantities of retroperitoneal air, will heal with conservative measures. This is important for supporting a patient in whom nasal tube drainage must be maintained for several days (14 days in the case reported by Matsushita et al.).

Our report [1] tried to underline that in Billroth II anatomy the cut in the papilla must be directed downwards in the visual field. In fact, our perforation occurred in the opposite direction, in the real papillary anatomy, compared with that reported by Matsushita et al.

In conclusion, we agree with Matsushita et al. that retroperitoneal perforations related to endoscopic biliary sphincterotomy should be initially treated conservatively. In all cases, the appropriate treatment has to be tailored to the specific situation, and a team approach to management of such complications will ensure the best outcome [7].

Competing interests: None

References

• 1 García-Cano J, Viñuelas-Chicano M, Marqués-Medina E. et al . Retroperitoneal perforation caused by precut biliary access in a Billroth II gastrectomy.  Endoscopy. 2008;  [Epub ahead of print]
• 2 McCune W S, Shorb P E, Moscovitz H. Endoscopic cannulation of the ampulla of Vater: a preliminary report.  Ann Surg. 1968;  167 752-756
• 3 Summerfield J A. Biliary obstruction is best managed by endoscopists.  Gut. 1988;  29 741-745
• 4 García-Cano J, González-Martín J A. et al . Complications of endoscopic retrograde cholangiopancreatography. A study in a small ERCP unit.  Rev Esp Enferm Dig.. 2004;  96 163-173
• 5 García-Cano J, González-Martín J A. Bile duct cannulation: success rates for various ERCP techniques and devices at a single institution.  Acta Gastroenterol Belg.. 2006;  69 261-267
• 6 García-Cano J. A simple technique to aid intubation of the duodenoscope in the afferent limb of Billroth II gastrectomies for endoscopic retrograde cholangiopancreatography.  Endoscopy.. 2008;  [Epub ahead of print]
• 7 Enns R, Eloubeidi M A, Mergener K. et al . ERCP-related perforations: risk factors and management.  Endoscopy. 2002;  34 293-298