title: Management of duodeno-pancreato-biliary perforations after ERCP: outcomes from an Italian tertiary referral center.
abstract: BACKGROUND
  The management of post-endoscopic retrograde cholangiopancreatography (ERCP) perforation is often unknown by many physicians, and there is a paucity of literature regarding the best surgical management approach.
  
  
  METHODS
  A retrospective review of ERCP-related perforations to the duodeno-pancreato-biliary tract observed at the Digestive Surgery Department of the Catholic University of Rome was conducted to identify their optimal management and clinical outcome.
  
  
  RESULTS
  From January 1999 to December 2011, 30 perforations after ERCP were observed. Seven patients underwent ERCP at another institution, and 23 patients underwent an endoscopic procedure at our hospital. Diagnosis of perforation was both clinical and instrumental. Fifteen patients (50 %) were successfully treated conservatively. Fifteen patients (50 %) underwent surgery after a mean time of 8.1 days (range 1-26 days) from ERCP: ten received a retroperitoneal laparostomy approach, three of them both an anterior and posterior laparostomy approach, and two an anterior laparostomy approach. Duodenal leak closure was observed after a mean (± standard deviation, SD) of 12.6 (± 4.6) and 24.6 (± 7.9) days after conservative and surgical treatment, respectively (p < 0.001). The overall and postoperative mortality rates were 13.3 % (4 of 30 patients) and 26.6 % (4 of 15 patients), respectively.
  
  
  CONCLUSIONS
  Post-ERCP perforation is burdened by a high risk of mortality. Early clinical and radiographic features have to be used to determine which type of surgical or conservative treatment is indicated. Half of patients can be treated conservatively, but in case of sepsis or unstable general conditions, early surgical procedure is indicated as the only possible chance of recovery.
authors.affiliation: Digestive Surgery Department, Catholic University, A. Gemelli Hospital, Largo A. Gemelli, 8, 00168, Rome, Italy.
authors.forename: Sergio
authors.initials: S
authors.lastname: Alfieri
authors.forename: Fausto
authors.initials: F
authors.lastname: Rosa
authors.forename: Caterina
authors.initials: C
authors.lastname: Cina
authors.forename: Antonio Pio
authors.initials: AP
authors.lastname: Tortorelli
authors.forename: Andrea
authors.initials: A
authors.lastname: Tringali
authors.forename: Vincenzo
authors.initials: V
authors.lastname: Perri
authors.forename: Chiara
authors.initials: C
authors.lastname: Bellantone
authors.forename: Guido
authors.initials: G
authors.lastname: Costamagna
authors.forename: Giovanni Battista
authors.initials: GB
authors.lastname: Doglietto
mesh_terms: D000328:Adult; D000368:Aged; D001659:Biliary Tract / Q000293:injuries*; D002760:Cholangiopancreatography, Endoscopic Retrograde / Q000009:adverse effects*; D004322:Drainage / Q000379:methods; D004386:Duodenum / Q000293:injuries*; D005260:Female; D006801:Humans; D007431:Intraoperative Complications / Q000601:surgery; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome