Abstracts
1998 Digestive Disease Week

#1047

ERCP-ASSOCIATED DUODENAL PERFORATION USUALLY CAN BE TREATED NON-OPERATIVELY. R.B. Claytor#, F.J. Vittimberga#, M. Malik#, J. Saltzman+, P. Krims+, M.P. Callery#, R.S. Swanson#. Departments of Surgery (#) and Medicine (+), University of Massachusetts Medical Center. Worcester, Massachusetts.

Perforation of the duodenum (PD) is a known complication of ERCP. The optimal management of this complication is not clear. We reviewed our experience to determine the role of surgery. Between 1993 and 1997, of 1063 ERCP's only 11 (1.0%) were associated with PD. The reason for ERCP was choledocholithiasis (n=6), gallstone pancreatitis (n=2), stricture at the Sphincter of Oddi (n=2), and pancreatic mass (n=1). The mechanisms for perforation were presumably endoscopic sphincterotomy (n=10) or endoscope trauma from a pancreatic tumor tethering the duodenum (n=1). The perforation was recognized immediately at ERCP (n=9) or within hours when abdominal pain developed (n=2). Management initially was conservative (n=8) or immediate surgery (n=3). Immediate surgery was done to treat PD and impacted common duct stones in hemodynamically stable patients (n=2) or to treat PD in a hemodynamically unstable patient with massive retroperitoneal free air (n=1). Of the 8 managed conservatively, only one required surgery for persistent pain and tenderness; the remaining 7 had resolution of symptoms within 12 hours. There were no deaths with PD. On average, patients managed conservatively were discharged on post-perforation day 4; patients managed surgically were discharged on post-operative day 12. No one laboratory, radiologic, or clinical factor predicted successful
non-operative management, other than resolution of pain and tenderness within 12 hours of ERCP. We conclude that duodenal perforation is an infrequent complication of ERCP that usually can be managed non-operatively. Surgery should be considered if: (1) common duct obstruction and perforation coexist after ERCP; (2) if massive free air with hemodynamic instability occurs; or (3) if abdominal pain and tenderness do not resolve within hours after ERCP-associated duodenal perforation.

Copyright 1996 - 1998, SSAT, Inc. Revised 29 June 1998.