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World J Clin Cases. Oct 16, 2014; 2(10): 522-527
Published online Oct 16, 2014. doi: 10.12998/wjcc.v2.i10.522
Endoscopic retrograde cholangiopancreatography-related perforation: Management and prevention
Varayu Prachayakul, Pitulak Aswakul
Varayu Prachayakul, Siriraj GI Endoscopy Center, Division of Gastroenterology, Department of Internal Medicine, Siriraj Hospital, Faculty of Medicine, Mahidol University, Bangkok 10700, Thailand
Pitulak Aswakul, Liver and Digestive Institute, SamitivejSukhumvit Hospital, Bangkok 10120, Thailand
Author contributions: Prachayakul V and Aswakul P contributed equally to this work; Prachayakul V designed the concept; Prachayakul V and Aswakul P reviewed the literature, wrote and revised the paper.
Correspondence to: Varayu Prachayakul, Assist Professor, Siriraj GI Endoscopy Center, Division of Gastroenterology, Department of Internal Medicine, Siriraj Hospital, Faculty of Medicine, Mahidol University, 7 Prannok Rd., Bangkoknoi, Bangkok 10700, Thailand. kaiyjr@gmail.com
Telephone: +66-2-4121088 Fax: +66-2-4199610
Received: May 1, 2014
Revised: July 7, 2014
Accepted: July 25, 2014
Published online: October 16, 2014
Processing time: 167 Days and 1.2 Hours
Abstract

Endoscopic retrograde cholangiopancreatography (ERCP) is a procedure that can result in serious complications, and thus should be handled by a skilled endoscopist to minimize the risk of complications and to enhance the success rate. The incidence of ERCP-related complications is 5%-10%, most commonly involving post-ERCP pancreatitis and clinically significant post-endoscopic sphincterotomy bleeding. Although ERCP-related perforation has a relatively lower incidence of 0.14%-1.6%, this complication is associated with a high mortality rate of 4.2%-29.6%. A classification of perforation type based on the instrument that caused the perforation was recently described that we postulated could affect the implementation of perforation management. In the present article, an algorithm for management and prevention of ERCP-related perforations is proposed that is based on the perforation type and delay of diagnosis. Available evidence demonstrates that a delayed diagnosis and/or treatment of perforation results in a poorer prognosis, and thus should be at the forefront of procedural consideration. Furthermore, this review provides steps and recommendations from the pre-procedural stage through the post-procedural evaluation with consideration of contributing factors in order to minimize ERCP-related complication risk and improve patient outcome. To avoid perforation, endoscopists must evaluate the risks related to the individual patient and the procedure and perform the procedure gently. Once a perforation occurs, immediate diagnosis and early management are key factors to minimize mortality.

Keywords: Endoscopic retrograde cholangiopancreatography; Endoscopic retrograde cholangiopancreatography; Perforation; Prevention; Management; Classification

Core tip: Endoscopic retrograde cholangiopancreatography (ERCP)-related perforation, is a rare complication with a high morbidity and mortality. An immediate diagnosis and early management of ERCP-related perforation are key factors to minimize mortality. In this review article, the authors shared their experiences and propose an algorithm to avoid perforation and for management once a perforation occurs.