Small papilla: another risk factor for post-sphincterotomy perforation

We read with interest the article by García-Cano et al [1] on retroperitoneal perforation caused by precut endoscopic sphincterotomy for biliary access in a patient with a Billroth II gastrectomy. Because of failed standard cannulation, biliary access was gained after needle knife precut sphincterotomy. After the procedure, the presence of a large volume of retroperitoneal air was suspected from plain radiography, and was confirmed by computed tomography (CT). During surgery, only a pinpoint perforation was noted, and tubal drainage without closure of the perforation was done resulting in uneventful recovery. The authors suspected that the precut procedure and the reversed endoscopic view of the papilla in Billroth II anatomy had led to the perforation. We have encountered perforation after a standard endoscopic sphincterotomy in a patient with a small papilla and normal gastric anatomy. Although a large volume of retroperitoneal air was present, conservative management was successful.

A 61-year-old woman with normal gastric anatomy underwent endoscopic sphincterotomy for removal of biliary stones. A short sphincterotomy was performed by using a standard papillotome because of the presence of a small papilla with a parapapillary diverticulum ([Fig. 1]), and the stones were all extracted endoscopically. After the procedure, the patient complained of persistent dull abdominal pain and fever, and there was no elevation of serum pancreatic enzymes. Although we had not identified any perforation during extraction of the stones, immediate plain radiography suggested a large volume of retroperitoneal air ([Fig. 2]), which was confirmed by CT ([Fig. 3]).

Fig. 1 Endoscopy shows a small papilla with a small parapapillary diverticulum.

Fig. 2 A plain radiograph suggests a large volume of retroperitoneal air.

Fig. 3 Computed tomography shows a large volume of pararenal, para-aortic, and retropancreatic air.

Given that the abdominal pain was mild and there was no free air in the abdominal cavity, we managed the patient successfully with conservative measures, including intravenous feeding with antibiotic therapy, no oral intake, and the placement of a nasogastric drain. The patient resumed a normal diet on day 14.

Retroperitoneal perforation, a rare complication of therapeutic endoscopic retrograde cholangiopancreatography (ERCP), occurs in about 0.4 % of patients, and is mostly associated with endoscopic sphincterotomy [2]. Because post sphincterotomy perforations are small, retroperitoneal, and easily recognized during ERCP, conservative management is usually successful when patients appear clinically stable, and only about 10 % of the patients require surgery [2] [3]. Free perforation is a more serious complication with a mortality rate of up to 25 %. Conservative management might have been successful in the patient of García-Cano et al. [1], as with our patient, because only a pinpoint perforation was subsequently noted during surgery.

Post-ERCP complications have been associated with endoscopic technique, skill of the endoscopist, the presence of duodenal anatomic abnormalities, parapapillary diverticulum, and underlying disease [2]. Post sphincterotomy perforations mostly occur in patients undergoing a more extensive sphincterotomy for removal of large biliary stones [3]. Precut sphincterotomy has also been identified as a potential risk factor for perforation [3] [4] [5] [6], especially in patients with Billroth II anatomy [6] as in the patient of García-Cano et al [1], and there is still controversy regarding its safety [2] [7]. Although a standard endoscopic sphincterotomy was performed in our patient who had normal gastric anatomy, the perforation occurred because of the presence of a small papilla with a parapapillary diverticulum. In the case of a small papilla, we suspect that the sphincterotomy incision would tend to extend beyond the papillary mound, resulting in perforation. As all endoscopists would like to reduce the risk of post sphincterotomy perforation by identifying the predictable factors, we draw attention to a small papilla as another risk factor for perforation associated with endoscopic sphincterotomy.

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 Kayhan B, Akdoğan M, Sahin B. ERCP subsequent to retroperitoneal perforation caused by endoscopic sphincterotomy.  Gastrointest Endosc. 2004;  60 833-835
• 3 Enns R, Eloubeidi M A, Mergener K. et al . ERCP-related perforations: risk factors and management.  Endoscopy. 2002;  34 293-298
• 4 Williams E J, Taylor S, Fairclough P. et al . Risk factors for complication following ERCP; results of a large-scale, prospective multicenter study.  Endoscopy. 2007;  39 793-801
• 5 Horiuchi A, Nakayama Y, Kajiyama M. et al . Effect of precut sphincterotomy on biliary cannulation based on the characteristics of the major duodenal papilla.  Clin Gastroenterol Hepatol. 2007;  5 1113-1118
• 6 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
• 7 de Weerth A, Seitz U, Zhong Y. et al . Primary precutting versus conventional over-the-wire sphincterotomy for bile duct access: a prospective randomized study.  Endoscopy. 2006;  38 1235-1240