Causes and Management of Retroperitoneal Perforation with ERCP

Abstract

ERCP has become an essential technique for the diagnosis of biliopancreatic disease. Various therapeutic techniques using ERCP have been developed and are widely used in the clinical setting. However, ERCP and related techniques are generally highly technical methods and complications associated with ERCP are potentially severe. Of all these ERCP-associated complications, retroperitoneal perforation is associated with a high mortality rate and must be diagnosed and dealt with promptly. We experienced ten cases of retroperitoneal perforation as an ERCP-associated complication among 4,076 ERCP procedures performed at our institution between January 1999 and May 2015 (0.25% of all ERCP procedures). We investigated the cause and management in these cases. When retroperitoneal perforation during ERCP is suspected, decompression is considered, for example by endoscopic biliary tract drainage or a nasogastric tube, and CT imaging is always performed after ERCP to confirm the severity of the retroperitoneal perforation. Emergency surgery is generally performed if fluid accumulation is observed in the retroperitoneal space on the CT scan immediately after ERCP and there are symptoms of fever or pain. Patients with only retroperitoneal emphysema on CT immediately after ERCP or patients with only a small volume of retroperitoneal fluid accumulation and no symptoms are monitored and undergo conservative treatment. Monitored patients are followed up over time for pain and retroperitoneal liquid accumulation on CT; if the symptoms or scan findings worsen, urgent consideration is given to emergency surgery before it is too late.