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REVIEWOpenAccess Endoscopicduodenalperforation:surgical strategiesinaregionalcentre RichardCTurner 1* ,ChristinaMSteffen 2 andPeterBoyd 2 Abstract Background: Duodenalperforationisanuncommoncomplicationofendoscopicretrogradecholangio-pancreatography (ERCP)andararecomplicationofuppergastrointestinalendoscopy.Mostareminorperforationsthatsettlewith conservativemanagement.Afewperforationshoweverresultinlife-threateningretroperitonealnecrosisandrequire surgicalintervention.Thereisarelativepaucityofreferencesspecificallydescribingthesurgicalinterventionsrequired forthiseventuality. Methods: Fivecasesofiatrogenicduodenalperforationwereascertainedbetween2002and2007atCairnsBase Hospital.Clinicalfeatureswereanalyzedandcompared,withreferencetoareviewofERCPatthatinstitutionforthe years2005/2006. Results: Onepatientrecoveredwithconservativemanagement.Oftheotherfour,onediedafterinitiallaparotomy. Theotherthreesurvived,undergoingmultipleproceduresandlonginpatientstays. Conclusions: Iatrogenicduodenalperforationwithretroperitonealnecrosisisanuncommoncomplicationof endoscopy,butwhenitdoesoccuritispotentiallylife-threatening.Earlyrecognitionmayleadtoabetteroutcome throughearlierintervention,althoughaprotractedcoursewithmultipleproceduresshouldbeanticipated.Anumber ofsurgicaltechniquesmayneedtobeemployedaccordingtotheindividualcircumstancesofthecase. Keywords: Duodenum,Perforation,Endoscopy,Surgery,Necrosis Background Duodenalperforationisanuncommoncomplicationof endoscopicretrogradecholangiopancreatography(ERCP) andaveryrarecomplicationofuppergastrointestinal endoscopy.Mostseriesreportamajorityofnon-life- threateningperforationswhichsettlewithconservative management[1,2].Therearefewreferencesspecifically describingthesurgicalinterventionsrequiredforthemi- norityofiatrogenicduodenalperforationswheresurgery isindicated. Fivecasesofiatrogenicduodenalperforationoccurring between2002and2007atCairnsBaseHospitalarepre- sentedforcomparison,withreferencetoareviewof ERCPatCairnsBaseHospitalfortheyears2005/2006. Further,afocusedreviewoftheliteraturewasunder- takentoinformdiscussionofthesurgicalmanagement ofsuchcases. Methods CairnsBaseHospitalisasecondaryreferralhospitalin FarNorthQueensland,Australia.Itservesacatchment populationofapproximately250000,15%ofwhich identifyasIndigenousAustralian.Hospitalsurgicalaudit andendoscopyrecordsfortheperiod2002 – 2008were searchedforcasesofduodenalperforationfollowingen- doscopyorERCP.Age,sex,indicationforendoscopy/ ERCP,timingordelaytodiagnosisanddefinitivemanage- ment,typeofperforation,surgicalmanagement,complica- tions,lengthofstay,andlatemorbiditywererecordedfor eachcase. AnauditofERCPatCairnsBaseHospitalforthetwo yearperiod2005/2006wasutilizedtodeterminein- cidenceofcomplicationsofERCPandispresentedin Tables1and2. Forthefocusedliteraturereview,aPubMedsearch wasundertakenusingtheterms “ duodenalperforation ” , “ endoscopic ” and “ retroperitonealnecrosis ” .Case-based articlescitedbyreviewsweresecondarilysourced.Articles *Correspondence: richard.turner@utas.edu.au 1 DepartmentofSurgery,HobartClinicalSchool,UniversityofTasmania, Hobart,Australia Fulllistofauthorinformationisavailableattheendofthearticle WORLD JOURNAL OF EMERGENCY SURGERY ©2014Turneretal.;licenseeBioMedCentralLtd.ThisisanopenaccessarticledistributedunderthetermsoftheCreative CommonsAttributionLicense(http://creativecommons.org/licenses/by/2.0),whichpermitsunrestricteduse,distribution,and reproductioninanymedium,providedtheoriginalworkisproperlycited. Turner etal.WorldJournalofEmergencySurgery 2014, 9 :11 http://www.wjes.org/content/9/1/11 withEnglishlanguageabstractswereconsidered,andex-cludedifendoscopywasnotthecauseoftheperforation(ratheratreatment)orifspecificoperativedetailswerenotreported.Similarly,onlycasesthatunderwentsomeformofsurgicalmanagementwereincluded.Approvaltoaccessandanalyzede-identifiedpatientrecordsforthisstudywasgivenbytheHumanResearchEthicsCommitteeoftheCairnsandHinterlandHealthServiceDistrict.Fivepatientssustainingiatrogenicduodenalperforationwereidentified.TheclinicaldatapertainingtothesearepresentedinTable3.AllfouroftheERCPcaseshadanassociatedpre-cutsphincterotomy.Nosignificantbleed-ingwasnoted,andnoadditionalproceduressuchaslithotripsyorstentingwereperformed.Intwocases,therewasnospecificevidenceofcholedocholithiasis,withtheERCPbeingintendedsolelyfordiagnosticpur-poses.Figure1showsarepresentativeCTimagefromCase2priortosurgicalintervention.Figure2illustratesthenecroticretroperitonealmaterialdebridedviaarightflankincisioninCase1.Incases1,2and4,theactualduodenalperforationcouldnotbeidentifiedatoperation.Thismayhavebeenduetoasmallersizeoftheperforationand/ordelaytosurgeryresultingindifficultyidentifyingtheperforation.OngoingleakageinCase2necessitatedsubsequentpyloricexclusionandgastrojejunostomy.Case5,whereendoscopyalonewasperformed,islikelytohaveper-foratedthroughaduodenaldiverticulum,whichisaknownriskfactorforperforationbothinendoscopyandERCP[4-6].Thislargeperforationwasobviousatthetimeandearlyoperationenableddefinitiverepair.Asin-tegrityoftherepairwasdemonstratedradiologically,thesubsequentdelayedextensiveretroperitonealnecrosispresumablyarosefromtheleakagethatoccurredinthefewhoursbetweeninjuryandlaparotomyforrepair.Timingofinterventionwasassistedbyserialcomputer-izedtomographyexamination.Inthefourcasestreatedsurgically,definitiveinterventionconsistedofopensurgi-caldrainagewithorwithoutsubsequentCT-guidedpercu-taneousdrainageofamenablecollections.Whileopensurgicaldrainagewasimmediatelyeffectiveinallcases,percutaneousdrainageasaninitialinterventionwasnoteffectiveinCase1,attributabletothelargevolumesofsemi-solidnecroticmaterialintheretroperitoneumofthispatient.Thisisconsistentwithexperienceinpancreaticnecrosectomy[7,8].Incontrast,percutaneousdrainagewasaneffectivemodalityforthesmaller,lessaccessiblebutmorefluidpresacralcollectioninCase5.Retroperitonealnecrosiswasprogressiveandinmostcasesmultipleoperationswererequiredduetoongoingsymptoms.AnobliquerightflanktorightiliacfossaincisionwasperformedinCases1and5givinggoodac-cesstotheupperandlowerrightretroperitonealspaceandtothepresacralspace.Afeatureofthethreecasesinmaleswasinvolvementoftherightinguinoscrotaltract,withCases2and5requiringseparatedrainageofsymptomaticinguinoscrotalcollections.Nonehadpre-existinghernias.Onepatient(Case4)diedindirectlyasaresultoftheperforation,fromsepsisassociatedwithvascularaccess.Thispatienthadsignificantco-morbidities,beingsteroid-dependentforpulmonaryinterstitialfibrosisandrheuma-toidarthritis.Ofthefoursurvivors,onerecoveredquicklywithconservativemanagementalone,buttheotherthreeenduredlonghospitalstays,underwentmultiplesurgicalandotherprocedures,anddevelopedshort-termandlong-termcomplicationsasaresultoftheoriginalperfor-ationanditstreatment.DiscussionAllcasesinthisseriesweremanagedbyGeneralSurgeonsataregionalhospital,servingapopulationof250000andgeographicallyremotefromlargerfacilities.Theendo-scopicprocedureswereperformedbyaGastroenterologistandaGeneralSurgeon,bothofwhomwereformallytrainedandaccreditedintheseskills.AsupperendoscopyandnowERCParereadilyavailableinlargerregionalcentres,anawarenessofthisseriousbutfortunatelyrare Table1ComplicationsofERCPproceduresfor20056atCairnsBaseHospital(N=211)ComplicationN(%)Pancreatitis9(4.3%)Cholangitis7(3.3%)Bleeding4(1.9%)Perforation2(0.95%)Death3(1.4%)Other:Stroke1(0.5%)Total(withcomplications)22(12.3%)AdaptedfromCottonetal.1991[ Table2IndicationsforERCP200506,CairnsBaseHospital(N=202)IndicationN(%)CBDstone(s)115(57%)Cholangitis6(3%)Malignantjaundice29(14%)Stentchangeorunblocking33(16%)Abdominalpain,abnormalLFTs,dilatedduct5(2.5%)Chronicpancreatitis10(10%)AbnormalCT1(0.5%)Bileleak3(1.5%)etal.WorldJournalofEmergencySurgery:11Page2of7http://www.wjes.org/content/9/1/11 Table3Characteristicsofendoscopicallyinducedduodenalinjuries,CairnsBaseHospital,2002Case(year)1(2002)2(2004)3(2005)4(2006)5(2007)Age/Sex51male69male42female61female72maleIndicationforERCP/endoscopyPost-cholecystectomypainCholedocholithiasisPost-cholecystectomypancreatitisCholedocholithiasisPost-cholecystectomypainPost-proceduresymptoms,Severeabdominalpain,tachycardiaSevereabdominalpainMildabdominalpainAbdominalpainAbdominalpainTypeofperforationNotidentifiedNotidentified(Duodenaldiverticulum)Type2(seeResults)NotidentifiedType1(seeResults)(DuodenalDelaytoDiagnosis/Intervention48hoursthen5weeks5daysImmediatediagnosisImmediatediagnosis,surgerywithin24hoursImmediatediagnosis,surgeryat6hoursIndicationsforsurgerya)Duodenalperforationa)DuodenalperforationNila)Duodenalperforationa)Largedefectduodenum,a)atdiagnosisb)Infectedretroperitonealnecrosis/collectionsb)Extensiveretroperitonealnecrosis/collectionsPersistentduodenalleakb)Extensiveretroperitonealnecrosis/collectionsb)subsequentDuodenalstenosis,Necrosisofposteriorcaecalwallb)Extensiveretroperitonealnecrosisa)Laparotomy,repairduodenumManagementa)Laparotomya)LaparotomyConservativea)Laparotomy,retroperitonealwashout,pyloric,exclusion,gastrojejunostomy,jejunalfeedingtubeb)Opendrainage/evacuationrightretroperitonealspacex2a)ondiagnosisb)Attemptedpercutaneousdrainageb)7xdebridementofnecrosis(nosurgery)Drainagerightscrotumb)subsequent2xOpendrainageprocedurerightretroperitonealspaceOpendrainagerightinguinoscrotaltractRighthemicolectomy,endileostomyandmucousfistulaPyloricexclusion,gastrojejunostomyComplicationsoftreatmentDeepveinthrombosisGastroparesis,UTI,CVLinfection,woundinfection,leftbrachialplexopathyNilNecrotisingfasciitisrightthigh/abdomenRightinguinalhaematomaIncisionalherniaSeromaLengthofstay(days)991324663CasefatalityNoNoNoYesNoResidualdisabilityResidualpresacralcollectionandsinustorightiliacfossaRetainedCBDstonesremoved2007NilDiedNiletal.WorldJournalofEmergencySurgery:11Page3of7http://www.wjes.org/content/9/1/11 complicationanditsclinicalcourseisusefulforGeneral Surgeonsfacedwithitsmanagement.CertainlyCase5, undertakenwiththebenefitofspecificexperiencegained inthemanagementofCase1,doesseemtohavehada betterqualityoutcome,withshorterlengthofstay,fewer procedures,andfewercomplications. Whileduodenalperforationatendoscopyaloneisex- tremelyrare,therateduringERCPissignificantlyhigher, estimatedtobebetween0.4and1%[9].Therateof 0.95%intheauditedseriesfromCairnsBaseHospitalis withintheselimits(Table1).TheindicationsforERCP atourinstitutionareshowninTable2.Itshouldbe notedthattwopatientsintheserieshadtheuncommon indicationofpost-cholecystectomypain.Duringthetime periodofthisseries,nootherimagingmodalitiesforthe commonbileductwerereadilyavailable.Despitetheex- cellentstandardssetfortrainingandqualityassurance, ERCP,particularlywhenassociatedwithsphincterotomy, stillincursadefiniteriskofcomplication,anditsindi- cationsshouldbeprimarilyinterventional[10].The emergingavailabilityinregionalcentresoflessinvasive diagnosticmodalitiessuchasMRCPandendoscopic ultrasound(EUS)shouldreduceexposuretotheriskof duodenalperforationinthisgroup,[11,12]ashasindeed beenthecaseatourinstitutionsince2007.Wherethese arenotavailable,considerationshouldbegiventotrans- ferringpatientstocentreswheretheyare,particularly whenthereisnotherapeuticintentattheoutset. Fourtypesofduodenalperforationhavebeende- scribed – Type1:lateralduodenalwall,Type2:peri- Vaterianduodenum,Type3:bileduct,andType4:tiny retroperitonealperforationscausedbytheuseofcom- pressedairduringendoscopy.Mostperforationsare Type2,duetoconcomitantendoscopicsphincterotomy, andmaybesuitableforatrialofconservativemanage- ment[13-15].Inourseries,Case3wasdocumentedasa Type2perforation.Case5wasdocumentedasaType1 perforation,andCases1,2,4weremostlikelythis, basedontheensuingclinicalcourse.Type1perforations havethemostseriousconsequencesandtypicallyre- quirecomplexandinvasivetreatment.Theyaremostly causedbytheendoscopeitselfandmayresultincon- siderableintra-orextraperitonealspillageofduodenal fluid(amixtureofgastricjuice,bileandpancreatic juice),thelattercausingrapid,extensive,andongoing necrosisoftherightretroperitoneum.Thepatientbe- comesintenselycatabolicwithfevers,raisedinflamma- torymarkers,leucocytosis,andnutritionaldepletion. Withoutsurgicalinterventiondeathislikelyfromacom- binationofmassiveauto-digestion,nutritionaldepletion andsepsis.Delayindiagnosisincreasesthelikelihoodofa fataloutcome[16,17]. Variousmanagementalgorithmsforduodenalinjuries havebeenproposed,largelyfocusingonearlydiagnosis andthedecisionforsurgicalmanagement[18-21].Indi- cationsforsurgeryhavebeenwelldescribed.IfaType1 injuryisnotedatendoscopyoronsubsequentimaging (eg.extravasationofcontrast),immediateoperativeinter- ventionisgenerallymandated.Failureofconservative managementduetosignsofprogressivesystemicinflam- matoryresponsesyndrome(SIRS)isarelativeindication foroperation.Guidelinesforspecificoperativestrategies inthefaceofERCP-relatedduodenalinjuryandretro- peritonealnecrosishavebeenproposed,butareoften basedonevidencederivedfromindividualcasereports orcaseseries,orfromexperienceinthetraumasetting [22,23].Duetoitsuncommonnature,prospectivecom- parativestudiestodeterminetheoptimalprocedurefor Figure1 CTimageshowingextensiveretroperitonealnecrosis priortosurgicalintervention(Case2). Figure2 Necroticretroperitonealtissuedebridedviaright flankincision(Case1). Turner etal.WorldJournalofEmergencySurgery 2014, 9 :11Page4of7 http://www.wjes.org/content/9/1/11 Table4ReportsintheliteratureofType1and2duodenalinjuriescausedbyendoscopicproceduresCase/seriesN=Rangeofmanagementstrategiesfor:Averagedaysinhospitalfatality(%)DuodenalinjuryRetroperitonealnecrosisUnderlyingpathologyStapferetal.2000[]8Pyloricexclusionandgastro-jejunostomyDrainplacementCholecystectomy62.92(25%)TubeduodenostomyCBDexplorationDuodeno-antrectomyHepatico-jejunostomyPreethaetal.2003[]13PrimaryrepairNotdescribedCholecystectomy23.83(23.1%)Pyloricexclusionandgastro-jejunostomyCBDexplorationT-tubeHepatico-jejunostomyBoweldecompressionKalyanietal.2005[]1JejunalserosalpatchNotrequiredNilrequired�150(0%)Melitaetal.2005[]1NilrequiredCT-guidedabscessdrainageNilrequiredNotspecified0(0%)Wuetal.2006[]10PrimaryrepairDrainplacementCholecystectomy31.44(40%)OmentalpatchOpenabscessdrainageCBDexplorationDuodenostomyPercutaneousabscessdrainageCholecysto-jejunostomyFatimaetal.2007[]22PrimaryrepairDrainplacementCholedocho-jejunostomy163(13.6%)OmentalpatchKnudsonetal.2008[]12PrimaryrepairDrainplacementHepatico-jejunostomy4.50(0%)T-tubeOpenabscessdrainageOmentalpatchDuodenostomytubeJejunostomytubePyloricexclusionMaoetal.2008[]3NilrequiredDrainplacementCholecystectomy500(0%)CBDexplorationAngiòetal.2009[]1KocherizationandprimaryNotdescribedCBDexploration230(0%)Avgerinosetal.2009[]15PrimaryrepairNotdescribedCholedocho-duodenostomy423(20%)OmentalpatchPyloricexclusionGastro-enterostomyMorganetal.2009[]10PrimaryrepairgastrojejunostomyDrainplacementNotavailable1(10%)Dubeczetal.2012[]4PrimaryrepairNotdescribedHepatico-jejunostomy230(0%)Ercanetal.2012[]13PrimaryrepairPercutaneousabscessdrainageCholecystectomy10.26(46.2%)PyloricexclusionOpenabscessdrainageCBDexplorationGastro-enterostomyT-tubeCaliskanetal.2013[]9PrimaryrepairNotdescribedCBDexploration22.64(44.4%)DuodenostomyT-tubePyloricexclusion,gastro-jejunostomyPancreatico-duodenectomyetal.WorldJournalofEmergencySurgery:11Page5of7http://www.wjes.org/content/9/1/11 endoscopicallyinducedduodenalperforationhaveyettobepublished[24].PublishedcaseseriesandreportsregardingpossiblesurgicalmanagementoptionsforendoscopicallyinducedType1and2duodenalinjuriesaresummarizedinTable4[13,18,19,21,25-34].Ingeneral,operativeproceduresaretailoredtoconditionsencounteredatthetimeoflapa-rotomy,aswellastoanyunderlyingpathologythatpre-cededorwastheindicationfortheendoscopicprocedure.Primaryrepairofabreachintheduodenalwallmaybepossiblewheretheinjuryisdiagnosedearlyandthereislimitedcontaminationofsurroundingtissues.Kocheriza-tionisusuallyneededtofacilitatethis,alongwithde-bridementofanydevitalizedtissue.Additionaloperativevariationsworthyofconsiderationincluderepairinoneortwolayers,transverseorlongitudinalclosure,andaug-mentationwithajejunalserosal[35]oromentalpatch.Forpatientsdeemedtobeathighriskforleakorfistulaformation,anumberofadditionalprotectivemeasureshavebeenproposed[24,36].Tubedecompressioninvolvesplacementofatrans-muraltrans-parietalduodenostomyorjejunostomytube[37].Thereareconcernsthatthisengendersadditionaltraumatothegastrointestinaltractandmaynotprovideadequatedecompression.Duodenaldiverticulationisacomplexprocedurethatinvolvesduo-denalrepair,distalBillrothIIgastrectomy,placementofadecompressiveduodenostomytube,andperi-duodenaldrainage[38].Thisisobviouslytime-consumingandisofteninappropriateforhaemodynamicallyunstablepa-tients.Alessonerousprocedureispyloricexclusion,whichentailsprimaryduodenalrepair,pyloricsutureorstaplingviagreatercurvaturegastrotomy,andgastrojejunostomyusingthegastrotomyincision[39].Incertaincircum-stances,itmaybesuitabletoperformaduodenojejunost-omy,preferablywithRoux-en-Yreconstruction[40].Suchamaneuverwouldobviouslybepredicatedonastablepa-tientandaduodenumwallthatisamenabletosutures.ItisclearthattheGeneralSurgeonmusthaveavarietyoftechniquesinhis/herrepertoireinordertoadapttothesituationathand.Theotherimportantissuetocontendwithinduo-denalinjuriesisthemanagementofretroperitonealne-crosisorsepsis.Inmostcaseswherelaparotomyisperformed,somedegreeofdebridementandplacementofdrainsisundertaken.Thismaybeallthatcanbedoneifprimaryduodenalrepairisnotfeasible,ortheperfor-ationcannotbelocalizedamidthedevitalizedtissue.Asillustratedbyourowncaseseries,repeateddrainagepro-ceduresareoftennecessaryifsignsofrecurrentsepsisdevelop.Ashasbeennotedbyotherauthors,[41]malesarealsoatriskofdevelopingsepsisoftheinguinoscrotaltract.Percutaneousdrainageofanyrecurrentcollectionsmaybeattemptedusingradiologicalguidance,unlessthesemi-solidnatureofthedebrisnecessitatesanopenapproach.Thetechniqueofvideo-assistedretroperiton-ealdebridement,[42]asvalidatedforinfectednecrotiz-ingpancreatitis,maybeofuse,buttherehavebeennoreportsofitsapplicationinthiscontext.RetroperitonealnecrosisduetoduodenalperforationisararebutseriouscomplicationofERCP.Earlyrecogni-tionbasedonriskfactorsandclinicalsuspicionmayleadtoabetteroutcome,althoughaprotractedcoursewithmultipleandvarioustypesofproceduresshouldbean-ticipated.Urgentinterventionstypicallyinvolvedebride-mentanddrainage,duodenalrepairwherefeasible,andifindicated,duodenaldiversionorotherprotectivepro-cedures.Familiaritywithanumberofpossiblesurgicalstrategiesisdesirableduetotheneedtoadapttoindi-vidualcircumstances.Surgicalmanagementplansshouldalsotakeintoaccountanyunderlyingpathologythatwastheinitialindicationfortheendoscopicprocedure,al-thoughdefinitiveproceduresmaynotbefeasibleatfirstoperation.TheuseofERCPforpurelydiagnosticpur-posesshouldonlybeconsideredwherelessinvasiveim-agingmodalitiesarenotpossible.Commonbileduct;CVL:Centralvenousline;CT:Computerizedtomography;ERCP:Endoscopicretrogradecholangiopancreatography;EUS:Endoscopicultrasound;LFTs:Liverfunctiontests;MRCP:Magneticresonancecholangiopancreatography;SIRS:Systemicinflammatoryresponsesyndrome;UTI:Urinarytractinfection.CompetinginterestsTheauthorsdeclarethattheyhavenocompetinginterests.RTcontributedclinicalcasestotheseries,co-wrotethemanuscriptandattendedtoreviewercomments.CScontributedclinicalcasestotheseriesandco-wrotethemanuscript.PBprovidedthesummarydataofinstitutionalendoscopyoutcomesandeditedthefirstdraftofthemanuscript.Allauthorsreadandapprovedthefinalmanuscript.AuthordetailsDepartmentofSurgery,HobartClinicalSchool,UniversityofTasmania,Hobart,Australia.DepartmentofSurgery,CairnsBaseHospital,Cairns&HinterlandHealthServiceDistrict,Cairns,Australia.Received:30June2013Accepted:19January2014Published:24January20141.EnnsR,EloubeidiMA,MergenerK,JowellPS,BranchMS,PappasTM,BaillieERCP-relatedperforations:riskfactorsandmanagement.2.KayhanB,AkdoanM,SahinB:ERCPsubsequenttoretroperitonealperforationcausedbyendoscopicsphincterotomy.GastrointestEndosc3.CottonPBLG,VennesJ,GeenenJE,RussellRC,MeyersWC,LiguoryC,NicklEndoscopicsphincterotomycomplicationsandtheirmanagement:anattemptatconsensus.GastrointestEndosc4.ChristensenM,MatzenP,SchulzeS,RosenbergJ:ComplicationsofERCP:aprospectivestudy.GastrointestEndosc5.MillerRE,BossartPW,TiszenkelHI:Surgicalmanagementofcomplicationsofuppergastrointestinalendoscopyandesophagealdi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Submit your next manuscript to BioMed Central and take full advantage of: € Convenient online submission € Thorough peer review € No space constraints or color “gure charges € Immediate publication on acceptance € Inclusion in PubMed, CAS, Scopus and Google Scholar € Research which is freely available for redistribution Submit your manuscript at www.biomedcentral.com/submit Turner etal.WorldJournalofEmergencySurgery 2014, 9 :11Page7of7 http://www.wjes.org/content/9/1/11