Management of Post Endoscopic Retrograde Cholangio-Pancreatography (ERCP) Duodenal Perforation, Experience of a University Hospital

Management of Post Endoscopic Retrograde Cholangio-Pancreatography (ERCP) Duodenal Perforation, Experience of a University Hospital

Hossam S. Abdelrahim, MD, MRCS; Mohammed Abdalmegeed Hamed, MD, MRCS; Ahmed F. Amer, MD

Department of General Surgery, Faculty of Medicine, Ain Shams University, Egypt

Background: Duodenal perforation is an uncommon complication of endoscopic retrograde cholangio- pancreatography (ERCP). Most cases are minor perforations that can be managed with conservative management. A few cases may result in life-threatening retroperitoneal collection and necrosis requiring surgical intervention. There is a relative paucity of references specifically describing the surgical interventions required for this eventuality.

Methods: Ten cases of post-ERCP duodenal perforation were referred to our department at Ain Shams university Hospital between 2015 and 2019. Clinical features of our cases were analyzed, and the management plan was tailored to each case after discussion in multidisciplinary team (MDT) and review of the latest available literatures.

Results: Seven patients recovered with conservative management. Three patients needed surgical intervention. All patients were successfully discharged home. There were no mortalities.

Conclusions: Post-ERCP duodenal perforation is an uncommon complication of endoscopy, but when it does occur, it is potentially life-threatening. Early diagnosis may lead to a better outcome through early intervention. Most cases need only conservative treatment. A variety of surgical techniques may need to be employed according to the individual circumstances of the case.

Key words: Duodenum, perforation, ERCP, pancreatic necrosis, retroperitoneal collection.

Background

Endoscopic retrograde cholangiopancreatography (ERCP) is an important diagnostic and therapeutic modality in the management of obstructive jaundice (OJ) cases. One of the uncommon complications of ERCP is duodenal (DU) perforation which ranges from 0.4% to 1%. It carries a mortality rate of 16% to 18%.1,2

Surgical   intervention   has   been   the   standard practice in managing both traumatic and atraumatic duodenal   perforations;   however,   in   the   past decade, management of limited and contained duodenal perforations (especially post-ERCP) has shifted toward a more conservative approach. Arguments have been made for both surgical and nonsurgical management of ERCP-related duodenal perforations, but consensus is lacking.3

In this study, we present our hospital experience in the management of post-ERCP DU perforation, trying to suggest a management strategy based on clinical and radiological features, anatomical details of the perforation, and treatment outcomes.

Methods

Our study is a case series discussing our experience in the management of post-ERCP duodenal perforation. This study includes 10 patients with post-ERCP DU perforation referred to our surgical unit at Ain Shams University hospitals -a tertiary referral center in Egypt- between 2015 and 2019.

History   taking,   general   assessment   including vital data and local abdominal examination were routinely done on admission. All cases underwent full blood tests along with abdominal x-ray erect and supine position and a pelvi-abdominal computerized topography (C.T.) scan with contrast. Duodenal perforation was confirmed by presence of air under diaphragm or dye extravasation from DU with or without retroperitoneal collection.

As regard the management, two cases underwent immediate surgical intervention, one of them was explored after failure of ERCP to extract a large stone causing OJ with cholangitis, while the other case had major dye extravasation in peritoneal cavity. The other 8 cases underwent conservative treatment

in the form of nil per os (N.P.O.), intravenous (IV) fluids, intravenous antibiotics, monitoring vital data, frequent abdominal examination, serial blood tests and a follow up C.T. which didn’t show further changes (collection or major dye leak) except for one case, which developed a retroperitoneal collection and underwent an ultrasound guided pigtail catheter drainage with no clinical improvement. A follow up CT, 48 hours later, showed a regressive course with a decrease in the collection size; however, the stent was found to be piercing the junction between the 2nd  and 3rd  parts of the duodenum, hence surgery was warranted. Another patient (from the group  managed  conservatively)  presented  with an agonizing abdominal pain (not responding to analgesics) due to severe distension; subsequently, a percutaneous decompression with a wide bore cannula, inserted subcostally at left midclavicular line, managed to decompress air and ease the pain.

Description   of   surgical   management   in

operated cases:

All our three operated cases were explored via a midline laparotomy. Initially, kocherization of the duodenum was performed; this was primarily to assess and identify the type, site and size of the perforation and to allow for better drainage of collection and debridement of necrotic tissue. Subsequently, a cholecystectomy with an intraoperative cholangiogram was done to rule out bile duct pathologies as impacted stone or stricture.

As regard the case (1), after failure of the conservative treatment, a midline laparotomy was done revealing a large perforation at the posterior wall of DU between the 2nd and 3rd part of Du

> 50% of circumference (with migrated piercing stent) along with a retroperitoneal collection. We did drainage of collection, resected the 3rd and 4th part of duodenum, then mobilization of duodenojejunal (D.J) flexure with proximal jejunal loop was done, then we passed it through D.J flexure aperture in the transverse mesocolon and we performed a hand sewn, double layered duodenojejunostomy using a continuous 3/0 polydioxanone (PDS) suture and patient passed well.

In case (2), cholecystectomy was done with CBD exploration and extraction of 2 large stones. Then kocherization of duodenum was done revealing retroperitoneal air with minor collection, and a leakage from the medial wall of duodenum upon injection of dye through the CBD, confirming perforation.  No  trial  to  repair  the  perforation were undertaken and we decided to do duodenal exclusion by:

•    T-tube CBD drainage.

•    Tube duodenostomy.

•     Pyloric exclusion by antrotomy and closure of pyloric ring by non-absorbable proline 2/0 in a continuous manner followed by hand sewn gastrojejunostomy (omega loop, 50 cm distal to D-J junction).

As regard case (3), immediate surgical intervention through a midline laparotomy was done revealing a large 3cm perforation at the lateral wall of the 2nd part of Du .Trimming of the edge was done followed by a primary repair in a transverse direction (With

2/0 PDS continuous manner) with serosal patch.

Morison and pelvic wide bore drains were applied in   all   patients.   The   three   operated   patients were admitted to the intensive care unit (ICU) postoperatively to be monitored.

All data related to our cases were retrospectively collected including age, sex, indication for endoscopy, timing of diagnosis, definitive management, type of perforation, type of surgical management with postoperative complications, length of hospital stay, and comorbidities for each case.

Results

Between 2015 and 2019, 10 cases of post-ERCP Du perforation were admitted to our unit. As regard our cases’ demographics data and comorbidities,

5 cases were male and 5 cases were female. The age ranged from 28 to 60 years old with a median age of 44.2 years old. One case was diabetic on insulin (case 9) and another case had hypertension (Case 6) (Table 1).

Regarding the indication of ERCP, it was calcular OJ for 5 cases, biliary pancreatitis for another 2 (Cases 3,6), cholangitis with CBD stone for case (2), CBD stricture for case (4) and biliary pancreatitis with stricture for case (7) (Table 1).

All  cases  underwent  sphincterotomy  and  only one needed plastic stent insertion (Case 1), the cannulation of papillae was difficult in all cases except cases (9,10) and no further ERCP-related complications, such as bleeding, occurred in our cases. No biliary anomalies (as periampullary diverticulum) were noted (Table 1).

Table 1: Personal characteristics of endoscopically induced Du injury in our study

As soon as the patients presented to our unit, general assessment was done. All patients were vitally stable except for cases (1,2) who were tachycardic and feverish and case (3) who was tachycardic with no fever and all cases were normotensive. As regard the clinical manifestation, all cases presented with severe abdominal pain and jaundice associated with severe abdominal distension (tense abdomen) and

3 cases (2,4,5) had surgical emphysema reaching to the chest wall, neck and scrotum. On abdominal examination, there were no signs of peritonitis in all cases except for case (3) which had generalized peritonitis. Regarding time of presentation, apart from case (1) who presented 48 hours after ERCP, all other cases presented early within 24 hours. Case (3) was referred immediately by endoscopist after direct visualization of a perforation at the lateral DU wall. (Table 2).

All  cases  had  full  blood  tests  with  2  cases (1,2)  showing  leukocytosis.  Moreover,  the  all cases underwent an abdominal x-ray erect and supine  position  along  with  pelvi-abdominal  C.T. scan with contrast. Duodenal perforation was confirmed by the presence of air under diaphragm (Figure 1). One case showed a retroperitoneal collection (Case 1) (Figure 2) while another case showed a free intra-peritoneal dye extravasation from the lateral wall (Case 3) (Figure 3) and from the group of patients managed conservatively, 2 cases (Cases 9,10) showed minimal dye leak from the medial wall. (Table 2).

Fig 1a: Air under diaphragm in X-ray.

Fig 1b: C.T axial view with retroperitoneal air.

Fig 1c: (c) C.T coronal view with air under diaphragm. (Case 2).

Fig  2b:  C.T  coronal  view  with  retroperitoneal collection and migrated piercing stent   (Arrow) (Case 1).

Fig   2a:   C.T   axial   view   with   retroperitoneal collection.

Fig 3: C.T axial view with a later DU wall dye leak

(Type I) (Case 3).

Table 2:  Clinical characteristics of endoscopically induced Du injury in our study

Case 1           2                   3                    4                  5                  6                  7                  8                  9                        10

Com-

plain

General

sign

Severe abdomi- nal pain, jaundice, abdomi- nal   Dis- tension

Tachy- cardic

Severe abdomi- nal pain, jaundice, abdomi- nal   Dis- tension

Tachy- cardia

Severe abdomi- nal pain, jaundice, abdominal Distension

Tachycardia,

Severe abdomi- nal pain, jaundice, abdominal Distension

Severe abdomi- nal pain, jaundice, abdomi- nal   Dis- tension

Severe abdomi- nal pain, jaundice, abdominal Distension

Severe abdomi- nal pain, jaundice, abdominal Distension

Severe abdomi- nal pain, jaundice, abdomi- nal   Dis- tension

Severe abdomi- nal pain, jaundice, abdominal Distension

Severe abdomi- nal pain, jaundice, abdominal Distension

and exam- ination

Surgical

feverish, no perito- nitis

feverish, no perito- nitis

genelazided peritonitis

NAD

NAD            NAD             NAD

NAD            NAD             NAD

emphy-

sema

ü                                        ü                 ü

C.T

finding

Type of perfora-

perito- neal air, retroper- itoneal collection

Type IV large, retroper- itoneal

Retroper- itoneal air

Type  II tiny un- identified

neal air,

Large intra- peritoneal dye leak

Type  I large 3cm at lateral

Retroperi- toneal air

Suggested

Retroper- itoneal air

Suggest-

Retroperi- toneal air

Suggested

Retroperi- toneal air

Suggested

Retroperi- toneal air

Suggest-

Retroperi- toneal air, minimal dye leak

neal air, minimal

dye leak

tion

between

2nd, 3rd

at medial

wall of

wall of 2nd

part  of DU

type  II

ed type

II

type  II

type  II

ed type

II

Type  II        Type  II

part of

2nd

part

Du

Time of presen- tation

of DU

According to Stapfer classification (for post-ERCP DU perforartion), case (1) was type IV , case (2) was type II, case (3) was type I and the other 7 cases ( of conservative group) were suggested to be type II (due to it is the most common type and C.T. did not show an anterolateral or posterior Du wall perforation) (Table 2).

As    regard    management,    7    cases    (Cases

4,5,6,7,8,9,10) underwent conservative treatment and passed well with follow up C.T. showed no further changes (collection or major dye leak). All cases of conservative group stayed in the hospital for 3 to 4 days and then discharged to home (Table 3).

Case (1), which had retroperitoneal collection, not improved clinically with still tachycardic and feverish after pig tail insertion then, follow up C.T. scan after

48 hours showed regressive course of collection but

the stent was migrated and piercing the junction between the 2nd and 3rd part of duodenum and so, surgery was indicated (Table 3).

Two cases underwent an immediate surgical intervention, one of them (Case 2) was explored due to OJ with failed extraction of large stone by ERCP with cholangitis, and another case (Case 3) had major dye extravasation in peritoneal cavity (Table 3).

As regard postoperative data:

Case  (1)  passed  well  with  mild  wound  seroma and discharged to home after 10 days. Case (2) complained of minor leak from the duodenostomy with ileus, was managed conservatively and discharged after 3 week. Case (3) passed well with no postoperative complication and discharged after

7 days. There were no mortality cases in our study

(Table 3).

Table 3: Management Characteristics of endoscopically induced Du injury in our study

Case 1             2                  3                    4                  5                  6                  7                 8                 9                10

Sur gery

Man- age- ment

Time of surgery after presen- tation

Surgery  af- ter                      failure of conser- vative treat- ment

2 days

Sur gery due                         to c h o l - angi ti s, impac t - ed   CBD stone

I m m e - d i a tel y within  24 hrs

due         to large    de- fect at lat- eral              wall with free int r ape r i - toneal  dye leak

I mme di - ately within

24 hrs

Conserv a - tive     treat- ment

C on ser - v a t i v e treatment

C on serva - tive   treat- ment

C on ser - v a t i v e treatment

C on ser - v a t i v e treatment

Conserva- tive treat- ment

Conserva- tive treat- ment

Postop- erative compli- cation

Hospi-

Mild  wound

seroma

ileus with m i n o r

leak from         No

duode - nostomy

tal stay

10 days       3 weeks        7 days           3 days          3 days         4 days         3 days        3 days        4 days        3 days

Discussion

ERCP is considered the best diagnostic and therapeutic tool in patients with OJ. So, with its widespread use nowadays, the experience of endoscopists with ERCP related complications (even uncommon ones) increased. This experience has reflected the early referral of suspected complicated cases to our tertiary hospital and led to good prognosis in the management of such cases.1,2

In general, the indications of ERCP are OJ, biliary pancreatitis, biliary injury and stricture.4,5  In our study, all of 10 cases had indications for ERCP, 5 cases for calcular OJ, 2 cases for biliary pancreatitis (case 3&6), case (2) for cholangitis with CBD stone, case (4) for CBD stricture and case (7) for biliary pancreatitis with stricture.

Post-ERCP abdominal pain is almost always mild pain and so, once patient complains of severe abdominal pain you must suspect complications such as pancreatitis or even perforation especially if sphincterotomy was done as in all our cases in which reports of ERCP documented sphincterotomy.6

So, sphinctrotomy is a considerable risk factor for duodenal perforation after ERCP. Another risk factor for injury is difficult cannulation of the papillae which is documented in 8 cases (80%) of our study.2,7

Another risk factor for post-ERCP complication is altered duodenal papillae anatomy as diverticulum

but according to our cases’ ERCP reports, there was no altered anatomy.2

Post-ERCP abdominal distention is an uncommon complain and mostly due to bowel insufflation by air but you must exclude duodenal perforation in which abdominal distention is well marked due to over insufflation of air.6

In all our cases, there was marked abdominal distention (tense abdomen) which was very annoying to the patient.

The next step, once we suspect ERCP related complication, is to order blood tests including serum amylase, lipase, abdominal x-ray (erect and supine views) and even computerized tomography (CT) with contrast. These investigations are the gold standard for assessment of ERCP related complication.8

There was leukocytosis in 2 cases of our study (case 1 for retroperitoneal collection, case 2 for cholangitis).

Presence of air under diaphragm, retroperitoneal air, and collection or dye extravasation in CT are the diagnostic data in the images for duodenal perforation.8

If endoscopist suspected DU perforation, limited contrast study through endoscope can confirm the perforation and so, early referral of case with good

prognosis of early management.3

In our study, only one case (3) was diagnosed for perforation by endoscopist by direct inspection of a lateral perforation by the endoscope.

Stapfer et.al. classified post-ERCP duodenal perforation according to anatomical site, mechanism of injury and severity into four types:

Type I: duodenal wall (lateral or even medial) away

from the papillae.

Type II: perivaterian duodenum. Type III: bile duct.

Type IV: tiny retroperitoneal perforation caused by use of compressed air of endoscopy (Figure 4).3

Fig 4: Classification of duodenal perforations into types I through IV based on anatomical location and mechanism of injury (type IV not shown).9

Type I (lateral duodenal wall) is the least common and the most serious one due to it tends to be large with early extravasation of bile, duodenal and gastric fluid to both the intraperitoneal and retroperitoneal spaces with a risk of pancreatic necrosis and even abdominal wall fasciitis if neglected. So, this type needs early detection with immediate aggressive intervention (mostly surgical) to improve prognosis and avoid mortality.10

Type I DU perforation is caused by the endoscope itself and usually diagnosed during the endoscopic procedure and in the presence of available facilities and experienced endoscopists it can be managed immediately by endoloop or endoscopic clip (Figure 5).11

In our study, case (3) was type I duodenal perforation. CT image showed a large lateral wall perforation in the 2nd part of duodenum with free extravasation of dye in the intraperitoneal space so, no role for conservative treatment and decision was

an immediate laparotomy.

Type II duodenal perforation is the most common type as it is the target site of maneuver (papillae cannulation). This type is related to procedure difficulties and mostly caused by sphincteroromy especially if there is difficult cannulation or distorded papillae anatomy by mass or periampullary diverticulum. It has the best prognosis because it is mostly tiny and concealed in the retroperitoneal space.12

If endoscopist suspects this type of perforation during procedure, a biliary stent or even nasobiliary tube can be applied to settle the condition.3

Fig 5: ERCP view of a lateral DU wall perforation

(Type I).3

Most cases of type II are diagnosed by exclusion by the presence of air under diaphragm or retroperitoneal air in CT (which is marked air due to endoscopic insufflation and may results in even emphysema in the abdominal wall reaching the scrotum as in cases (2,4,5) with no major collection or major dye leakage or even noticeable perforation in CT image (even intraoperatively this perforation is mostly tiny and couldn’t be seen).12

So, conservative treatment is very effective in this type of perforation and the indications of surgery in type II are persistent stone, stricture in bile duct, cholangitis with failed drainage by ERCP or sizeable retroperitoneal collection with failed external drainage which is rare in this type.13

In our study, most cases (2,4,5,6,7,8,9,10) were thought to be type II and so, conservative treatment was done in form of N.P.O, IV fluids, IV antibiotics, analgesic and one case (6) needed subcostal air evacuation by wide bore cannula to relieve pain of compressed air, then follow up CT for these cases (there was no significant collection to be drained) and all cases of conservative group passed well.

But in case (2) which is type II, due to failure of extraction of a large impacted stone and cholangitis so, surgery was indicated.

Type IV duodenal perforation (retroperitoneal perforation)  is  mostly  a  microperforation  that occurs due to guidewire, sphincterotome and rarely endoscope, it is mostly related to the compressed air. It is the second common type and rarely needs surgical intervention. This type can be diagnosed by CT (retroperitoneal air, collection with dye leakage). The best management is conservative treatment with a pigtail drainage of collection if present and follow up. With follow up, if still undrained collection or extensive retroperitoneal necrosis or still toxic patient, surgery is indicated as in our study (case 1) in which we started follow up and pigtail drainage but with follow up CT., still there is inadequately drained collection and presence of  migrated stent passing through the perforation.3

Type III duodenal perforation is mostly a minor one in the distal CBD and mostly associated with instrumentation of CBD by wire, dormia basket or stent especially with presence of an obstructing stone, stricture or cholangitis and if suspected by the endoscopist, immediate stenting or nasobiliary

tube  is  indicated  and  can  resolve  the  problem. If  the  perforation  missed,  patient  may  present with collection. A pigtail drainage in association with ERCP stenting is enough and rarely needs surgery.14

So,  the  conservative  treatment  is  successful  in most cases of post-ERCP duodenal perforation and indications of surgery are:

•    Persistent stone or stricture.

•    Cholangitis with failed ERCP drainage.

•     Large  perforation  with  free  intraperitoneal extravasation.

•    Failed drainage of retroperitoneal collection.

•    Extensive retroperitoneal necrosis.

•    Presence of foreign body as stent.

•    Presence of perforated neoplasm.3

As regard types of surgical intervention, there are no  specific  guidelines  for  surgical  management of post-ERCP DU perforation but intervention is tailored from case to case (Table 4).

Table 4: Reports in the literature of Type 1 and 2 duodenal injuries caused by endoscopic procedures

Different management  of:                                                         Average

Case/series              N

Duodenal injury                Retroperitoneal necrosis              Underlying etiology

days of hospital stay

Mortality

Stapfer et al.

2000 (3)                                                                  8

Preetha et al. 2003

(15)                                                                                   13

Morgan et al. 2009

Pyloric exclusion and gastro-je- junostomy

Tube duodenostomy

Duodeno-antrectomy

Primary repair

Pyloric exclusion and gastro-je- junostomy

T-tube

Bowel decompression

Primary repair gastrojejunos-

Drain placement

Not described

Cholecystectomy CBD exploration Hepatico-jejunostomy

Cholecystectomy CBD exploration Hepatico-jejunostomy

62.9           2 (25%)

23.8          3 (23.1%)

(16)                                                                                   10

Dubecz et al.

2012(17)                                                                  4

tomy                                Drain placement                                                                Not available      1 (10%)

Primary repair

Not described                        Hepatico-jejunostomy                   23              0 (0%) T-tube

Primary repair

Drain placement

Cholecystectomy

Wu et al. 2006 (18)                    10

Ercan et al. 2012

(19)                                                                                   13

Avgerinos et al.

Omental patch

Duodenostomy

Primary repair

Pyloric exclusion

Gastro-enterostomy

Primary repair

Omental patch

Open abscess drainage

Percutaneous abscess drainage

Percutaneous abscess drainage

Open abscess drainage

CBD exploration

Cholecysto-jejunostomy

Cholecystectomy CBD exploration T-tube

31.4           4 (40%)

10.2          6 (46.2%)

2009(20)                                                               15

Fatima et al. 2007

(13)                                                                                   22

Angiò et al. 2009

Pyloric exclusion

Gastro-enterostomy

Primary repair

Omental patch

Kocherization and primary

Not described                    Choledocho-duodenostomy                42             3 (20%)

Drain placement                    Choledocho-jejunostomy                 16            3 (13.6%)

(21)                                                                                      1

repair                                  Not described                            CBD exploration                        23              0 (0%)

Cholecystectomy

Mao et al. 2008(22)                      3                   Nil required                             Drain placement

Kalyani et al.

CBD exploration

T-tube

50              0 (0%)

2005(23)                                                                  1             Jejunal serosal patch                         Not required                                Nil required                         > 15            0 (0%)

Melita et al. 2005

(24)                                                                                      1                   Nil required                     CT-guided abscess drainage                      Nil required                   Not specified       0 (0%)

Primary repair

T-tube

Knudson et al.

2008 (25)                                                            12

Omental patch Duodenostomy tube Gastrostomy Jejunostomy tube

Drain placement

Open abscess drainage

Hepatico-jejunostomy                   45             0 (0%)

Caliskan et al.

2013(26)                                                                  9

Pyloric exclusion

Primary repair

Duodenostomy

Pyloric exclusion, gastro-jeju- nostomy

Not described

CBD exploration

T-tube

Pancreatico-duodenectomy

22.6          4 (44.4%)

The next step is according to type of perforation:

If type II (perivaterian): Mostly it is tiny one in the medial wall and cannot be seen and the surgery is mostly indicated due to persistent stone, stricture or undrained cholangitis. So, with CBD exploration, injection  of  methylene  blue  is  done  to  confirm the perforation and duodenal exclusion is enough without any trial to search for and repair the perforation.27

As in our study case (2) which was diagnosed as type II perforation, surgery was indicated due to persistent impacted stone with cholangitis. CBD exploration, extraction of 2 large CBD stones with cholecystectomy then intra-operative cholangiogram were done followed by duodenal exclusion by T-tube CBD drainage, tube duodenostomy and pyloric exclusion with gastrojejunostomy.

In type I perforation (lateral wall), if early within 12 hears, a primary repair with patch (omental or serosal) is enough. If late diagnosis, repair of perforation is according to the site:  

Second part of DU→ repair with duodenal exclusion or side to side duodenojejunostomy.

Third part of DU →If  more  than  50%  of  the  circumference  → resection and anastomosis (duodenojejunostomy).→ If less than 50% → repair with duodenal exclusion or side to side duodenojejunostomy.26,28 

In case (3), with a lateral duodenal wall large extravasation,  a  midline  laparotomy  was  done which showed a large perforation at the lateral wall of the 2nd part of duodenum, a trimming of the edge was done with a primary repair in a transverse direction followed by a serosal jejunal patch and pyloric exclusion with gastrojejunostomy. 

In type IV perforation, if failed conservative treatment, the laparotomy is indicated and the intervention is according to the site (2nd   or 3rd part of DU) and time of presentation as type I perforation. 15 

In our study, case (1) was type IV and after failure of  conservative  treatment,  midline  laparotomy was done revealing a large perforation at the the posterior wall between the 2nd  and 3rd part of Du > 50% of circumference (with migrated piercing stent) along with a retroperitoneal collection. We did drainage of collection, resected the 3rd  and 4th  part of duodenum, then mobilization of duodenojejunal (D.J) flexure with proximal jejunal loop was done, then we passed it through D.J flexure aperture in transverse mesocolon and we performed a hand sewn, double layered duodenojejunostomy using a continuous 3/0 polydioxanone (PDS) suture and patient passed well.

Conclusion

ERCP with sphincterotomy is commonly used in the treatment of CBD stones or stricture. ERCP-related perforations is uncommon occur in about 1% of patients. Early diagnosis and prompt management are important to decrease morbidity and mortality. If it is not detected by the endoscopist, CT is the gold standard tool to diagnose this problem. Post- ERCP duodenal perforations include different types I, II, III, or IV. Conservative management is very effective in most of cases with no need to surgical intervention except in specific indications. The type of surgical management should be individualized on case-by-case basis depending on the site of perforation and timing of intervention with no specific guideline.

Conflict of interest: The authors declare that they have no conflict of interest.

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