title: Post-endoscopic retrograde cholangiopancreatography perforation managed by surgery or percutaneous drainage.
abstract: OBJECTIVE
  Post-endoscopic retrograde cholangiopancreatography (ERCP) perforation usually resolves conservatively; however, intervention is sometimes needed, and there is a paucity of literature regarding the best management approach. We evaluated our experience of managing post-ERCP perforations to help define the role of surgery with percutaneous drainage (PCD).
  
  
  METHODS
  A retrospective chart review revealed 14 cases of post-ERCP perforation with intra-abdominal sepsis referred for intervention. We analyzed data pertaining to clinical details, management, and outcome.
  
  
  RESULTS
  There were 12 patients with duodenal perforation and 2 with biliary perforation. Most (10/14; 72%) had symptom onset within 48 h, but delayed diagnosis or referral resulted in a mean delay until intervention of 6.6 days (range 1-18 days). Computed tomography revealed localized collections in 9 (64%) patients. Seven patients with localized collections and no or minimal contrast leak underwent PCD and rest, and 7 underwent surgery. The indications for surgery were free perforation, generalized peritonitis, and major contrast leak. Overall morbidity was 50% and there was one early postoperative death, caused by severe sepsis.
  
  
  CONCLUSIONS
  There should be a high index of suspicion of perforation when abdominal signs and symptoms develop after ERCP. Computed tomography is the investigation of choice for diagnosis and guiding therapy. With judicious selection of surgery or PCD based on clinical and imaging features, patients can be managed with acceptable morbidity and low mortality.
authors.affiliation: Department of Surgical Gastroenterology, Sanjay Gandhi Post-graduate Institute of Medical Sciences, Raebareli Road, Lucknow, 226014, India.
authors.forename: Ravula Phani
authors.initials: RP
authors.lastname: Krishna
authors.forename: Rajneesh Kumar
authors.initials: RK
authors.lastname: Singh
authors.forename: Anu
authors.initials: A
authors.lastname: Behari
authors.forename: Ashok
authors.initials: A
authors.lastname: Kumar
authors.forename: Rajan
authors.initials: R
authors.lastname: Saxena
authors.forename: Vinay K
authors.initials: VK
authors.lastname: Kapoor
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D001659:Biliary Tract / Q000293:injuries*; D002648:Child; D002760:Cholangiopancreatography, Endoscopic Retrograde / Q000009:adverse effects*; D004322:Drainage / Q000379:methods*; D004386:Duodenum / Q000293:injuries*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D014057:Tomography, X-Ray Computed; D014950:Wounds, Penetrating / Q000601:surgery / Q000628:therapy*; D055815:Young Adult