Endoscopic retrograde cholangiopancreatography-related perforations: Diagnosis and management

Table 1 Incidence of perforations and overall mortality

Ref.	Design	n	Perforations (%)		Types1				Mortality (%)
					I	II	III	IV
Assalia et al[11], 2007	Prosp	3104	22	(0.70)	2	17	2		1	(4.5)
Avgerinos et al[12], 2009	Retro	4358	15	(0.34)	9	3		1	3	(20)
Dubecz et al[13], 2012	Retro	12232	11	(0.08)	7	3	1		2	(18)
Enns et al[14], 2002	Case control	9314	33	(0.35)	5	13	15		1	(3)
Fatima et al[15], 2007	Retro	12427	75	(0.60)	8	26	35	6	5	(6.6)
Jin et al[16], 2013	Retro	22998	59	(0.26)	17	36	6		5	(8.4)
Kayhan et al[17], 2004	Retro	3124	17	(0.54)	2	15			-	-
Kim et al[18], 2011	Retro	7638	13	(0.17)	4	5	4		0	(0)
Kim et al[19], 2012	Retro	11048	68	(0.61)	13	31	22		4	(5.8)
Knudson et al[20], 2008	Retro	4919	32	(0.65)	6	11	7		0	(0)
Kwon et al[21], 2012	Retro	8381	53	(0.63)	21	24	8		3	(5.6)
Li et al[22], 2012	Retro	8504	16	(0.45)	7	5	4		0	(0)
Mao et al[23], 2008	Retro	2432	9	(0.37)	8	1			0	(0)
Miller et al[24], 2013	Retro	1638	27	(1.60)	5	12	5	5	9	(33)
Morgan et al[25], 2009	Retro	12817	24	(0.18)	12	12			1	(4.1)
Polydorou et al[26], 2011	Retro	9880	44	(0.44)	7	30	5	2	2	(4.5)
Stapfer et al[8], 2000	Retro	1413	14	(0.99)	5	6	3		2	(14)
Wu et al[27], 2006	Retro	6620	30	(0.45)	5	11	7		5	(16)
Total		142847	562	(0.39)	143 (25%)	261 (46%)	124 (22%)		43/545	(7.8)

¹Classification of types is assumed, because not all studies clearly defined the type of perforation according to Stapfer classification[8].

Table 2 Assumed etiology of perforations

Ref.	Endo scope	ES	Guide wire	Dilation of strictures	Other instruments	Stent insertionor migration	Unknown
Alfieri et al[28], 2013	6	15	1				8
Assalia et al[11], 2007	2	17	2			1
Avgerinos et al[12], 2009	9	3					3
Dubecz et al[13], 2012	7	3	1
Enns et al[14], 2002	5	13	13	2
Fatima et al[15], 2007	8	11	24	5	9	7	11
Krishna et al[29], 2011	11	1	2
Kayhan et al[17], 2004	2	15
Kim et al[18], 2011	4	3	4		2
Kim et al[19], 2012	13	25	23		2		5
Knudson et al[20], 2008	6	11			4	3	8
Kwon et al[21], 2012	21	24	2	6
Mao et al[23], 2008	-	8			1
Li et al[22], 2012	7	5			4
Morgan et al[25], 2009	12	12
Polydorou et al[26], 2011	7	30	2	2	3
Stapfer et al[8], 2000	5	6	3
Wu et al[27], 2006	5	11	7				7
Total (%)	130 (25)	213 (41)	84 (16)	15 (3)	25 (5)	11 (2)	42 (8)

ES: Endoscopic sphincterotomy.

Table 3 Time to diagnosis of endoscopic retrograde cholangiopancreatography related perforations

Ref.	During ERCP (%)	After ERCP
Avgerinos et al[12], 2009	4 (26)	11
Dubecz et al[13], 2012	5 (45)	6
Enns et al[14], 2002	28 (84)	5
Fatima et al[15], 2007	45 (60)	30
Kayhan et al[17], 2004	17 (100)	0
Kim et al[18], 2011	10 (77)	3
Kim et al[19], 2012	46 (95)	2
Knudson et al[20], 2008	11 (34)	21
Kwon et al[21], 2012	39 (73)	14
Li et al[22], 2012	16 (100)	0
Mao et al[23], 2008	8 (88)	1
Miller et al[24], 2013	18 (66)	9
Polydorou et al[26], 2011	42 (95)	2
Stapfer et al[8], 2000	13 (93)	1
Wu et al[27], 2006	19 (63)	11
Total	321(73)	116

ERCP: Endoscopic retrograde cholangiopancreatography.

Table 4 Comparison of different types of stents used for type II, III perforations

	Technical success	Biliary drainage	Covering the perforation	Repeat ERCP for removal	Cost
SEMS	+++	+++	+++	Y	+++
Plastic biliary stents	+++	++	+	Y	+
Nasobiliary drain	+++	+	_	N	+

SEMS: Covered self expanding metallic biliary stents; Y: Yes; N: No; ERCP: Endoscopic retrograde cholangiopancreatography.

Table 5 Outcome after initial non-surgical management of type II and III perforations

Ref.	Type II				Type III
	n	Surgery(%)	Mortality (%)		n	Surgery (%)	Mortality (%)
			After surgery	Overall
Assalia et al[11], 2007	17	2 (11)	1 (50)	1 (6)	2	0	0
Enns et al[14], 2002	13	2 (15)	0	0	15	0	0
Kim et al[18], 2011	3	1 (33)	0	0	4	0	0
Kwon et al[21], 2012	24	0	0	1 (4)	7	0	0
Li et al[22], 2012	5	0		0	4	0	0
Mao et al[23], 2008	8	3 (37)	0	0	1	0	0
Miller et al[24], 2013	9	7 (77)	5 (71)	6 (66)	5	0	0
Morgan et al[25], 2009	12	0		0
Polydorou et al[26], 2011	30	6 (20)	0	0	5	0	0
Stapfer et al[8], 2000	5	3 (60)	1 (33)	1 (20)	3	0	0
Wu et al[27], 2006	11	5 (45)	4 (80)	4 (36)	7	0	0
Total	137	29 (21)	11 (38)	13 (9.4)	53	0	0