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1.  Management of ERCP-related small bowel perforations: the pivotal role of physical investigation 
Canadian Journal of Surgery  2012;55(2):99-104.
Management of endoscopic retrograde cholangiopancreatography (ERCP)–associated duodenal perforation remains controversial. Some recommend surgery, while others recommend conservative treatment.
A retrospective chart review was conducted to identify patients treated at our institution for ERCP-related duodenal perforations. Study variables included indication for ERCP, clinical presentation, diagnostic procedures, time to diagnosis and treatment, location of injury, management, length of stay in hospital and survival.
Between January 2000 and October 2009, 12 232 ERCP procedures were performed at our centre, and perforation occured in 11 patients (0.08%; 5 men, 6 women, mean age 71 yr). Six of the perforations were discovered during ERCP; 5 required radiologic imaging for diagnosis. Three perforations were diagnosed incidentally by follow-up ERCP. In 1 patient, perforation occurred 3 years after the procedure owing to a dislocated stent. Four of 11 perforations were stent-related; in 2 patients ERCP was performed in a nonanatomic situation (Billroth II gastroenterostomy). Free peritoneal perforation occurred in 4 patients; 1 was successfully managed conservatively. Four patients (36%) were treated surgically and none died. Five patients were managed conservatively with a successful outcome, and 2 patients died after conservative treatment (18%). Operative treatment included hepaticojejunostomy and duodenostomy (1 patient), suture of the perforation with T-drain (1 patient) and suture only (2 patients). The mean length of stay in hospital for all patients was 20 days.
Post-ERCP duodenal perforations are associated with significant morbidity and mortality. Immediate surgical evaluation and close monitoring is needed. Management should be individually tailored based on clinical findings only.
PMCID: PMC3310764  PMID: 22564521
2.  Immediate detection of endoscopic retrograde cholangiopancreatography-related periampullary perforation: Fluoroscopy or endoscopy? 
World Journal of Gastroenterology : WJG  2014;20(42):15797-15804.
AIM: To investigate the causes and intraoperative detection of endoscopic retrograde cholangiopancreatography (ERCP)-related perforations to support immediate or early diagnosis.
METHODS: Consecutive patients who underwent ERCP procedures at our hospital between January 2008 and June 2013 were retrospectively enrolled in the study (n = 2674). All procedures had been carried out using digital fluoroscopic assistance with the patient under conscious sedation. For patients showing alterations in the gastrointestinal anatomy, a short-type double balloon enteroscope had been applied. Cases of perforation had been identified by the presence of air in or leakage of contrast medium into the retroperitoneal space, or upon endoscopic detection of an abdominal cavity related to the perforated lumen. For patients with ERCP-related perforations, the data on medical history, endoscopic findings, radiologic findings, diagnostic methods, management, and clinical outcomes were used for descriptive analysis.
RESULTS: Of the 2674 ERCP procedures performed during the 71-mo study period, only six (0.22%) resulted in perforations (male/female, 2/4; median age: 84 years; age range: 57-97 years). The cases included an endoscope-related duodenal perforation, two periampullary perforations related to endoscopic sphincterotomy, two periampullary perforations related to endoscopic papillary balloon dilation, and a periampullary or bile duct perforation secondary to endoscopic instrument trauma. No cases of guidewire-related perforation occurred. The video endoscope system employed in all procedures was only able to immediately detect the endoscope-related perforation; the other five perforation cases were all detected by subsequent digital fluoroscope applied intraoperatively (at a median post-ERCP intervention time of 15 min). Three out of the six total perforation cases, including the single case of endoscope-related duodenal injury, were surgically treated; the remaining three cases were treated with conservative management, including trans-arterial embolization to control the bleeding in one of the cases. All patients recovered without further incident.
CONCLUSION: ERCP-related perforations may be difficult to diagnose by video endoscope and digital fluoroscope detection of retroperitoneal free air or contrast medium leakage can facilitate diagnosis.
PMCID: PMC4229546  PMID: 25400465
Endoscopic retrograde cholangiopancreatography; Fluoroscopy; Duodenum; Perforation; Diagnosis
3.  Operative and non-operative management of endoscopic retrograde cholangiopancreatography-associated duodenal injuries 
Endoscopic retrograde cholangiopancreatography (ERCP) is indispensable in everyday surgical practice. Despite this, as an invasive procedure, it has its own mortality and morbidity, the most feared of which is periduodenal perforations. Our experience with ERCP related periduodenal perforations and its treatment strategies are presented. Additionally, a rarely encountered subtype is highlighted.
Patients who underwent ERCP and sustained a periduodenal perforation between August 2008 and October 2011 were reviewed.
During the period from August 2008 to October 2011, 597 ERCP procedures were performed in our hospital. Ten of these patients (3 male, 7 female) had a perforation. The mean patient age was 56.6 years. During the procedure, injury was suspected in four patients; it passed unnoticed in the remaining six. The decision to operate or follow a conservative policy was based on a combination of clinical and radiological findings. Operative intervention was required in three patients, with one mortality, while conservative treatment was followed in the remaining seven. A laparotomy was performed early in two patients whereas it was performed after an initial period of conservative treatment in one. The presence of periduodenal fluid collection, contrast extravasation or free intraperitoneal air were decisive factors for performing laparotomy.
ERCP-related periduodenal perforations include different categories. Certain types require operative repair while others should be treated conservatively. The choice of the management approach should be individualised, depending on the clinical picture and radiological findings. Although rare, these are potentially serious complications that may end fatally. Early recognition and appropriate intervention is the only way to avert a fatal outcome.
PMCID: PMC4132505  PMID: 23676815
Cholangiopancreatography; Endoscopic retrograde; Duodenum; Wound; Injury
4.  Complications Following Endoscopic Retrograde Cholangiopancreatography: Minimal Invasive Surgical Recommendations 
PLoS ONE  2014;9(11):e113073.
ERCP has a complication rate ranging between 4% and 16% such as post-ERCP pancreatitis, hemorrhage, cholangitis and perforation. Perforation rate was reported as 0.08% to 1% and mortality rate up to 1.5%. Besides, injury related death rate is 16% to 18%. In this study we aimed to present a retrospective review of our experience with post ERCP-related perforations, reveal the type of injuries and management recommendations with the minimally invasive approaches.
Medical records of 28 patients treated for ERCP-related perforations in Okmeydani Training and Research Hospital between March 2007 and March 2013 were reviewed retrospectively. Patient age, gender, comorbidities, ERCP indication, ERCP findings and details were analyzed. All previous and current clinical history, laboratory and radiological findings were used to assess the evaluation of perforations.
Between March 2007 and March 2013, 2972 ERCPs were performed, 28 (0.94%) of which resulted in ERCP-related perforations. 10 of them were men (35.8%) and 18 women (64.2%). Mean age was 53.36±14.12 years with a range of 28 to 78 years. 14 (50%) patients were managed conservatively, while 14 (50%) were managed surgically. In 6 patients, laparoscopic exploration was performed due to the failure of non-surgical management. In 6 of the patients that ERCP-related perforation was suspected during or within 2 hours after ERCP, underwent to surgery primarily. There were two mortalities. The mean length of hospitalization stay was 10.46±2.83 days. The overall mortality rate was 7.1%.
Successful management of ERCP-related perforation requires immediate diagnosis and early decision to decide whether to manage conservatively or surgically. Although traditionally conventional surgical approaches have been suggested for the treatment of perforations, laparoscopic techniques may be used in well-chosen cases especially in type II, III and IV perforations.
PMCID: PMC4245110  PMID: 25426633
5.  Management of endoscopic retrograde cholangiopancreatography-related perforations 
The purpose of this study is to analyze the treatment strategies of patients with endoscopic retrograde cholangiopancreatography (ERCP)-related perforations. This is a retrospective study.
We experienced 13 perforations associated with ERCP. We reviewed the medical recordsand classified ERCP-related perforations according to mechanism of injury in terms of perforating device. Injury by endoscopic tip or insertion tube was classified as type I, injury by cannulation catheter or sphincterotomy knife as type II, and injury by guidewire as type III.
Of four type I injuries, one case was managed by conservative management after primary closure with a hemoclip during ERCP. The other three patients underwent surgical treatments such as primary closure orpancreatico-duodenectomy. Of five type II injuries, two patients underwent conservative management and the other three cases were managed by surgical treatment such as duodenojejunostomy, duodenal diverticulization and pancreatico-duodenectomy. Of four type III injuries, three patients were managed conservatively and the remaining patient was managed by T-tube choledochostomy.
Type I injuries require immediate surgical management after EPCP or immediate endoscopic closure during ERCP whenever possible. Type II injuries require surgical or conservative treatment according to intra- and retro-peritoneal dirty fluid collection findings following radiologic evaluation. Type III injuries almost always improve after conservative treatment with endoscopic nasobilliary drainage.
PMCID: PMC3204541  PMID: 22066121
Endoscopic retrograde cholangiopancreatography; Perforation; Surgery
6.  Endoscopic retrograde cholangiopancreatography-related perforation: Management and prevention 
Endoscopic retrograde cholangiopancreatography (ERCP) is a procedure that can result in serious complications, and thus should be handled by a skilled endoscopist to minimize the risk of complications and to enhance the success rate. The incidence of ERCP-related complications is 5%-10%, most commonly involving post-ERCP pancreatitis and clinically significant post-endoscopic sphincterotomy bleeding. Although ERCP-related perforation has a relatively lower incidence of 0.14%-1.6%, this complication is associated with a high mortality rate of 4.2%-29.6%. A classification of perforation type based on the instrument that caused the perforation was recently described that we postulated could affect the implementation of perforation management. In the present article, an algorithm for management and prevention of ERCP-related perforations is proposed that is based on the perforation type and delay of diagnosis. Available evidence demonstrates that a delayed diagnosis and/or treatment of perforation results in a poorer prognosis, and thus should be at the forefront of procedural consideration. Furthermore, this review provides steps and recommendations from the pre-procedural stage through the post-procedural evaluation with consideration of contributing factors in order to minimize ERCP-related complication risk and improve patient outcome. To avoid perforation, endoscopists must evaluate the risks related to the individual patient and the procedure and perform the procedure gently. Once a perforation occurs, immediate diagnosis and early management are key factors to minimize mortality.
PMCID: PMC4198404  PMID: 25325062
Endoscopic retrograde cholangiopancreatography; Endoscopic retrograde cholangiopancreatography; Perforation; Prevention; Management; Classification
7.  Treatment results of gastrointestinal perforation after endoscopic retrograde cholangiopancreatography 
Przegla̜d Gastroenterologiczny  2013;8(5):299-304.
Duodenal perforation, damage to common bile duct or ampulla of Vater complicates from 0.7% to 10% of endoscopic retrograde cholangiopancreatography (ERCP) procedures. This complication is associated with high risk of contracting fatal diseases and death. As the endoscopic and minimally invasive treatment methods develop and gain popularity, it becomes increasingly important to determine the correct procedure in the event of gastrointestinal perforation after ERCP.
To present the results of treatment of gastrointestinal perforation after ERCP and indicate the correct procedure for such cases.
Material and methods
The material includes 19 patients who underwent ERCP in the years 2008–2011 and were subsequently diagnosed with duodenal perforation (except for duodenal bulb) and common bile duct (CBD). Women accounted for 68% of patients (13/19), while men constituted 32% (6/19). The mean age of patients was 66.6 years old. Indications for ERCP included cholelithiasis in 95% of cases and bile duct strictures in the remaining 5%. Treatment was conditional on the result of X-ray examination of the abdominal cavity, followed by computed tomography with aqueous contrast medium administered orally.
Four patients were diagnosed with intraperitoneal perforation and 15 patients with retroperitoneal perforation. In the patient group with retroperitoneal perforation the contrast media leakage (10 patients) required surgical intervention – the perforation site was located in 5 cases; in the other 5 the site could not be found. With the absence of active contrast media leakage in computed tomography (CT) (5 patients) conservative treatment was applied. Four patients with intraperitoneal perforation were referred for operative treatment. In patients under conservative treatment no complications were observed and the average hospitalization time was 9 days. Among patients with retroperitoneal perforation, who had undergone surgical treatment, complications occurred in 3 cases. The average hospitalization time in the group in which the perforation site was located was 16 days, while in the group with an unidentified perforation site it was 17 days. Patients with intraperitoneal perforation were given operative treatment, with the average hospitalization time of 12 days.
Each patient with suspected post-ERCP perforation should undergo CT of the abdominal cavity with aqueous contrast medium administered orally. In the event of no contrast leak in patients with retroperitoneal duodenal perforation, conservative treatment should be applied. In the case of retroperitoneal perforation with active contrast media leakage outside the gastrointestinal tract, and in the case of intraperitoneal perforation, an immediate surgical intervention is recommended.
PMCID: PMC4027826  PMID: 24868273
retrograde cholangiopancreatography; gastrointestinal perforation
8.  Non-operative management is superior to surgical stabilization in spine injury patients with complete neurological deficits: A perspective study from a developing world country, Pakistan 
Surgical stabilization of injured spine in patients with complete spinal cord injury is a common practice despite the lack of strong evidence supporting it. The aim of this study is to compare clinical outcomes and cost-effectiveness of surgical stabilization versus conservative management of spinal injury in patients with complete deficits, essentially from a developing country's point of view.
A detailed analysis of patients with traumatic spine injury and complete deficits admitted at the Aga Khan University Hospital, Pakistan, from January 2004 till January 2010 was carried out. All patients presenting within 14 days of injury were divided in two groups, those who underwent stabilization procedures and those who were managed non-operatively. The two groups were compared with the endpoints being time to rehabilitation, length of hospital stay, 30 day morbidity/mortality, cost of treatment, and status at follow up.
Fifty-four patients fulfilled the inclusion criteria and half of these were operated. On comparing endpoints, patients in the operative group took longer time to rehabilitation (P-value = 0.002); had longer hospital stay (P-value = 0.006) which included longer length of stay in special care unit (P-value = 0.002) as well as intensive care unit (P-value = 0.004); and were associated with more complications, especially those related to infections (P-value = 0.002). The mean cost of treatment was also significantly higher in the operative group (USD 6,500) as compared to non-operative group (USD 1490) (P-value < 0.001).
We recommend that patients with complete SCI should be managed non-operatively with a provision of surgery only if their rehabilitation is impeded due to pain or deformity.
PMCID: PMC3229809  PMID: 22145085
Complete neurological deficits; spinal cord injuries; surgical stabilization
9.  How do we manage post-OLT redundant bile duct? 
AIM: To address endoscopic outcomes of post-Orthotopic liver transplantation (OLT) patients diagnosed with a “redundant bile duct” (RBD).
METHODS: Medical records of patients who underwent OLT at the Liver Transplant Center, University Texas Health Science Center at San Antonio Texas were retrospectively analyzed. Patients with suspected biliary tract complications (BTC) underwent endoscopic retrograde cholangiopancreatography (ERCP). All ERCP were performed by experienced biliary endoscopist. RBD was defined as a looped, sigmoid-shaped bile duct on cholangiogram with associated cholestatic liver biomarkers. Patients with biliary T-tube placement, biliary anastomotic strictures, bile leaks, bile-duct stones-sludge and suspected sphincter of oddi dysfunction were excluded. Therapy included single or multiple biliary stents with or without sphincterotomy. The incidence of RBD, the number of ERCP corrective sessions, and the type of endoscopic interventions were recorded. Successful response to endoscopic therapy was defined as resolution of RBD with normalization of associated cholestasis. Laboratory data and pertinent radiographic imaging noted included the pre-ERCP period and a follow up period of 6-12 mo after the last ERCP intervention.
RESULTS: One thousand two hundred and eighty-two patient records who received OLT from 1992 through 2011 were reviewed. Two hundred and twenty-four patients underwent ERCP for suspected BTC. RBD was reported in each of the initial cholangiograms. Twenty-one out of 1282 (1.6%) were identified as having RBD. There were 12 men and 9 women, average age of 59.6 years. Primary indication for ERCP was cholestatic pattern of liver associated biomarkers. Nineteen out of 21 patients underwent endoscopic therapy and 2/21 required immediate surgical intervention. In the endoscopically managed group: 65 ERCP procedures were performed with an average of 3.4 per patient and 1.1 stent per session. Fifteen out of 19 (78.9%) patients were successfully managed with biliary stenting. All stents were plastic. Selection of stent size and length were based upon endoscopist preference. Stent size ranged from 7 to 11.5 Fr (average stent size 10 Fr); Stent length ranged from 6 to 15 cm (average length 9 cm). Concurrent biliary sphincterotomy was performed in 10/19 patients. Single ERCP session was sufficient in 6/15 (40.0%) patients, whereas 4/15 (26.7%) patients needed two ERCP sessions and 5/15 (33.3%) patients required more than two (average of 5.4 ERCP procedures). Single biliary stent was sufficient in 5 patients; the remaining patients required an average of 4.9 stents. Four out of 19 (21.1%) patients failed endotherapy (lack of resolution of RBD and recurrent cholestasis in the absence of biliary stent) and required either choledocojejunostomy (2/4) or percutaneous biliary drainage (2/4). Endoscopic complications included: 2/65 (3%) post-ERCP pancreatitis and 2/10 (20%) non-complicated post-sphincterotomy bleeding. No endoscopic related mortality was found. The medical records of the 15 successful endoscopically managed patients were reviewed for a period of one year after removal of all biliary stents. Eleven patients had continued resolution of cholestatic biomarkers (73%). One patient had recurrent hepatitis C, 2 patients suffered septic shock which was not associated with ERCP and 1 patient was transferred care to an outside provider and records were not available for our review.
CONCLUSION: Although surgical biliary reconstruction techniques have improved, RBD represents a post-OLT complication. This entity is rare however, endoscopic management of RBD represents a reasonable initial approach.
PMCID: PMC3646140  PMID: 23674851
Redundant bile duct; Orthotopic liver transplantation; Biliary complications; Biliary stent; Endoscopic retrograde cholangiopancreatography
10.  Early Management Experience of Perforation after ERCP 
Background and Aim. Perforation after endoscopic retrograde cholangiopancreatography (ERCP) is a rare complication, but it is associated with significant mortality. This study evaluated the early management experience of these perforations. Patients and Methods. Between November 2003 and December 2011, a total of 8504 ERCPs were performed at our regional endoscopy center. Sixteen perforations (0.45%) were identified and retrospectively reviewed. Results. Nine of these 16 patients with perforations were periampullary, 3 duodenal, 1 gastric fundus, and 3 patients had a perforation of an afferent limb of a Billroth II anastomosis. All patients with perforations were recognized during ERCP by X-ray and managed immediately. One patient with duodenal perforation and three patients with afferent limb perforation received surgery, others received medical conservative treatment which included suturing lesion, endoscopic nasobiliary drainage (ENBD), endoscopic retrograde pancreatic duct drainage (ERPD), gastrointestinal decompression, fasting, broad-spectrum antibiotics, and so on. All patients with perforation recovered successfully. Conclusions. We found that: (1) the diagnosis of perforation during ERCP may be easy, but you must pay attention to it. (2) Most retroperitoneal perforations can recover with only medical conservative treatment in early phase. (3) Most peritoneal perforations need surgery unless you can close the lesion up under endoscopy in early phase.
PMCID: PMC3412108  PMID: 22899906
11.  Successful Endoscopic Therapy of Traumatic Bile Leaks 
Traumatic bile leaks often result in high morbidity and prolonged hospital stay that requires multimodality management. Data on endoscopic management of traumatic bile leaks are scarce. Our study objective was to evaluate the efficacy of the endoscopic management of a traumatic bile leak. We performed a retrospective case review of patients who were referred for endoscopic retrograde cholangiopancreatography (ERCP) after traumatic bile duct injury secondary to blunt (motor vehicle accident) or penetrating (gunshot) trauma for management of bile leaks at our tertiary academic referral center. Fourteen patients underwent ERCP for the management of a traumatic bile leak over a 5-year period. The etiology included blunt trauma from motor vehicle accident in 8 patients, motorcycle accident in 3 patients and penetrating injury from a gunshot wound in 3 patients. Liver injuries were grade III in 1 patient, grade IV in 10 patients, and grade V in 3 patients. All patients were treated by biliary stent placement, and the outcome was successful in 14 of 14 cases (100%). The mean duration of follow-up was 85.6 days (range 54–175 days). There were no ERCP-related complications. In our case review, endoscopic management with endobiliary stent placement was found to be successful and resulted in resolution of the bile leak in all 14 patients. Based on our study results, ERCP should be considered as first-line therapy in the management of traumatic bile leaks.
PMCID: PMC3604865  PMID: 23525187
Bile leak; Trauma; Endoscopy; Bile injury; Hepatic injury; Endoscopic retrograde cholangiopancreatography; ERCP
12.  ERCP-related perforations in the new millennium: A large tertiary referral center 10-year experience 
Endoscopic retrograde cholangiopancreatography (ERCP) is an important diagnostic and therapeutic modality for pancreatic and biliary disorders. Perforation is one of the most dreaded complications of ERCP. Since it is uncommon, there has been little study of incidence, risk factors, and outcomes of management.
We aim to assess the incidence of ERCP-related perforations and outcomes at a large tertiary referral center.
We undertook a review of an ERCP database for all perforations from 2002 to December 2012.
The cumulative incidence of ERCP-related perforations was 0.14% (12 out of 8264), and sphincterotomy-related perforations constituted the most common cause. The mean age of these 12 patients was 58.6 years and majority were female (83.3%). The most common indications for ERCP were: suspected sphincter of Oddi dysfunction (SOD) 41%, and common bile duct stones (CBD stones) 41%. Nine of the 12 patients (75%) had a leak and were managed medically, and four who had a perforation had surgical repair (25%).
In our study, leaks were much more common than perforations and the majority of patients were successfully managed with conservative therapy alone. We report a very low perforation rate and most perforations can be managed conservatively with a good outcome.
PMCID: PMC4315685  PMID: 25653856
ERCP perforation; ERCP complication; ERCP perforation management; ERCP leak
13.  Primary endoscopic approximation suture under cap-assisted endoscopy of an ERCP-induced duodenal perforation 
Duodenal perforation during endoscopic retrograde cholangiopancreatography (ERCP) is a rare complication, but it has a relatively high mortality risk. Early diagnosis and prompt management are key factors for the successful treatment of ERCP-related perforation. The management of perforation can initially be conservative in cases resulting from sphincterotomy or guide wire trauma. However, the current standard treatment for duodenal free wall perforation is surgical repair. Recently, several case reports of endoscopic closure techniques using endoclips, endoloops, or fully covered metal stents have been described. We describe four cases of iatrogenic duodenal bulb or lateral wall perforation caused by the scope tip that occurred during ERCP in tertiary referral centers. All the cases were simply managed by endoclips under transparent cap-assisted endoscopy. Based on the available evidence and our experience, endoscopic closure was a safe and feasible method even for duodenoscope-induced perforations. Our results suggest that endoscopists may be more willing to use this treatment.
PMCID: PMC2868227  PMID: 20458771
Duodenal perforation; Endoscopic retrograde cholangiopancreatography; Endoscopic therapy; Endoclip
14.  Unusual Complications Related to Endoscopic Retrograde Cholangiopancreatography and Its Endoscopic Treatment 
Clinical Endoscopy  2013;46(3):251-259.
Endoscopic retrograde cholangiopancreatography (ERCP)-induced complications, once occurred, can lead to significant morbidity. Commonly 5% to 10% of patients experience procedure related complications such as post-ERCP pancreatitis, biliary hemorrhage, and cholangitis, in descending order. However, complications such as perforation, pneumothorax, air embolism, splenic injury, and basket impaction are rare but are associated with high mortality if occurred. Such unexpected unusual complications might extend the length of hospitalization, require urgent surgical intervention, and put the patient in miserable condition leading to permanent disability or mortality. Although these ERCP-induced complications can be minimized by a skilled operator using advanced techniques and devices, the occurrence of unusual complications are hard to expect and induce very difficult management condition. In this review, we will focus on the uncommon complications related to ERCP. This review is also aimed at suggesting optimal endoscopic treatment strategies for several complications based on our institutional experiences.
PMCID: PMC3678063  PMID: 23767036
Cholangiopancreatography, endoscopic retrograde; Complication; Endoscopy
15.  Analysis of colonoscopic perforations at a local clinic and a tertiary hospital 
AIM: To define the clinical characteristics, and to assess the management of colonoscopic complications at a local clinic.
METHODS: A retrospective review of the medical records was performed for the patients with iatrogenic colon perforations after endoscopy at a local clinic between April 2006 and December 2010. Data obtained from a tertiary hospital in the same region were also analyzed. The underlying conditions, clinical presentations, perforation locations, treatment types (operative or conservative) and outcome data for patients at the local clinic and the tertiary hospital were compared.
RESULTS: A total of 10  826 colonoscopies, and 2625 therapeutic procedures were performed at a local clinic and 32  148 colonoscopies, and 7787 therapeutic procedures were performed at the tertiary hospital. The clinic had no perforations during diagnostic colonoscopy and 8 (0.3%) perforations were determined to be related to therapeutic procedures. The perforation rates in each therapeutic procedure were 0.06% (1/1609) in polypectomy, 0.2% (2/885) in endoscopic mucosal resection (EMR), and 3.8% (5/131) in endoscopic submucosal dissection (ESD). Perforation rates for ESD were significantly higher than those for polypectomy or EMR (P < 0.01). All of these patients were treated conservatively. On the other hand, three (0.01%) perforation cases were observed among the 24  361 diagnostic procedures performed, and these cases were treated with surgery in a tertiary hospital. Six perforations occurred with therapeutic endoscopy (perforation rate, 0.08%; 1 per 1298 procedures). Perforation rates for specific procedure types were 0.02% (1 per 5500) for polypectomy, 0.17% (1 per 561) for EMR, 2.3% (1 per 43) for ESD in the tertiary hospital. There were no differences in the perforation rates for each therapeutic procedure between the clinic and the tertiary hospital. The incidence of iatrogenic perforation requiring surgical treatment was quite low in both the clinic and the tertiary hospital. No procedure-related mortalities occurred. Performing closure with endoscopic clipping reduced the C-reactive protein (CRP) titers. The mean maximum CRP titer was 2.9 ± 1.6 mg/dL with clipping and 9.7 ± 6.2 mg/dL without clipping, respectively (P < 0.05). An operation is indicated in the presence of a large perforation, and in the setting of generalized peritonitis or ongoing sepsis. Although we did not experience such case in the clinic, patients with large perforations should be immediately transferred to a tertiary hospital. Good relationships between local clinics and nearby tertiary hospitals should therefore be maintained.
CONCLUSION: It was therefore found to be possible to perform endoscopic treatment at a local clinic when sufficient back up was available at a nearby tertiary hospital.
PMCID: PMC3447272  PMID: 23002362
Colonoscopy; Colon perforation; Endoscopic clipping; Endoscopic submucosal dissection; Endoscopic mucosal resection; Polypectomy
16.  Closure of a persistent sphincterotomy-related duodenal perforation by placement of a covered self-expandable metallic biliary stent 
Retroperitoneal duodenal perforation as a result of endoscopic biliary sphincterotomy is a rare complication, but it is associated with a relatively high mortality risk, if left untreated. Recently, several endoscopic techniques have been described to close a variety of perforations. In this case report, we describe the closure of a persistent sphincterotomy-related duodenal perforation by using a covered self-expandable metallic biliary (CEMB) stent. A 61-year-old Greek woman underwent an endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy for suspected choledocholithiasis, and a retroperitoneal duodenal perforation (sphincterotomy-related) occurred. Despite initial conservative management, the patient underwent a laparotomy and drainage of the retroperitoneal space. After that, a high volume duodenal fistula developed. Six weeks after the initial ERCP, the patient underwent a repeat endoscopy and placement of a CEMB stent with an indwelling nasobiliary drain. The fistula healed completely and the stent was removed two weeks later. We suggest the transient use of CEMB stents for the closure of sphincterotomy-related duodenal perforations. They can be placed either during the initial ERCP or even later if there is radiographic or clinical evidence that the leakage persists.
PMCID: PMC3218146  PMID: 22110286
Endoscopic sphincterotomy; Complications; Retroperitoneal perforation; Duodenal perforation; Metallic stent
17.  Endoscopic Treatments of Endoscopic Retrograde Cholangiopancreatography-Related Duodenal Perforations 
Clinical Endoscopy  2013;46(5):522-528.
Iatrogenic duodenal perforation associated with endoscopic retrograde cholangiopancreatography (ERCP) is a very uncommon complication that is often lethal. Perforations during ERCP are caused by endoscopic sphincterotomy, placement of biliary or duodenal stents, guidewire-related causes, and endoscopy itself. In particular, perforation of the medial or lateral duodenal wall usually requires prompt diagnosis and surgical management. Perforation can follow various clinical courses, and management depends on the cause of the perforation. Cases resulting from sphincterotomy or guidewire-induced perforation can be managed by conservative treatment and biliary diversion. The current standard treatment for perforation of the duodenal free wall is early surgical repair. However, several reports of primary endoscopic closure techniques using endoclip, endoloop, or newly developed endoscopic devices have recently been described, even for use in direct perforation of the duodenal wall.
PMCID: PMC3797938  PMID: 24143315
Cholangiopancreatography, endoscopic retrograde; Perforation; Duodenum; Therapeutics
18.  Clinical outcomes and risk factors for perforation in gastric endoscopic submucosal dissection: A prospective pilot study 
AIM: To evaluate clinical outcomes and risk factors for endoscopic perforation during endoscopic submucosal dissection (ESD) in a prospective study.
METHODS: We investigated the clinical outcomes and risk factors for the development of perforation in 98 consecutive gastric neoplasms undergoing ESD regarding. Demographic and clinical parameters including patient-, tumor-, and treatment-related factors, clinical parameters, and duration of hospital stay were analyzed for risk factors for perforation. In subgroup analysis, we also compared the clinical outcomes between perforation and “silent” free air without endoscopically visible perforation detected only by computed tomography.
RESULTS: Perforation was identified in 8.2% of patients. All patients were managed conservatively by the administration of antibiotics. The mean procedure time was significantly longer in patients with endoscopic perforation than in those without. According to the receiver-operating characteristic analysis, the resulting cutoff value of the procedure time for perforation was 115 min (87.5% sensitivity, 56.7% specificity). Prolonged procedure time (≥ 115 min) was associated with an increased risk of perforation (odds ratio 9.15; 95%CI: 1.08-77.54; P = 0.04). Following ESD, body temperature and C-reactive protein level were significantly higher in patients with perforation than in those without (P = 0.02), whereas there was no difference between these patient groups on the starting day of oral intake or of hospitalization. In subgroup analysis, the post-ESD clinical course was not different between endoscopic perforation and silent free air.
CONCLUSION: Only prolonged procedure time (≥ 115 min) was significantly associated with perforation. The clinical outcomes of perforation are favorable and are comparable to those of patients with or without silent free air.
PMCID: PMC3680617  PMID: 23772265
Gastric cancer; Endoscopic submucosal dissection; Perforation; Risk factors; Treatment outcome
19.  Risk of transmission of carbapenem-resistant Enterobacteriaceae and related “superbugs” during gastrointestinal endoscopy 
To evaluate the risk of transmission of carbapenem-resistant Enterobacteriaceae (CRE) and their related superbugs during gastrointestinal (GI) endoscopy. Reports of outbreaks linked to GI endoscopes contaminated with different types of infectious agents, including CRE and their related superbugs, were reviewed. Published during the past 30 years, both prior to and since CRE’s emergence, these reports were obtained by searching the peer-reviewed medical literature (via the United States National Library of Medicine’s “MEDLINE” database); the Food and Drug Administration’s Manufacturer and User Facility Device Experience database, or “MAUDE”; and the Internet (via Google’s search engine). This review focused on an outbreak of CRE in 2013 following the GI endoscopic procedure known as endoscopic retrograde cholangiopancreatography, or ERCP, performed at “Hospital X” located in the suburbs of Chicago (IL; United States). Part of the largest outbreak of CRE in United States history, the infection and colonization of 10 and 28 of this hospital’s patients, respectively, received considerable media attention and was also investigated by the Centers for Disease Control and Prevention (CDC), which published a report about this outbreak in Morbidity and Mortality Weekly Report (MMWR), in 2014. This report, along with the results of an independent inspection of Hospital X’s infection control practices following this CRE outbreak, were also reviewed. While this article focuses primarily on the prevention of transmissions of CRE and their related superbugs in the GI endoscopic setting, some of its discussion and recommendations may also apply to other healthcare settings, to other types of flexible endoscopes, and to other types of transmissible infectious agents. This review found that GI endoscopy is an important risk factor for the transmission of CRE and their related superbugs, having been recently associated with patient morbidity and mortality following ERCP. The CDC reported in MMWR that the type of GI endoscope, known as an ERCP endoscope, that Hospital X used to perform ERCP in 2013 on the 38 patients who became infected or colonized with CRE might be particularly challenging to clean and disinfect, because of the complexity of its physical design. If performed in strict accordance with the endoscope manufacturer’s labeling, supplemented as needed with professional organizations’ published guidelines, however, current practices for reprocessing GI endoscopes, which include high-level disinfection, are reportedly adequate for the prevention of transmission of CRE and their related superbugs. Several recommendations are provided to prevent CRE transmissions in the healthcare setting. CRE transmissions are not limited to contaminated GI endoscopes and also have been linked to other reusable flexible endoscopic instrumentation, including bronchoscopes and cystoscopes. In conclusion, contaminated GI endoscopes, particularly those used during ERCP, have been causally linked to outbreaks of CRE and their related superbugs, with associated patient morbidity and mortality. Thorough reprocessing of these complex reusable instruments is necessary to prevent disease transmission and ensure patient safety during GI endoscopy. Enhanced training and monitoring of reprocessing staffers to verify the proper cleaning and brushing of GI endoscopes, especially the area around, behind and near the forceps elevator located at the distal end of the ERCP endoscope, are recommended. If the ERCP endoscope features a narrow and exposed channel that houses a wire connecting the GI endoscope’s control head to this forceps elevator, then this channel’s complete reprocessing, including its flushing with a detergent using a procedure validated for effectiveness, is also emphasized.
PMCID: PMC4198391  PMID: 25324917
Endoscopy; Gastrointestinal; Carbapenem-resistant Enterobacteriaceae; Cross infection; Disease outbreaks; Healthcare-associated infections; Risk assessment; Disinfection; Sterilization; Anti-bacterial agents; Bacterial infections; Carbapenems; Beta-lactams
20.  ERCP's Role in the Management of Acute Biliary-pancreatic Pathology in the Laparoscopic Era 
Laparoscopic cholecystectomy (LC) combined with endoscopic retrograde cholangiopancreatography (ERCP) has been widely used in the management of the acute biliopancreatic pathology. Nevertheless, controversy remains about the appropriate timing for retrograde cholangiopancreatography.
A retrospective study was undertaken on a consecutive series of 117 patients with acute biliary-pancreatic pathology, who underwent laparoscopic cholecystectomy between April 1995 and April 1999. Criteria for preoperative endoscopic retrograde cholangiopancreatography were defined, and the patients were divided into 3 groups based on the presence or absence of a preoperative retrograde cholangiopancreatography indication: (1) ERCP+LC group: patients with retrograde cholangiopancreatography indicated and performed (n = 30); (2) LC group: patients without retrograde cholangiopancreatography criteria treated only by LC (n = 47); (3) LC-ERCP group: patients with retrograde cholangiopancreatography criteria but not performed (n = 40).
The groups were similar in age, sex, ASA, and clinical diagnosis. No statistical differences occurred in operative times (73.8 min, 68 min, 67 min), major complications (3.3%, 4.25%, 12.5%), and mean postoperative stay (3.7 ± 4; 4.7 ± 2; 5.7 ± 2). Postoperative retrograde cholangiopancreatography had to be used, respectively, in 0%, 10.6%, and 7.5%. The best predictive criteria for common bile duct pathology were choledocholithiasis on an ultrasound scan and the presence of cholangitis. The other criteria tested had a low predictive value.
Preoperative endoscopic retrograde cholangiopancreatography followed by early laparoscopic chole-cystectomy can be performed safely in acute biliary-pancreatic pathology, avoiding 2-stage treatment of these patients and minimizing hospital stay and inconvenience to the patients. Nevertheless, this therapeutic/diagnostic tool must be used selectively.
PMCID: PMC3043444  PMID: 12500836
Acute cholecystectomy; Laparoscopic cholecystectomy; Retrograde cholangiopancreatography; Cholecystitis; Choledocholithiasis; Laparoscopic cholecystectomy
21.  A Case of Ampullary Perforation Treated with a Temporally Covered Metal Stent 
Clinical Endoscopy  2012;45(2):177-180.
Endoscopic retrograde cholangiopancreatography (ERCP)-related perforation is classified into three or four types based on anatomical location and the mechanism of injury. Although ampullary injury, among them, may be managed nonsurgically, surgical management is required in cases of perforation with retroperitoneal fluid collection and severe condition. Here, a patient with ERCP-related severe ampullary perforation with retroperitoneal fluid collection that was treated nonsurgically with a covered stent is presented.
PMCID: PMC3401625  PMID: 22866262
Perforation; Endoscopic retrograde cholangiopancreatography; Stents
22.  Endoscopic treatment of duodenal fistula after incomplete closure of ERCP-related duodenal perforation 
Endoscopic retrograde cholangiopancreatography (ERCP) is an important diagnostic and therapeutic modality for various pancreatic and biliary diseases. The most common ERCP-induced complication is pancreatitis, whereas hemorrhage, cholangitis, and perforation occur less frequently. Early recognition and prompt treatment of these complications may minimize the morbidity and mortality. One of the most serious complications is perforation. Although the incidence of duodenal perforation after ERCP has decreased to < 1.0%, severe cases still require prolonged hospitalization and urgent surgical intervention, potentially leading to permanent disability or mortality. Surgery remains the mainstay treatment for perforations of the luminal organs of the gastrointestinal tract. However, evidence from case reports and case series support a beneficial role of endoscopic clipping in the closure of these defects. Duodenal fistulas are usually a result of sphincterotomies, perforated duodenal ulcers, or gastrectomy. Other causative factors include Crohn’s disease, trauma, pancreatitis, and cancer. The majority of duodenal fistulas heal with nonoperative management. Those that fail to heal are best treated with gastrojejunostomy. Recently proposed endoscopic approaches for managing gastrointestinal leaks caused by fistulas include fibrin glue injection and positioning of endoclips. Our patient developed a secondary persistent duodenal fistula as a result of previous incomplete closure of duodenal perforation with hemoclips and an endoloop. The fistula was successfully repaired by additional clipping and fibrin glue injection.
PMCID: PMC4055996  PMID: 24932379
Perforation; Duodenal; Endoscopic retrograde cholangiopancreatography; Fistula; Glue
23.  Safety and Utility of Single-Session Endoscopic Ultrasonography and Endoscopic Retrograde Cholangiopancreatography for the Evaluation of Pancreatobiliary Diseases 
Gut and Liver  2014;8(3):329-332.
Endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) are essential for diagnosing and treating pancreatobiliary diseases. Single-session EUS and ERCP are considered to be essential in reducing the duration of hospital stays; however, complications are a primary concern. The aim of this study was to evaluate the safety and efficacy of single-session EUS and ERCP. Sixty-eight patients underwent single-session EUS and ERCP at a tertiary referral center between June 2008 and December 2012. We retrospectively reviewed patient data from a prospectively maintained EUS-ERCP database and evaluated the procedural characteristics and complications. Thirty-eight patients (56%) underwent diagnostic EUS, and 30 patients (44%) underwent EUS fine-needle aspiration, which had an overall accuracy of 100%. Sixty patients (89%) underwent therapeutic ERCP, whereas the remaining eight procedures were diagnostic. Thirteen patients underwent biliary stone extraction, and 48 underwent biliary drainage. The median total procedural time was 75 minutes. Complications were observed in seven patients (10%). Six complications were post-ERCP pancreatitis, which were resolved using conservative management. One patient developed Mallory-Weiss syndrome, which required endoscopic hemostasis. No sedation-related cardiopulmonary complications were observed. Single-session EUS and ERCP provided accurate diagnosis and effective management with a minimal complication rate.
PMCID: PMC4026653  PMID: 24827632
Endoscopic retrograde cholangiopancreatography; Endoscopic ultrasound; Single-session procedure
24.  Epidemiology of workplace-related fall from height and cost of trauma care in Qatar 
This study was designed to identify the incidence, injury patterns, and actual medical costs of occupational-related falls in Qatar, in order to provide a reference for establishing fall prevention guidelines and recommendations.
Settings and Design:
Retrospective database registry review in Level 1 Trauma Center at Tertiary Hospital in Qatar.
Materials and Methods:
During a 12-month period between November 1st 2007 and October 31st 2008, construction workers who fell from height were enrolled. A database was designed to characterize demographics, injury severity score (ISS), total hospital length of stay, resource utilization, and cost of care.
Statistical Analysis:
Data were presented as proportions, mean ± standard deviation or median and range as appropriate. In addition, case fatality rate and cost analysis were obtained from the Biostatistics and finance departments of the same hospital.
There were 315 fall-related injuries, of which 298 were workplace related. The majority (97%) were male immigrants with mean age of 33 ± 11 years. The most common injuries were to the spine, head, and chest. Mean ISS was 16.4 ± 10. There was total of 29 deaths (17 pre-hospital and 12 in-hospital deaths) for a case fatality rate of 8.6%. Mean cost of care (rounded figures) included pre-hospital services Emergency Medical Services (EMS), trauma resuscitation room, radiology and imaging, operating room, intensive care unit care, hospital ward care, rehabilitation services, and total cost (123, 82, 105, 130, 496, 3048,434, and 4418 thousand United States Dollars (USD), respectively). Mean cost of care per admitted patient was approximately 16,000 USD.
Falling from height at a construction site is a common cause of trauma that poses a significant financial burden on the health care system. Injury prevention efforts are warranted along with strict regulation and enforcement of occupational laws.
PMCID: PMC3665115  PMID: 23724377
Cost of care; falls from height; Qatar; workplace
25.  Two-stage vs single-stage management for concomitant gallstones and common bile duct stones 
AIM: To evaluate the safety and effectiveness of two-stage vs single-stage management for concomitant gallstones and common bile duct stones.
METHODS: Four databases, including PubMed, Embase, the Cochrane Central Register of Controlled Trials and the Science Citation Index up to September 2011, were searched to identify all randomized controlled trials (RCTs). Data were extracted from the studies by two independent reviewers. The primary outcomes were stone clearance from the common bile duct, postoperative morbidity and mortality. The secondary outcomes were conversion to other procedures, number of procedures per patient, length of hospital stay, total operative time, hospitalization charges, patient acceptance and quality of life scores.
RESULTS: Seven eligible RCTs [five trials (n = 621) comparing preoperative endoscopic retrograde cholangiopancreatography (ERCP)/endoscopic sphincterotomy (EST) + laparoscopic cholecystectomy (LC) with LC + laparoscopic common bile duct exploration (LCBDE); two trials (n = 166) comparing postoperative ERCP/EST + LC with LC + LCBDE], composed of 787 patients in total, were included in the final analysis. The meta-analysis detected no statistically significant difference between the two groups in stone clearance from the common bile duct [risk ratios (RR) = -0.10, 95% confidence intervals (CI): -0.24 to 0.04, P = 0.17], postoperative morbidity (RR = 0.79, 95% CI: 0.58 to 1.10, P = 0.16), mortality (RR = 2.19, 95% CI: 0.33 to 14.67, P = 0.42), conversion to other procedures (RR = 1.21, 95% CI: 0.54 to 2.70, P = 0.39), length of hospital stay (MD = 0.99, 95% CI: -1.59 to 3.57, P = 0.45), total operative time (MD = 12.14, 95% CI: -1.83 to 26.10, P = 0.09). Two-stage (LC + ERCP/EST) management clearly required more procedures per patient than single-stage (LC + LCBDE) management.
CONCLUSION: Single-stage management is equivalent to two-stage management but requires fewer procedures. However, patient’s condition, operator’s expertise and local resources should be taken into account in making treatment decisions.
PMCID: PMC3386330  PMID: 22791952
Laparoscopic cholecystectomy; Laparoscopic common bile duct exploration; Endoscopic retrograde cholangiopancreatography; Endoscopic sphincterotomy; Gallstones; Common bile duct stones; Meta-analysis

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