Clinical Endoscopy

The Korean Society of Gastrointestinal Endoscopy (대한소화기내시경학회)
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Management of Duodenal Perforations after Endoscopic Retrograde Cholangiopancreatography

내시경적 역행성 담췌관조영술 후 발생한 십이지장 천공에 대한 치료

  • Kim, Jong-Hyun (Department of Surgery, Inha University School of Medicine) ;
  • Lee, Keon-Young (Department of Surgery, Inha University School of Medicine) ;
  • Ahn, Seung-Ik (Department of Surgery, Inha University School of Medicine) ;
  • Hong, Kee-Chun (Department of Surgery, Inha University School of Medicine) ;
  • Jung, Seok (Department of Internal Medicine, Inha University School of Medicine) ;
  • Lee, Don-Haeng (Department of Internal Medicine, Inha University School of Medicine) ;
  • Choe, Yun-Mee (Department of Surgery, Inha University School of Medicine) ;
  • Choi, Sun-Keun (Department of Surgery, Inha University School of Medicine) ;
  • Hur, Yoon-Seok (Department of Surgery, Inha University School of Medicine) ;
  • Kim, Sei-Joong (Department of Surgery, Inha University School of Medicine) ;
  • Cho, Young-Up (Department of Surgery, Inha University School of Medicine) ;
  • Shin, Seok-Hwan (Department of Surgery, Inha University School of Medicine) ;
  • Kim, Kyung-Rae (Department of Surgery, Inha University School of Medicine)
  • 김종현 (인하대학교 의학전문대학원 외과학교실) ;
  • 이건영 (인하대학교 의학전문대학원 외과학교실) ;
  • 안승익 (인하대학교 의학전문대학원 외과학교실) ;
  • 홍기천 (인하대학교 의학전문대학원 외과학교실) ;
  • 정석 (인하대학교 의학전문대학원 내과학교실) ;
  • 이돈행 (인하대학교 의학전문대학원 내과학교실) ;
  • 최윤미 (인하대학교 의학전문대학원 외과학교실) ;
  • 최선근 (인하대학교 의학전문대학원 외과학교실) ;
  • 허윤석 (인하대학교 의학전문대학원 외과학교실) ;
  • 김세중 (인하대학교 의학전문대학원 외과학교실) ;
  • 조영업 (인하대학교 의학전문대학원 외과학교실) ;
  • 신석환 (인하대학교 의학전문대학원 외과학교실) ;
  • 김경래 (인하대학교 의학전문대학원 외과학교실)
  • Published : 2011.02.27
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Abstract

Background/Aims: Surgery has been the mainstay of treatment for duodenal perforations after the introduction of endoscopic retrograde cholangiopancreatography (ERCP). Yet there have recently been arguments that conservative management with or without endoscopic intervention may be possible and safe. Methods: For the patients who received ERCP at Inha University Hospital from Jan. 2001 to Dec. 2007, we retrospectively analyzed the clinical manifestations, the treatment and the clinical outcomes of the cases with duodenal perforation. Results: Among the 1708 ERCP cases, duodenal perforation occurred in eleven (0.6%) patients. There were two cases of duodenal perforations (type I), four cases of peri-Vaterian injury (type II), two cases of bile duct perforations (type III) and three cases of retroperitoneal perforations (type IV). Six patients (55%) were treated surgically while the others were managed conservatively. Except for one death (9.1%), ten patients fully recovered. Either residual diseases or fluid collections, as seen on CT, were present in the surgically managed patients. The median time interval between ERCP and surgery was 19 hours (range: 8~30 hours). Conclusions: To decide on the management of duodenal perforation after ERCP, the presence of residual disease or the leakage of intraluminal contents should be considered along with the type of the perforation.

목적: 내시경적 역행성 담췌관조영술 후 발생하는 십이지장 천공의 치료는 수술적 방법이 표준이 되어 왔다. 그러나 최근 클립을 이용한 내시경적 일차 봉합을 포함한 보존적 치료의 안전성이 보고되면서 그 치료 방침에 대한 논의가 활발하다. 대상 및 방법: 2001년 1월부터 2007년 12월까지 인하대병원에서 내시경적 역행성 담췌관조영술을 받은 환자들 중에서 십이지장 천공이 발생한 환자들을 찾아 그 임상양상, 진단, 치료방법과 결과를 후향적으로 분석하였다. 결과: 모두 1,708 명의 시술 환자 중 11예(0.6%)에서 천공이 발생하였고, 이 중 8예는 내시경 시술 중에, 나머지 3예는 영상학적 검사를 통해 진단하였다. 십이지장 천공(1형)이 2예, 바터팽대부 주위 천공(2형)이 4예, 담관 천공(3형)이 2예 그리고 후 복막 유리 공기(4형)가 3예였다. 여섯 명의 환자(55%)가 수술적 치료를, 다른 환자들은 보존적 치료를 받았다. 수술적 치료를 받은 환자 중 1명(전체 천공 환자의 9.1%)이 사망하였고, 다른 환자들은 완쾌하였다. 수술 환자들은 시술 후 남은 질환이 있거나 전산화 단층촬영상 액체 저류가 있었다. 수술까지 경과시간의 중앙값은 19시간(8~30시간)이었다. 결론: 내시경적 역행성 담췌관조영술 후 발생하는 십이지장 천공의 치료 방침을 결정하는 데는 그 유형과 함께 남은 질환의 유무나 장관 내용물의 누출 여부가 함께 고려되어야 한다.

Keywords

References

  1. Freeman ML, Nelson DB, Sherman S, et al. Complications of endoscopic biliary sphincterotomy. N Engl J Med 1996;335:909-918. https://doi.org/10.1056/NEJM199609263351301
  2. Vandervoort J, Soetikno RM, Tham TC, et al. Risk factors for complications after performance of ERCP. Gastrointest Endosc 2002;56:652-656. https://doi.org/10.1016/S0016-5107(02)70112-0
  3. Cho MS, Park DE, Chae KM. Management for duodenal perforation caused by endoscopic retrograde cholangiopancreatography (ERCP). J Korean Surg Soc 2007;72:210-215.
  4. Choi JS, Kim MH, Lee SS, et al. The clinical course of ERCP-related bowel perforation. Korean J Gastrointest Endosc 2004;29:63-69.
  5. Enns R, Eloubeidi MA, Mergener K, et al. ERCP-related perforations: risk factors and management. Endosocpy 2002;34:293-298. https://doi.org/10.1055/s-2002-23650
  6. Preetha M, Chung YF, Chan WH, et al. Surgical management of endoscopic retrograde cholagiopancreatography-related perforations. ANZ J Surg 2003;73:1011-1014. https://doi.org/10.1046/j.1445-2197.2003.t01-15-.x
  7. Howard TJ, Tan T, Lehman GA, et al. Classification and management of perforations complicating endoscopic sphincterotomy. Surgery 1999;126:658-663. https://doi.org/10.1016/S0039-6060(99)70119-4
  8. Stapfer M, Selby RR, Stain SC, et al. Management of duodenal perforation after endoscopic retrograde cholagiopancreatography and sphincterotomy. Ann Surg 2000;232:191-198. https://doi.org/10.1097/00000658-200008000-00007
  9. Roses LL, Ramirez AG, Seco AL, et al. Clip closure of a duodenal perforation secondary to a biliary stent. Gastrointest Endosc 2000;51:487-489. https://doi.org/10.1016/S0016-5107(00)70454-8
  10. Fatima J, Baron TH, Topazian MD, et al. Pancreaticobiliary and duodenal perforations after periampullary endoscopic procedures: diagnosis and management. Arch Surg 2007;142:448-454. https://doi.org/10.1001/archsurg.142.5.448
  11. Avgerinos DV, Llaguna OH, Lo AY, Voli J, Leitman IM. Management of endoscopic retrograde cholangiopancreatography: related duodenal perforations. Surg Endosc 2009;23:833-838. https://doi.org/10.1007/s00464-008-0157-9
  12. Scarlett PY, Falk GL. The management of perforation of the duodenum following endoscopic sphincterotomy: a proposal for selective therapy. Aust N Z J Surg 1994;64:843-846. https://doi.org/10.1111/j.1445-2197.1994.tb04561.x
  13. Wu HM, Dixon E, May GR, Sutherland FR. Management of perforation after endoscopic retrograde cholangiopancreatography (ERCP): a population-based review. HPB (Oxford) 2006;8:393-399. https://doi.org/10.1080/13651820600700617
  14. Cicek B, Parlak E, Disibeyaz S, Koksal AS, Sahin B. Endoscopic retrograde cholangiopancreatography in patients with Billroth II gastroenterostomy. J Gastroenterol Hepatol 2007;22:1210-1213. https://doi.org/10.1111/j.1440-1746.2006.04765.x
  15. Martin DF, Tweedle DE. Retroperitoneal perforation during ERCP and endoscopic sphincterotomy: causes, clinical features and management. Endoscopy 1990;22:174-175. https://doi.org/10.1055/s-2007-1012833
  16. Lee TH, Bang BW, Jeong JI, et al. Primary endoscopic approximation suture under cap-assisted endoscopy of an ERCP-induced duodenal perforation. World J Gastroenterol 2010;16:2305-2310. https://doi.org/10.3748/wjg.v16.i18.2305
  17. Lee J, Ko KH, Kim JK, et al. A case of type I duodenal perforation treated with covered metal stent. Korean J Gastrointest Endosc 2005;30:95-98.
  18. Lee YJ, Lee SU, Sun IO, et al. Two cases of successful clipping closure of iatrogenic duodenal perforation occurred during endoscopic procedure. Korean J Gastrointest Endosc 2006;32:210-214.
  19. Genzlinger JL, McPhee MS, Fisher JK, Jacob KM, Helzberg JH. Significance of retroperitoneal air after endoscopic retrograde cholangiopancreatography with sphincterotomy. Am J Gastroenterol 1999;94:1267-1270. https://doi.org/10.1111/j.1572-0241.1999.00996.x
  20. Cotton PB, Lehman G, Vennes J, et al. Endoscopic sphincterotomy complications and their management: an attempt at consensus. Gastrointest Endosc 1991;37:383-393. https://doi.org/10.1016/S0016-5107(91)70740-2
  21. Zissin R, Shapiro-Feinberg M, Oscadchy A, Pomeranz I, Leichtmann G, Novis B. Retroperitoneal perforation during endoscopic sphincterotomy: imaging findings. Abdom Imaging 2000;25:279-282. https://doi.org/10.1007/s002610000033