Post Endoscopic Retrograde Cholangiopancreatography (ERCP) Perforation Going through the Wall - Endoscopist Greatest Agony

Endoscopic retrograde cholangiopancreatography (ERCP) is one of the therapeutic modality for various pancreatic and biliary problems. Endoscopic sphincterotomy (ES) usually done for removal stones and facilitate the entry of stent in bile duct. ES related perforation are not uncommon which are usually retroperitoneal and usually located in the perivaterian region. Perivaterian perforation could generally be managed by conservative management and non surgical interventions as they tend to be smaller in size and are usually well contained. These nonsurgical management includes endoscopic intervention like placement of endoscopic nasobiliary drainage catheter (ENBD), multiple plastic stents, endoclips, fibrin glue and placement of fully covered self-expandable metallic stents (FCSEMS) and radiologic interventions using percutaneous transhepatic biliary drainage (PTBD). The mechanism, site and extent of injury, suggested by clinical and radiographic findings, should guide towards operative or non-operative management. In type I perforations early surgical repair is indicated, unless endoscopic closure can be achieved. Patients with type II perforations should be treated initially non-operatively. Non-operative treatment was successful in 2/3 of patients with perivaterian perforation with little mortality. We are sharing our experience of managing different type of duodenal perforation during ERCP.