Management of perforation after endoscopic retrograde cholangiopancreatography (ERCP): a population-based review

Background. Perforation related to endoscopic retrograde cholangiopancreatography (ERCP) is a rare complication associated with significant morbidity and mortality. This study evaluated the management and outcomes of these perforations. Patients and methods. Between July 1996 and December 2002, a total of 6620 ERCPs were performed at our regional endoscopy unit serving the 1.5 million population of Southern Alberta. Thirty perforations (0.45%) were identified and retrospectively reviewed. Results. Seven of these 30 patients were found to have guidewire perforations of the bile duct, 11 perforations were peri-ampullary, 3 duodenal, 1 esophageal, and 1 patient had a perforation of an afferent limb of a Billroth II anastomosis. In seven patients the location of the perforation could not be determined (unknown). All patients with guidewire perforations were recognized during ERCP, and all were managed medically. Of the 11 peri-ampullary perforations, 7 of these patients had a pre-cut sphincterotomy, 5 underwent surgery and 4 patients died. Delay in diagnosis occurred in all patients that died. Of the three duodenal perforations, all required operation and one patient died. Of the seven ‘unknown’ retroperitoneal perforations, two patients required surgery and there was no mortality. The patients with esophageal and afferent limb perforations both recovered uneventfully after surgery. Most patients who required surgery had retroperitoneal fluid seen on CT scanning. Conclusions. We found that most guidewire perforations can be managed medically with little morbidity. Pre-cut sphincterotomy is a risk factor for perforation. Peri-ampullary and duodenal perforations have a high morbidity and mortality rate. In particular, retroperitoneal fluid collections on CT scans, delay in diagnosis and failure of medical therapy requiring salvage surgery are associated with poor outcomes. Early aggressive surgery may improve patient care.