ERCP Induced Perforation; A Revisit After Half a Century

Background: One of the most feared complications of endoscopic retrograde cholangiopancreatography (ERCP) is duodenal perforation. We aim to discuss the incidence and risk factors of ERCP induced perforation in light of pertinent literature and review therapeutic options of different perforation types. Methods In this case-control study, we reviewed the charts of all patients with ERCP-induced duodenal perforation between January 2016 and June 2020 and compared them to a control group without perforation. Data regarding patients’ demographics, comorbidities, indication for endoscopy, ERCP findings, presumed risk factors for complicated procedures, clinical presentation of perforation, radiologic findings, time to diagnosis and perforation type according to the Stapfer classification were collected. Treatment approach, additional interventions, length of hospital stay (LOS), morbidity and mortality were also documented. Results A total of 996 ERCP procedures were performed, 13 patients were diagnosed with ERCP-induced perforation (EIP). The most common indication for ERCP was obstructive jaundice. The most significant risk factor of duodenal perforation was failure or difficult cannulation (P = .003). 5 patients were treated surgically, the majority of them had type I perforation, whereas type IV was the most common in those treated conservatively. ICU admission rates and LOS in the ICU were higher among the surgical patients. The overall mortality rate was 15% with a slightly higher rate in the surgical group. Conclusion ERCP-induced duodenal perforation carries significant morbidity and mortality. Conservative management yields favorable outcomes in selected patients compared to the surgical approach.