title: Operative treatment of periampullary retroperitoneal perforation complicating endoscopic sphincterotomy.
abstract: BACKGROUND
  Evidence-based strategies are lacking regarding the appropriate management of periampullary retroperitoneal perforations complicating endoscopic retrograde cholangiopancreatography (ERCP) combined with endoscopic sphincterotomy (ES). We propose a transduodenal operative repair of periampullary retroperitoneal perforation.
  
  
  METHODS
  Six patients with duodenal periampullary perforation induced by endoscopic sphincterotomy underwent operation after failure of an attempt of conservative management. After mobilization of the second and the third part of the duodenum, a minimal transversal duodenotomy was carried out, the papilla was exposed, periampullary perforation was readily identified, and was sutured easily as a sphincteroplasty or by 2 or 3 Vicryl 3/0 sutures. Patient outcomes were measured.
  
  
  RESULTS
  Periampullary perforation was repaired as sphincteroplasty in 2 cases, and with Vicryl 3/0 sutures in 4 cases. The mean duration of operation was 176 minutes. There were no intraoperative complications. None of the patients required reoperation after transduodenal repair of the perforation. The patients had a normal postoperative course. The median hospital stay was 10.5 days (range, 9 to 20 days) and the mortality rate was nil. There were no delayed complications during a median follow-up of 60 months.
  
  
  CONCLUSIONS
  The transduodenal operative approach to periampullary perforation after ERCP/ES at an early stage in the clinical evolution of the perforation is a safe and effective procedure. We consider this approach a useful option for the treatment of periampullary perforation after ERCP/ES when initial endoscopic and conservative management do not yield good results within 24 hours.
authors.affiliation: Department of Surgical Sciences, Section of General Surgical Clinics and Surgical Therapy, Parma University, Medical School, Parma, Italy. leopoldo.sarli@unipr.it
authors.forename: Leopoldo
authors.initials: L
authors.lastname: Sarli
authors.forename: Cristina
authors.initials: C
authors.lastname: Porrini
authors.forename: Renato
authors.initials: R
authors.lastname: Costi
authors.forename: Gabriele
authors.initials: G
authors.lastname: Regina
authors.forename: Vincenzo
authors.initials: V
authors.lastname: Violi
authors.forename: Michelina
authors.initials: M
authors.lastname: Ferro
authors.forename: Luigi
authors.initials: L
authors.lastname: Roncoroni
mesh_terms: D000328:Adult; D000368:Aged; D014670:Ampulla of Vater; D002760:Cholangiopancreatography, Endoscopic Retrograde / Q000009:adverse effects*; D004386:Duodenum / Q000601:surgery; D005260:Female; D006801:Humans; D007902:Length of Stay; D008297:Male; D012187:Retroperitoneal Space / Q000293:injuries*; D016717:Sphincterotomy, Endoscopic / Q000009:adverse effects*; D013514:Surgical Procedures, Operative / Q000379:methods*; D016896:Treatment Outcome; D014950:Wounds, Penetrating / Q000209:etiology* / Q000601:surgery*