Validity of Clinical Criteria in the Management of Endoscopic Retrograde Cholangiopancreatography-Related Duodenal Perforations

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Validity of Clinical Criteria in the Management of Endoscopic Retrograde Cholangiopancreatography–Related Duodenal Perforations

Ahmad Assalia, MD; Alain Suissa, MD; Anat Ilivitzki, MD; Ahmad Mahajna, MD; Kamal Yassin, MD; Moshe Hashmonai, MD; Moshe Krausz, MD

Arch Surg. 2007;142(11):1059-1064.

Objective To assess the validity of predetermined clinical and radiologic criteria in the management of endoscopic retrograde cholangiopancreatography (ERCP)–related duodenal perforations (DPs).

Design Prospective case series.

Setting Tertiary medical facility.

Patients Twenty-two individuals with ERCP-related DPs.

Interventions The guidelines advocated operative management for patients with free contrast leak and those with positive peritoneal signs or other indicators suggesting sepsis irrespective of the mechanism or location of injury.

Main Outcome Measures Thirty-day mortality rates, success of nonoperative management, and complications related to nonoperative and operative policies.

Results Diagnosis of DP was accomplished early (within 6 hours of ERCP) in 20 of 22 patients (91%). Three patients with early positive peritoneal signs were treated surgically; 2 of them sustained injury from the endoscope, and the third by papillotomy. All 3 patients had significant findings justifying immediate surgery. Nineteen patients with retroperitoneal DPs due to papillotomy or guidewire insertion were treated nonoperatively. In patients diagnosed early (n = 17), only 1 failure (6%) occurred. In the 2 patients with delayed diagnosis, there was 1 failure, which culminated in death.

Conclusions Our results might validate the role of clinical criteria for the selective management of ERCP-related DPs. These criteria were found to correlate well with radiologic findings and the mechanism of injury.

Author Affiliations: Departments of Surgery B (Drs Assalia, Ilivitzki, and Hashmonai), Gastroenterology (Drs Suissa and Yassin), and Surgery A (Drs Mahajna and Krausz), Rambam Medical Center and the Bruce Rappaport School of Medicine, Technion-Israel Institute of Technology, Haifa