UNUSUAL PERFORATIONS FOLLOWING ERCP PROCEDURE: AN EXPLORATORY LITERATURE SEARCH AND THE LESSONS LEARNED FROM THREE CASE STUDIES

MURAT CILEKAR^a, RAMAZAN SERDAR ARSLAN^b, MURAT AKICI^a, SEZGIN YILMAZ^a

^aAfyon Kocatepe University, The Faculty of Medicine, General Surgery Department, 03020, Afyon, Turkey - ^bBanaz State Hospital, General Surgery Department, 64520, Banaz, Usak, Turkey

Introduction: ERCP procedure has severe risk of related complications that is about 5%-10%. The most feared complica- tion of ERCP is perforation since it has highest mortality rate. The most common localization of perforation after ERCP is peri- papillary area. However unusual anatomical localizations of perforations can also be seen. While most of the juxtapapillary per- forations can be managed by non-operative measures, unusual perforations usually require early surgical interventions.

Patients and methods

Case 1: An 86 year-old woman was referred to our centre with cholelithiasis and choledocholithiasis. During ERCP proce- dure, supracrural gastric perforation was detected in huge type III hiatal hernia by visualizing intraperitoneal cavity.

Case 2: A 53 year-old woman was interned for stent removal. ERCP was performed for removing the stent, however the patient had developed severe peritonitis 36 hours after the procedure. An urgent operation performed and a perforation around the Trietz ligament was detected.

Case 3: A 77 year-old woman was referred for choledocholithiasis. During ERCP there were large stones in biliary system that can not be removed endoscopically, so a temporary plastic biliary stent was inserted. Despite the stent placement, clinical condition of the patients has not improved and septic condition was developed due to extensive peritonitis.

Conclusion: Although the clinical presentaions are similar to each other, it seems that the mortality rate of unusual perfo- rations are quite higher than that of juxtapapillary perforations. The delay of surgical treatment in unusual perforations results in doubling the mortality rate. So every effort should be delineated to determine the perforation site and surgical treatment should be considered preferentially especially in first 24 hour.