Case Report
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Secondary iatrogenic duedonum perforation: a rare complication

Year 2024, , 241 - 244, 04.03.2024
https://doi.org/10.18621/eurj.1356093

Abstract

The incidence of perforations resulting from Endoscopic Retrograde Cholangiography (ERCP) is observed to be less than 1%. In this case report, we aim to present our unique experience as a mechanism, which is even more uncommon. A 68-year-old male with an ASA score of 2 was prediagnosed with a distal common bile duct tumor. ERCP was performed for therapeutic and diagnostic purposes and a 9F 10 cm plastic stent was placed to relieve obstruction. The patient, who had the sudden onset of abdominal pain within the initial 24-hour period following the procedure, underwent surgical intervention subsequent to a computed tomography assessment. In the third portion of the duodenum, an approximately 4 mm perforation originating from the stent was observed during the examination. It was repaired with a 3.0 prolene suture, followed by omentopexy. He was discharged uneventfully on the eighth day. Although duodenal perforation due to the placement of a plastic biliary stent with ERCP is a very uncommon complication, the patient's clinical and imaging findings are essential for treatment planning.

References

  • 1. Alghsoon SA, Shaban KS, Khan AH, et al. A comparison of radiation exposure during endoscopic retrograde cholangiopancreatography (ERCP) by different fluoroscope techniques. Innov Surg Interv Med. 2020;1(1):9-14. doi: 10.36401/ISIM-20-02.
  • 2. Mallery JS, Baron TH, Dominitz JA, et al. Complications of ERCP. Gastrointest Endosc. 2003;57(6):633-638. doi: 10.1053/ge.2003.v57.amge030576633.
  • 3. Solomon S, Baillie J. 7 - Indications for and contraindications to ERCP. In: Baron TH, Kozarek RA, Carr-Locke DL, eds., ERCP. 3rd ed., Philadelphia: Elsevier; 2019: pp. 54-58.e51.
  • 4. Talukdar R. Complications of ERCP. Best Pract Res Clin Gastroenterol. 2016;30(5):793-805. doi: 10.1016/j.bpg.2016.10.007.
  • 5. Ida Bagus B. A rare clinical presentation of third part duodenal perforation due to post-endoscopic retrograde cholangiopancreatography stent migration on advanced stage peri-ampullary tumor. JGH Open. 2021;5(8):968-970. doi: 10.1002/jgh3.12608.
  • 6. Mousa HM, Hefny AF, Abu-Zidan FM. Life-threatening duodenal perforation complicating endoscopic retrograde cholangiopanceatography: a case series. Int J Surg Case Rep. 2020;66:404-407. doi: 10.1016/j.ijscr.2020.01.001.
  • 7. Langerth A, Isaksson B, Karlson BM, Urdzik J, Linder S. ERCP-related perforations: a population-based study of incidence, mortality, and risk factors. Surg Endosc. 2020;34(5):1939-1947. doi: 10.1007/s00464-019-06966-w.
  • 8. Fujii Y, Matsumoto K, Miyamoto K, et al. Endoscopic treatment for duodenal perforation due to biliary stent dislocation: a case report and brief review of the literature. Medicine (Baltimore). 2022;101(48):e31868. doi: 10.1097/MD.0000000000031868.
  • 9. Prachayakul V, Aswakul P. Endoscopic retrograde cholangiopancreatography-related perforation: Management and prevention. World J Clin Cases. 2014;2(10):522-527. doi: 10.12998/wjcc.v2.i10.522.
  • 10. Bozbiyik O, Cetin B, Gumus T, Tekin F, Uguz A. Fully covered self-expandable metal stent for intraprocedural or late-diagnosed Type-II endoscopic retrograde cholangiopancreatography-related perforations. BMC Gastroenterol. 2022;22(1):385. doi: 10.1186/s12876-022-02466-9.
  • 11. Kumbhari V, Sinha A, Reddy A, et al. Algorithm for the management of ERCP-related perforations. Gastrointest Endosc. 2016;83(5):934-43. doi: 10.1016/j.gie.2015.09.039.
  • 12. Yuan XL, Ye LS, Liu Q, et al. Risk factors for distal migration of biliary plastic stents and related duodenal injury. Surg Endosc. 2020;34(4):1722-1728. doi: 10.1007/s00464-019-06957-x.
  • 13. Johanson JF, Schmalz MJ, Geenen JE. Incidence and risk factors for biliary and pancreatic stent migration. Gastrointest Endosc. 1992;38(3):341-346. doi: 10.1016/s0016-5107(92)70429-5.
  • 14. Arhan M, Odemiş B, Parlak E, Ertuğrul I, Başar O. Migration of biliary plastic stents: experience of a tertiary center. Surg Endosc. 2009;23(4):769-775. doi: 10.1007/s00464-008-0067-x.
Year 2024, , 241 - 244, 04.03.2024
https://doi.org/10.18621/eurj.1356093

Abstract

References

  • 1. Alghsoon SA, Shaban KS, Khan AH, et al. A comparison of radiation exposure during endoscopic retrograde cholangiopancreatography (ERCP) by different fluoroscope techniques. Innov Surg Interv Med. 2020;1(1):9-14. doi: 10.36401/ISIM-20-02.
  • 2. Mallery JS, Baron TH, Dominitz JA, et al. Complications of ERCP. Gastrointest Endosc. 2003;57(6):633-638. doi: 10.1053/ge.2003.v57.amge030576633.
  • 3. Solomon S, Baillie J. 7 - Indications for and contraindications to ERCP. In: Baron TH, Kozarek RA, Carr-Locke DL, eds., ERCP. 3rd ed., Philadelphia: Elsevier; 2019: pp. 54-58.e51.
  • 4. Talukdar R. Complications of ERCP. Best Pract Res Clin Gastroenterol. 2016;30(5):793-805. doi: 10.1016/j.bpg.2016.10.007.
  • 5. Ida Bagus B. A rare clinical presentation of third part duodenal perforation due to post-endoscopic retrograde cholangiopancreatography stent migration on advanced stage peri-ampullary tumor. JGH Open. 2021;5(8):968-970. doi: 10.1002/jgh3.12608.
  • 6. Mousa HM, Hefny AF, Abu-Zidan FM. Life-threatening duodenal perforation complicating endoscopic retrograde cholangiopanceatography: a case series. Int J Surg Case Rep. 2020;66:404-407. doi: 10.1016/j.ijscr.2020.01.001.
  • 7. Langerth A, Isaksson B, Karlson BM, Urdzik J, Linder S. ERCP-related perforations: a population-based study of incidence, mortality, and risk factors. Surg Endosc. 2020;34(5):1939-1947. doi: 10.1007/s00464-019-06966-w.
  • 8. Fujii Y, Matsumoto K, Miyamoto K, et al. Endoscopic treatment for duodenal perforation due to biliary stent dislocation: a case report and brief review of the literature. Medicine (Baltimore). 2022;101(48):e31868. doi: 10.1097/MD.0000000000031868.
  • 9. Prachayakul V, Aswakul P. Endoscopic retrograde cholangiopancreatography-related perforation: Management and prevention. World J Clin Cases. 2014;2(10):522-527. doi: 10.12998/wjcc.v2.i10.522.
  • 10. Bozbiyik O, Cetin B, Gumus T, Tekin F, Uguz A. Fully covered self-expandable metal stent for intraprocedural or late-diagnosed Type-II endoscopic retrograde cholangiopancreatography-related perforations. BMC Gastroenterol. 2022;22(1):385. doi: 10.1186/s12876-022-02466-9.
  • 11. Kumbhari V, Sinha A, Reddy A, et al. Algorithm for the management of ERCP-related perforations. Gastrointest Endosc. 2016;83(5):934-43. doi: 10.1016/j.gie.2015.09.039.
  • 12. Yuan XL, Ye LS, Liu Q, et al. Risk factors for distal migration of biliary plastic stents and related duodenal injury. Surg Endosc. 2020;34(4):1722-1728. doi: 10.1007/s00464-019-06957-x.
  • 13. Johanson JF, Schmalz MJ, Geenen JE. Incidence and risk factors for biliary and pancreatic stent migration. Gastrointest Endosc. 1992;38(3):341-346. doi: 10.1016/s0016-5107(92)70429-5.
  • 14. Arhan M, Odemiş B, Parlak E, Ertuğrul I, Başar O. Migration of biliary plastic stents: experience of a tertiary center. Surg Endosc. 2009;23(4):769-775. doi: 10.1007/s00464-008-0067-x.
There are 14 citations in total.

Details

Primary Language English
Subjects General Surgery
Journal Section Case Reports
Authors

Alperen Özdoğan 0009-0005-9122-0387

Oğuzhan Fatih Ay 0000-0002-0726-3968

İsmayil Yılmaz 0000-0001-7894-3613

Early Pub Date December 31, 2023
Publication Date March 4, 2024
Submission Date September 6, 2023
Acceptance Date November 11, 2023
Published in Issue Year 2024

Cite

AMA Özdoğan A, Ay OF, Yılmaz İ. Secondary iatrogenic duedonum perforation: a rare complication. Eur Res J. March 2024;10(2):241-244. doi:10.18621/eurj.1356093

e-ISSN: 2149-3189 


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