Operative treatment of periampullary retroperitoneal perforation complicating endoscopic sphincterotomy

Sarli, Leopoldo; Porrini, Cristina; Costi, Renato; Regina, Gabriele; Violi, Vincenzo; Ferro, Michelina; Roncoroni, Luigi

doi:10.1016/j.surg.2007.02.002

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Volume 142, Issue 1 , Pages 26-32, July 2007

Operative treatment of periampullary retroperitoneal perforation complicating endoscopic sphincterotomy

Leopoldo Sarli, MD
- Department of Surgical Sciences, Section of General Surgical Clinics and Surgical Therapy, Parma University, Medical School, Parma, Italy
- Reprint requests: Prof. Leopoldo Sarli, Dipartimento di Scienze Chirurgiche, Sezione di Chirurgia Generale e Terapia Chirurgica, Università di Parma, Via Gramsci 14, 43100 Parma, Italy.
Cristina Porrini, MD
- Department of Surgical Sciences, Section of General Surgical Clinics and Surgical Therapy, Parma University, Medical School, Parma, Italy
Renato Costi, MD, PhD
- Department of Surgical Sciences, Section of General Surgical Clinics and Surgical Therapy, Parma University, Medical School, Parma, Italy
Gabriele Regina, MD
- Department of Surgical Sciences, Section of General Surgical Clinics and Surgical Therapy, Parma University, Medical School, Parma, Italy
Vincenzo Violi, MD
- Department of Surgical Sciences, Section of General Surgical Clinics and Surgical Therapy, Parma University, Medical School, Parma, Italy
Michelina Ferro, MD
- Department of Surgery, Section of Anesthesiology, Intensive Care and Pain Therapy, Parma Hospital, Parma, Italy
Luigi Roncoroni, MD
- Department of Surgical Sciences, Section of General Surgical Clinics and Surgical Therapy, Parma University, Medical School, Parma, Italy

Accepted 2 February 2007. published online 04 May 2007.

Background

Evidence-based strategies are lacking regarding the appropriate management of periampullary retroperitoneal perforations complicating endoscopic retrograde cholangiopancreatography (ERCP) combined with endoscopic sphincterotomy (ES). We propose a transduodenal operative repair of periampullary retroperitoneal perforation.

Methods

Six patients with duodenal periampullary perforation induced by endoscopic sphincterotomy underwent operation after failure of an attempt of conservative management. After mobilization of the second and the third part of the duodenum, a minimal transversal duodenotomy was carried out, the papilla was exposed, periampullary perforation was readily identified, and was sutured easily as a sphincteroplasty or by 2 or 3 Vicryl 3/0 sutures. Patient outcomes were measured.

Results

Periampullary perforation was repaired as sphincteroplasty in 2 cases, and with Vicryl 3/0 sutures in 4 cases. The mean duration of operation was 176 minutes. There were no intraoperative complications. None of the patients required reoperation after transduodenal repair of the perforation. The patients had a normal postoperative course. The median hospital stay was 10.5 days (range, 9 to 20 days) and the mortality rate was nil. There were no delayed complications during a median follow-up of 60 months.

Conclusions

The transduodenal operative approach to periampullary perforation after ERCP/ES at an early stage in the clinical evolution of the perforation is a safe and effective procedure. We consider this approach a useful option for the treatment of periampullary perforation after ERCP/ES when initial endoscopic and conservative management do not yield good results within 24 hours.