title: Perforations following endoscopic retrograde cholangiopancreatography: a single institution experience and surgical recommendations.
abstract: BACKGROUND
  Perforation after endoscopic retrograde cholangiopancreatography (ERCP) is uncommon, and its management is dependent on the mechanism and the graded classification of injury.
  
  
  METHODS
  Records of patients undergoing ERCP were analyzed over a 16-year period, patterning the types of injuries, diagnosis, management, and patient outcome. Type I injuries damage the medial or lateral duodenal wall before sphincter cannulation. Type II injuries are periampullary and occur as a result of a precut or a papillotomy. Type III injuries occur secondary to guidewire insertion or stone extraction from the common bile duct. Type IV injuries are probably microperforations that are noted on excessive insufflation during and after ERCP withdrawal.
  
  
  RESULTS
  Between 1995 and 2011, 27 perforations were identified from 1,638 ERCP procedures (1.6%). Nearly half of the procedures were regarded as difficult by the endoscopist, with 70% of the ERCPs (19 of 27) being for therapeutic indications. There were 5 type I, 12 type II, 5 type III, and 5 type IV perforations, of which 18 cases were diagnosed at the time of ERCP. Delayed diagnosis of type I perforations that were associated with free intraperitoneal air and contrast leakage proved fatal. Most type II perforations required immediate surgery with pyloric exclusion; delayed surgery with simple drainage had a high mortality rate. Most type III and type IV injuries can successfully be managed conservatively without delayed sepsis.
  
  
  CONCLUSIONS
  In perforation, the mechanism of injury during ERCP predicts the need for surgical management. Type I and type II injuries require early diagnosis and aggressive surgery, whereas type III and type IV injuries may be managed conservatively.
authors.affiliation: Department of General Surgery, Kaplan Medical Center, Rehovot, Israel.
authors.forename: Rafi
authors.initials: R
authors.lastname: Miller
authors.forename: Andrew
authors.initials: A
authors.lastname: Zbar
authors.forename: Yoram
authors.initials: Y
authors.lastname: Klein
authors.forename: Victor
authors.initials: V
authors.lastname: Buyeviz
authors.forename: Ehud
authors.initials: E
authors.lastname: Melzer
authors.forename: Bruce N
authors.initials: BN
authors.lastname: Mosenkis
authors.forename: Eli
authors.initials: E
authors.lastname: Mavor
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002760:Cholangiopancreatography, Endoscopic Retrograde / Q000009:adverse effects*; D004064:Digestive System / Q000293:injuries*; D004386:Duodenum / Q000293:injuries*; D005260:Female; D006801:Humans; D007416:Intestinal Perforation / Q000453:epidemiology / Q000209:etiology*; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D016896:Treatment Outcome
keywords: Endoscopic retrograde cholangiopancreatography; Gastrointestinal perforation; Pyloric exclusion