Case Presentation Post ERCP Perforation From www.uptodate.com Dr.Mohammad Amin Mirza General Surgery Resident Saudi Board in GS(R1) Al-Noor Specialist Hospital Makkah - 2003

. B . S Age : 42 y.o Gender : Female Saudi Date of admission : 28 – 06 – 1424 AH Social status : Married , House wife (10 children's ) Family history : Mother is diabetic

Admitted through OPD with typical history of calculuar cholecystitis . H/O itching ; dark color of urine ; normal stool . No H/O jaundice On examination : - Not jaundice . - Chest & CVS – NAD - Abdomen : Soft lax , tender RHC , paraumblical bulging (hernia) .

Chemistry : normal on admission . USG abdomen (19 – 06 – 24 ) : Multiple stones in GB with dilated CBD (9mm) , up to 13 mm it distal end & faint showing seen distally. Small stones ? or sludge , needs further evaluation . No intrahepatic biliary tree dilatation . Chemistry : normal on admission .

Indication For ERCP: - Dilated CBD , containing Indication For ERCP: - Dilated CBD , containing ? stones - H/O itching ; dark color of urine ERCP done at 29 – 06 – 1424 AH : Difficult canulation of the ampulla of Vater , Stricture at lower end of CBD Duadenal diverticulum Precut sphyncterotomy done Bile flowing freely

Pt kept NPO , with IVF (3 L\hr) O² 10 L\m Pt received by Ward nurse at 14:50 She noticed that Pt is having face puffiness, gradually increasing abdominal distension, & swelling of the neck with vomiting content of bloody color Surgical Emphysema Vitally stable Surgical specialist has seen the Pt and informed the consultant on call. Pt kept NPO , with IVF (3 L\hr) O² 10 L\m

- USG abdomen : intraperitoneal air, No free fluid intra abdominal, subcut emphysema - CT chest : Bilateral pneumothorax, extensive emphysema retroperitoneal (abdomen & pelvis) Intra abdominal air (large amount); no esophageal injury. - Gastrographin swallow : no esophageal rupture, sever GE reflux, contrast not progressing from antral region on ward for 45 min . - Consulted Chest surgeon ,, who inserted Rt ICT . and later Lt ICT

Pt Taken to OR for urgent laparotomy at 21:00 Exploratory laparotomy: Cholecyctectomy, Sphyncteroplasty of sphyncter of Oddi, T-Tube insertion into CBD, Feeding jejunostomy tube, Repair of PUH.

Post operatively Pt was in ICU for close observation for 24 hrs Pt is stable Doing well Shifted to FSW and remains stable, & improving.

Patients progress MRSA – wound infection . (POD 8) Abdominal wall collection which is drained and treated by antibiotics according to C/S with dressing BID (POD 27) T-Tube is removed (T-Tube Nil , Drain – 200 ml ) and T-Tube cholangiogramm is showing free passage of the die into Duodenum , and no leakage US-guided aspiration of retroperitoneal abscess-210cc. C\S Ca.Albicans.

Patient is discharged from the hospital in good condition to be followed in surgical OPD First days of Ramadhan 1424

Overview of complications of E R C P & endoscopic biliary sphincterotomy

Classification of complications

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Risk factors Overall perforations: Pt related : -Sphincter of Oddi dysfunction - A dilated common bile duct. - Distal CBD Stricture . . Procedure related: - Sphincterotomy - Longer duration of the procedure - Biliary strictuer dilatation

Risk factors Risk factors for bowel wall perforation : - Patients who have stenosis in the upper gastrointestinal tract or bile ducts - patients who have undergone gastric resection (Billroth II gastrectomy)

Risk factors - precut sphincterotomy and larger sphincterotomies Risk factors for retroperitoneal perforation: - precut sphincterotomy and larger sphincterotomies particularly those that are created outside of the usually recommended landmarks (11 to 1 o'clock) - small caliber bile duct - the presence of a peripapillary diverticulum - intramural injection of contrast

PREVENTION The risk of perforation can be minimized when ERCP is performed by well-trained endoscopists and assistants abiding by the following technique-related principles: Proper orientation of the sphincterotome between 11 and 1 o'clock Step-by-step incision Avoiding a "zipper" cut Sphincterotomy length tailored to the size of papilla, bile duct, and eventual stone Judicious use of precut Appropriate technique in cases of anatomical variants such as peripapillary diverticula and Billroth II gastrectomy

MANAGEMENT NPO ,proper hydration , NGT , or naso-duodenal tube , & IV antibiotics . Patients with esophageal and free abdominal gastric, jejunal, or duodenal perforation usually require surgery: - choledochotomy with stone extraction and T-tube drainage, - repair of the perforation, - drainage of abscess or phlegmon, - choledochojejunostomy, or pancreatoduodenectomy - nasobiliary tube (during ERCP) - Percutaneous drainage - TPN for Pt who are expected to remain on bowel rest for at least one week

Conclusion

Close observation of patients who underwent ERCP at least 6 hours after procedure is mandatory by the resident on duty , especially the cases which had difficulty in the procedure