Management of duodenal perforation after endoscopic retrograde cholangiopancreatography and sphincterotomy

Objective To evaluate the authors' experience with periduodenal perforations to defin e a systematic management approach. Summary Background Data Traditionally, traumatic and atraumatic duodenal perforations have been man aged surgically; however, in the last decade, management has shifted toward a more selective approach. Some authors advocate routine nonsurgical manag ement, but the reported death rate of medical treatment failures is almost 50%. Others advocate mandatory surgical exploration. Those who favor a sele ctive approach have not elaborated distinct management guidelines. Methods A retrospective chart review at the authors' medical center from June 1993 to June 1998 identified 14 instances of periduodenal perforation related to endoscopic retrograde cholangiopancreatography (ERCP), a rate of 1.0%. Cha rts were reviewed for the following parameters: ERCP findings, clinical pre sentation of perforation, diagnostic methods, time to diagnosis, radiograph ic extent and location of duodenal leak, methods of management, surgical pr ocedures, complications, length of stay, and outcome. Results Fourteen patients had a periduodenal perforation. Eight patients were initi ally managed conservatively. Five of the eight patients recovered without i ncident. Three patients failed non surgical management and required extensi ve procedures with long hospital stays and one death. Six patients were man aged initially by surgery, with one death. Each injury was evaluated for l ocation and radiographic extent of leak and classified into types I through IV. Conclusions Clinical and radiographic features of ERCP-related periduodenal perforation s can be used to stratify patients into surgical or nonsurgical cohorts. A selective management scheme is proposed based on the features of each type.