Surgical management of endoscopic retrograde cholangiopancreatography-related perforations

Background: A retrospective review was carried out of consecutive cases of endoscopic retrograde cholangiopancreatography (ERCP)-related perforation to identify risk factors and technique affecting surgical outcome. Methods: Eighteen patients (0.45%) out of 4030 ERCP performed were operated on for ERCP-related perforation at Singapore General Hospital. Results: The group's median age was 72.5 years and 14 patients had ductal stone disease. Five perforations were discovered at ERCP while 10 required computed tomography for diagnosis. Eight patients were operated on within 24 h whereas 10 patients had surgery after 24 h. Five of six with type I (lateral duodenal) perforations had early surgery versus one of seven with type II (peri-Vaterian; P=0.03). There were four type III (bile duct) perforations and one type IV (retroperitoneal air). Five of six patients with type I perforation had simple repair compared with five of seven type II requiring the complex duodenal diversion procedure (P=0.10). Three patients (16.7%) succumbed after surgery due to sepsis and myocardial infarction. Advanced age>70 years resulted in higher mortality of 30% versus none in patients <70 years (P=0.22). Conclusions: Early diagnosis is important but difficult especially for the type II perforations. Duodenal diversion is used more frequently in patients with type II perforations and those operated on late. Advanced age contributes to poorer outcome in surgical treatment of ERCP perforations.