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

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Presentation on theme: "Case Presentation Post ERCP Perforation From www.uptodate.com Dr.Mohammad Amin Mirza General Surgery Resident Saudi Board in GS(R1) Al-Noor Specialist."— Presentation transcript:

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

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

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

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

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

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

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

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

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

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

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

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

14 Classification of complications Complications General (common to all endoscopic procedures) Medication Reaction O2 desaturation O2 desaturation Cardiopulm accident Hemorrhage Perforation induced by traumatic passage of the scope Selective (Specific to pancreatobiliary instrumentation) instrumentation) - Pancreatitis - Sepsis - Hemorrhage - Retroperitoneal duodenal - Retroperitoneal duodenalperforation

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19 . RISK FACTORS FOR OVERALL COMPLICATIONS RISK FACTORS FOR OVERALL COMPLICATIONS Volume of activity of Volume of activity of the endoscopic unity and experience of the endoscopists small center (<200 ERCPs per year) Method-related factors Method-related factors - difficulty of cannulation - precut - combined percutaneous-endoscopicprocedure Patient-related Patient-related factors factors sphincter of Oddi dysfunction & cirrhosis

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21 . Classification of perforation Symptomatic Retroperitonealperforation The same presentation The same presentation (31%)Post ERCP Pancreatitis(64%) (Of 63Pt) Retroperitoneal Air (in CT) Free bowel perforation pain, pain, fever, fever, leukocytosis leukocytosis CXR & CT scan CXR & CT scan Perforation of Bile ducts dilation of strictures, dilation of strictures, forceful cannulation, forceful cannulation, and guidewire and guidewire insertion insertion Asymptomatic in 29% (21 Pt study)

22 . Grading of post ERCO perforation Mild - Possible or only very Slight leak of fluid Or contrast - Treatable by fluids & Suction for ≤3 days Moderate perforation treated perforation treatedmedically for 4 to 10 days for 4 to 10 daysSevere Medical treatment Medical treatment for > 10 days for > 10 days intervention intervention(percutaneous or surgical)

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

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

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

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

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

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29 Conclusion

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

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