title: Algorithm for the management of ERCP-related perforations.
abstract: OBJECTIVE
  Perforation is a rare but serious adverse event of ERCP. There is no consensus to guide the clinician on the management of ERCP-related perforations, with particular controversy surrounding the immediate surgical management of postprocedurally detected duodenal perforation because of overextension of a sphincterotomy. Our aim was to assess patient outcomes using a predetermined algorithm based on managing ERCP-related duodenal perforations according to the mechanism of injury.
  
  
  METHODS
  A retrospective single-center study of all consecutive patients with Stapfer type I and II perforations between 2000 and 2014 were included. Our institutional algorithm since 2000 dictated that Stapfer type I perforations (duodenal wall perforation, endoscope related) should be managed surgically unless prohibited by underlying comorbidities and Stapfer type II perforations (periampullary, sphincterotomy related) managed nonsurgically unless a deterioration in clinical status necessitated surgery.
  
  
  RESULTS
  Sixty-one patients (mean age, 51 years; 80% women) were analyzed with Stapfer type I perforations diagnosed in 7 (11%) and type II in 54 (89%). A postprocedural diagnosis of perforation was made in 55 patients (90%). Four patients (7%) had Stapfer type II perforations that failed medical management and required surgery. The mean length of stay (LOS) in the entire cohort was 9.6 days with a low mortality rate of 3%. Systemic inflammatory response syndrome was observed in 18 patients (33%) with Stapfer type II perforations and was not associated with the need for surgery. Concurrent post-ERCP pancreatitis was diagnosed in 26 patients (43%) and was associated with an increased LOS.
  
  
  CONCLUSIONS
  Stapfer type II perforations have excellent outcomes when managed medically. We validate an algorithm for the management of ERCP-related perforations and propose that it should function as a guide.
authors.affiliation: Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA.
authors.forename: Vivek
authors.initials: V
authors.lastname: Kumbhari
authors.affiliation: Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA.
authors.forename: Amitasha
authors.initials: A
authors.lastname: Sinha
authors.affiliation: Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA.
authors.forename: Aditi
authors.initials: A
authors.lastname: Reddy
authors.affiliation: Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA.
authors.forename: Elham
authors.initials: E
authors.lastname: Afghani
authors.affiliation: Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA.
authors.forename: Deanna
authors.initials: D
authors.lastname: Cotsalas
authors.affiliation: Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA.
authors.forename: Yuval A
authors.initials: YA
authors.lastname: Patel
authors.affiliation: Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA.
authors.forename: Andrew C
authors.initials: AC
authors.lastname: Storm
authors.affiliation: Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA.
authors.forename: Mouen A
authors.initials: MA
authors.lastname: Khashab
authors.affiliation: Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA.
authors.forename: Anthony N
authors.initials: AN
authors.lastname: Kalloo
authors.affiliation: Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA.
authors.forename: Vikesh K
authors.initials: VK
authors.lastname: Singh
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000465:Algorithms; D002760:Cholangiopancreatography, Endoscopic Retrograde / Q000009:adverse effects*; D000072700:Conservative Treatment; D004378:Duodenal Diseases / Q000209:etiology / Q000601:surgery / Q000628:therapy*; D005260:Female; D006801:Humans; D007416:Intestinal Perforation / Q000209:etiology / Q000601:surgery / Q000628:therapy*; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D010195:Pancreatitis / Q000209:etiology; D011183:Postoperative Complications / Q000209:etiology / Q000601:surgery / Q000628:therapy*; D012189:Retrospective Studies; D016717:Sphincterotomy, Endoscopic / Q000009:adverse effects; D018746:Systemic Inflammatory Response Syndrome / Q000209:etiology; D014057:Tomography, X-Ray Computed