MANAGEMENT OF POST-ERCP

DUODENAL PERFORATION Magda Recsky

Sept 18, 2012

PATIENT JB

July 13, 2012

43 yr F – JW – history of vague RUQ pain;

investigations including U/S and CT scan

Dilated duct demonstrated: 14.8mm on U/S but

only ~7-8mm on CT

July 13, 2012: ERCP

Diverticulum noted at ampulla

No filling defect; no stone with balloon sweep

GB and cystic duct not visualized

Sphincterotomy conducted

INITIAL CONSULT

July13 – increasing pain

post ERCP

AXR and CXR and CT -

pneumomediastinum

small amount of free air

medially involving the

right inferior hemithorax

free air along the right

perihepatic space

retroperitoneal air

Patient hemodynamically stable; normal T; HR

50-60; improved pain on assessment

JULY 14

Worsening pain

Tachycardia

Increasing WBC

Decision made to take to OR

INTRA-OP FINDINGS

Bile-stained RUQ

Kocherize duodenum with exploration – unable

to identify site of perforation

WHAT WE DID

Pyloric exclusion with gastrotomy, oversew

pylorus

Roux-en-Y gastrojejunostomy using gastrotomy

Cholecystectomy

Drained widely

CLASSIFICATION OF DUODENAL INJURIES:

POST-ERCP

Type I – lateral

Type II – peri-

ampullary

Type III – CBD

injury

Type IV – only

retroperitoneal air

Stapfer M et al. Management of duodenal perforation after endoscopic retrograde cholangiopancreaticography and sphincterotomy. Am Surg 2000.

WHAT DOES THE LITERATURE TELL US?

No consensus on management guidelines and

selection criteria for surgery or conservative

management

Recommendations based on anecdotes and small

case series

MACHADO 2012

Literature review 2000 onwards (not a formal

systematic review) of reports that contained 9 or

more cases of post-ERCP perforations

251 cases in 10 reports

Mean age: 58.5

Locations of perforations:

Duodenal wall: 34.5%

Periamullary: 31.3%

CBD: 23%

Unknown: 7.9%

MACHADO 2012

Conservative management: 62.2% (156)

93% successful (145)

Surgical management: (not exclusive)

Primary closure: 49% (+/- other procedures)

Retroperitoneal drainage: 39%

Duodenal exclusion: 24%

CBD exploration and T-tube insertion: 13%

Overall mortality: 8% (20 patients)

6 (30%) – salvage surgery

5 (25%) – delay in diagnosis/intervention >3 days

3 (15%) – multiple surgeries

sepsis

TYPES OF PROCEDURES

Closure of perforation

T-tube insertion

Choledocholithotomy

Tube duodenostomy

Gastrojejunostomy

Retroperitoneal drainage

Duodenal exclusion

Choledochojejunostomy

Duodenogastrectomy

MACHADO 2012 - CONCLUSIONS

Conclusions:

“The most important factors for recent better

outcome were early detection and prompt

treatment. Delay in diagnosis and intervention,

salvage surgery after failed conservative

management, multiple operations, and older age

group contributed significantly to the poor

outcome.”

Delay in treatment well documented in literature

to result in increased morbidity and mortality

Howard TJ et al. Surgery 1999

Krishna RP et al. Surg Today 2011

Lai CH et al. Surgeon 2008

Avgerinos et al. Surg Endosc 2009

Mao Z et al. J LaproendoscAdvSurg Tech 2008

Morgan KA et al. Am Surg 2009

Etc…

DECISION TREE

Conservative vs Operative

Patient’s condition

Mechanism of injury

Site of injury

Site and mechanism (scope vs due to

sphincterotomy etc) may not always be possible

All require NG drainage/decompression

If decide on operative management – then need

to decide what to do

CLINICAL SIGNS AND SYMPTOMS

Epigastric pain and back pain (more intense than

usual)

Tenderness with or without peritoneal signs

(generally rebound tenderness)

Emphysema,

Later:

Tachycardia – constant finding by very sensitive and

not specific

Fever

Leukocytosis – often seen 12 hours or more after

completion of ERCP

SITE OF INJURY

Type I (lateral wall)

Require surgical intervention

Debridement of devitalized tissue

Primary closure in 1 or 2 layers (transversely)

If slightly larger and can’t close – consider a jejunal

serosal patch

If large, treat just like a traumatic

injury with pyloric exclusion and

diversion

DUODENAL DIVERSION TECHNIQUES

Tube decompression

Controversial – may not adequately decompress; may

cause new perforations

Duodenal diverticulization

Billroth II gastrectomy + closure of duodenal wound

+ duodenal catheter to decompress + multiple drains

+/- biliary drainage

Extensive procedure especially in hemodynamically

unstable patient

Pyloric exclusion

Repair of duodenal wound + closure of pylorus

(through gastrotomy or with stapler) + side-to-side

gastrojejunostomy

SITE OF INJURY

Type II (peri-amullary) and Type III (CBD)

Often contained and can be managed non-operatively NG; NPO; broad spectrum antibiotics

Often when type II perforations treated operatively – site of perforation could not be identified

Some advocate diversion of biliary flow in all Type II and Type III Percutaneous transhepatic biliary drainage

Internal biliary stent

Indications for operative management: Failure of non-op

Ongoing leakage

Peritoneal signs

? Large free or retroperitoneal collection Fatima J et al. Arch Surg 2007

Knudson K et al. Am J Surg 2008

MACHADO ET AL – FINAL CONCLUSIONS

“The optimal operation for ERCP induced duodenal perforation appears to be primary repair and duodenal diversion with gastrojejunostomy and pyloric exclusion.

However, if the perforation is noted and managed early, primary repair without diversion has similar results, provided the peritoneal contamination is minimal.

While patients with type I perforation would invariably require immediate surgical intervention, those with type II or III may often be managed conservatively. However, they would require constant observation supported by radiological investigation to confirm satisfactory progress failing which they may require surgical intervention.”

STAPFER ET AL 2000

Recommend that all patients with type I injuries

undergo surgery immediately

Nonsurgical management for type II and III injuries

is acceptable if early contrast study shows:

minimal extravasation OR

a sealed perforation without associated fluid collections

Type IV: probably need no additional treatment or

workup if the findings of the abdominal examination

are normal and there is no evidence or suspicion of

contrast extravasation

Type II, III, or IV injuries with retained stones and

unrelieved bile obstruction or foreign bodies should be

explored in the absence of other indications

WU ET AL.

1996-2002 – 6620 ERCPs performed

30 perforations (0.45%)

Type I: 3

Type II: 11

Type III: 7

Type IV: 0

Unknown: 7

Esophageal: 1

Afferent limb in previous Billroth II: 1

All those who died had a delay in their diagnosis

All those who died in Type II group had re-operations

Operations for all those who died minimal at first –

then progressed with re-operations

No single patient underwent a pyloric exclusion

procedure – most duodenostomy

Type I

(3)

Surgical

1/3 death from

sepsis/MOF

Type II

(11)

Surgical

(5)

3/5 death from sepsis

Medical

(6)

Type III

(7)

Non-operative

Unknown

(7)

Surgical (2) Medical (5)

FATIMA ET AL 2007

1994-2004

12,427

75 perforations identified (0.6%)

0.1% for diagnostic

0.8% for therapeutic

Overall mortality for those with peri-ampullary

perforations (Type II): 7%

Operative group (n=22) mortality: 13%

Non-operative group (n=53) mortality: 4%

Fatima et al. Archives of Surgery 2007

Fatima et al. Archives of Surgery 2007

PATIENTJB

POD #3: UGI study – gastrojej intact; distal

anastomosis intact; no contrast extravasation

POD #6: OR for sepsis – sudden deterioration in

SCCU

Washout; more drains

Feeding J-tube

Packs left in RUQ

POD #8: OR: packs removed; no evidence of

further contamination

POD #16: OR for sepsis; ongoing bile from drains

Large hole identified in duodenum

Melecot drain used for duodenostomy

More drains

Ongoing bile from drains

Ongoing sepsis

Died on POD #25 (26 days post ERCP)

ADDITIONAL THOUGHTS

No delay in treatment

Definitive operation first time

?Role for percutaneous decompression of biliary

tree

TYPE IV PERFORATION

Retroperitoneal air only

“Common benign finding after endoscopic sphincterotomy and had no predictive value in identifying patients who requires intervention”

13 to 29% incidence of inconsequential retroperitoneal air in several prospective studies

Stapfer M et al. Am Surgery 2000

Machado. J Pancreas 2012

Genzlinger JL et al. Gastroenterol 1999

de Vries JH et al. Endoscopy 1997