Endoscopic Treatment for Duodenal Perforation during ERCP

Gut perforations during ERCP and stenting or due to migration of stents are very rare complications, with an incidence of well below 2%. Moreover, direct duodenoscope-induced lateral or medial duodenal wall perforation is much less common, accounting for 0.1% of patients who undergo ERCP, but tends to be large and further away from the ampulla. Duodenal perforations from the superior duodenal angle to the descending duodenum may be complicated by leakage of digestive enzymes from the pancreas, which may severely damage other organs. Accordingly duodenal wall perforation is one of the most feared complications of ERCP. Traditionally, the standard treatment for traumatic or iatrogenic duodenal perforation is early surgical closure because of a relatively high mortality rate of 16%-18%. However, although ERCP-related lateral or medial duodenal wall perforations usually require immediate surgery, there are inoperable cases because of advanced patient age and combined comorbidities that prohibit surgical treatment. When nonoperative management of a large lateral or medial duodenal perforation is selected, early closure of the perforation is essential. Recently, numerous endoscopic trials of perforation management have increased and successful primary repair of duodenal perforation using the endoscope itself has been reported. However, till now the best therapeutic option of these complications remains a matter of debate.