Immediate detection of endoscopic retrograde cholangiopancreatography-related periampullary perforation: fluoroscopy or endoscopy?
OBJECTIVE
To investigate the causes and intraoperative detection of endoscopic retrograde cholangiopancreatography (ERCP)-related perforations to support immediate or early diagnosis.


METHODS
Consecutive patients who underwent ERCP procedures at our hospital between January 2008 and June 2013 were retrospectively enrolled in the study (n = 2674). All procedures had been carried out using digital fluoroscopic assistance with the patient under conscious sedation. For patients showing alterations in the gastrointestinal anatomy, a short-type double balloon enteroscope had been applied. Cases of perforation had been identified by the presence of air in or leakage of contrast medium into the retroperitoneal space, or upon endoscopic detection of an abdominal cavity related to the perforated lumen. For patients with ERCP-related perforations, the data on medical history, endoscopic findings, radiologic findings, diagnostic methods, management, and clinical outcomes were used for descriptive analysis.


RESULTS
Of the 2674 ERCP procedures performed during the 71-mo study period, only six (0.22%) resulted in perforations (male/female, 2/4; median age: 84 years; age range: 57-97 years). The cases included an endoscope-related duodenal perforation, two periampullary perforations related to endoscopic sphincterotomy, two periampullary perforations related to endoscopic papillary balloon dilation, and a periampullary or bile duct perforation secondary to endoscopic instrument trauma. No cases of guidewire-related perforation occurred. The video endoscope system employed in all procedures was only able to immediately detect the endoscope-related perforation; the other five perforation cases were all detected by subsequent digital fluoroscope applied intraoperatively (at a median post-ERCP intervention time of 15 min). Three out of the six total perforation cases, including the single case of endoscope-related duodenal injury, were surgically treated; the remaining three cases were treated with conservative management, including trans-arterial embolization to control the bleeding in one of the cases. All patients recovered without further incident.


CONCLUSIONS
ERCP-related perforations may be difficult to diagnose by video endoscope and digital fluoroscope detection of retroperitoneal free air or contrast medium leakage can facilitate diagnosis.
Yasuaki Motomura, Kazuya Akahoshi, Junya Gibo, Kenji Kanayama, Shinichiro Fukuda, Shouhei Hamada, Yoshihiro Otsuka, Masaru Kubokawa, Department of Gastroenterology, Aso Iizuka Hospital, Iizuka 820-8505, Japan.
Yasuaki
Y
Motomura
Yasuaki Motomura, Kazuya Akahoshi, Junya Gibo, Kenji Kanayama, Shinichiro Fukuda, Shouhei Hamada, Yoshihiro Otsuka, Masaru Kubokawa, Department of Gastroenterology, Aso Iizuka Hospital, Iizuka 820-8505, Japan.
Kazuya
K
Akahoshi
Yasuaki Motomura, Kazuya Akahoshi, Junya Gibo, Kenji Kanayama, Shinichiro Fukuda, Shouhei Hamada, Yoshihiro Otsuka, Masaru Kubokawa, Department of Gastroenterology, Aso Iizuka Hospital, Iizuka 820-8505, Japan.
Junya
J
Gibo
Yasuaki Motomura, Kazuya Akahoshi, Junya Gibo, Kenji Kanayama, Shinichiro Fukuda, Shouhei Hamada, Yoshihiro Otsuka, Masaru Kubokawa, Department of Gastroenterology, Aso Iizuka Hospital, Iizuka 820-8505, Japan.
Kenji
K
Kanayama
Yasuaki Motomura, Kazuya Akahoshi, Junya Gibo, Kenji Kanayama, Shinichiro Fukuda, Shouhei Hamada, Yoshihiro Otsuka, Masaru Kubokawa, Department of Gastroenterology, Aso Iizuka Hospital, Iizuka 820-8505, Japan.
Shinichiro
S
Fukuda
Yasuaki Motomura, Kazuya Akahoshi, Junya Gibo, Kenji Kanayama, Shinichiro Fukuda, Shouhei Hamada, Yoshihiro Otsuka, Masaru Kubokawa, Department of Gastroenterology, Aso Iizuka Hospital, Iizuka 820-8505, Japan.
Shouhei
S
Hamada
Yasuaki Motomura, Kazuya Akahoshi, Junya Gibo, Kenji Kanayama, Shinichiro Fukuda, Shouhei Hamada, Yoshihiro Otsuka, Masaru Kubokawa, Department of Gastroenterology, Aso Iizuka Hospital, Iizuka 820-8505, Japan.
Yoshihiro
Y
Otsuka
Yasuaki Motomura, Kazuya Akahoshi, Junya Gibo, Kenji Kanayama, Shinichiro Fukuda, Shouhei Hamada, Yoshihiro Otsuka, Masaru Kubokawa, Department of Gastroenterology, Aso Iizuka Hospital, Iizuka 820-8505, Japan.
Masaru
M
Kubokawa
Yasuaki Motomura, Kazuya Akahoshi, Junya Gibo, Kenji Kanayama, Shinichiro Fukuda, Shouhei Hamada, Yoshihiro Otsuka, Masaru Kubokawa, Department of Gastroenterology, Aso Iizuka Hospital, Iizuka 820-8505, Japan.
Kiyoshi
K
Kajiyama
Yasuaki Motomura, Kazuya Akahoshi, Junya Gibo, Kenji Kanayama, Shinichiro Fukuda, Shouhei Hamada, Yoshihiro Otsuka, Masaru Kubokawa, Department of Gastroenterology, Aso Iizuka Hospital, Iizuka 820-8505, Japan.
Kazuhiko
K
Nakamura
D000368:Aged; D000369:Aged, 80 and over; D014670:Ampulla of Vater / Q000000981:diagnostic imaging / Q000293:injuries / Q000473:pathology / Q000601:surgery; D002760:Cholangiopancreatography, Endoscopic Retrograde / Q000009:adverse effects*; D003137:Common Bile Duct Diseases / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000209:etiology / Q000473:pathology / Q000628:therapy; D003287:Contrast Media; D042241:Early Diagnosis; D016099:Endoscopy, Gastrointestinal; D005119:Extravasation of Diagnostic and Therapeutic Materials; D005260:Female; D005471:Fluoroscopy; D006801:Humans; D007416:Intestinal Perforation / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000209:etiology / Q000473:pathology / Q000628:therapy; D007564:Japan; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D012189:Retrospective Studies; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome
D003287:Contrast Media
Diagnosis; Duodenum; Endoscopic retrograde cholangiopancreatography; Fluoroscopy; Perforation