Limits...
Laparoscopic management of a retroperitoneal duodenal perforation following ERCP for periampullary cancer.

Palanivelu C, Jategaonkar PA, Rangarajan M, Anand NV, Senthilnathan P - JSLS (2008 Oct-Dec)

Bottom Line: Although it is proven to be efficient and relatively safe, complications do occur (1.8%).Both surgical and non-surgical management have been reported, each with its specific indications.Laparotomy is the preferred approach, though now laparoscopy is a viable and effective alternative, because it provides the benefits of minimal access, such as reduced pain and early ambulation.

View Article: PubMed Central - PubMed

Affiliation: GEM Hospital & Postgraduate Institute, Coimbatore, India.

ABSTRACT

Introduction: Endoscopic retrograde cholangiopancreatography (ERCP) is a fairly common procedure being performed in several centers worldwide. Although it is proven to be efficient and relatively safe, complications do occur (1.8%). We present a patient with ERCP-induced retroperitoneal perforation of the duodenum treated laparoscopically at our institution.

Case report: The patient is a 60-year-old female who underwent ERCP for obstructive jaundice due to periampullary carcinoma, during which the perforation occurred. Laparoscopy was performed 5 hours later and the perforation sutured primarily.

Results: The operating time was 125 minutes. On the fourth postoperative day, the patient developed a retroperitoneal collection, confirmed by computed tomographic scan. Re-look laparoscopy was performed and the fluid drained. She recovered completely and was discharged on the eighth postoperative day.

Conclusion: Duodenal perforation following ERCP is rare, with an incidence of 1.8%. Both surgical and non-surgical management have been reported, each with its specific indications. Our patient needed surgery, because the perforation was large and a retroperitoneal collection was present. Laparotomy is the preferred approach, though now laparoscopy is a viable and effective alternative, because it provides the benefits of minimal access, such as reduced pain and early ambulation.

Show MeSH

Related in: MedlinePlus

On laparoscopy, air trapped within the omentum and retroperitoneum.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
getmorefigures.php?uid=PMC3015994&req=5

Figure 1: On laparoscopy, air trapped within the omentum and retroperitoneum.

Mentions: The patient was a 60-year-old lady with acute abdominal pain referred to our hospital. She underwent ERCP for obstructive jaundice due to a periampullary tumor, with a plan to biopsy the tumor and stent the common bile duct. During the procedure, the (distal) second part of the duodenum was perforated, confirmed by visualizing the abdominal cavity with the scope passed through the perforation. The patient was then referred to our institution within 5 hours for further management. She was admitted with signs of acute abdomen. Intravenous fluids were administered, and a nasogastric tube was inserted. Intravenous antibiotics were administered (magnamycin-4gm/day + ornidazole-1g/day). Blood and urine investigations were performed, which showed leukocytosis, hyperbilirubinemia, and altered liver enzymes. A plain abdominal x-ray and ultrasonogram (USG) were normal, while a CT scan showed air and fluid in the retroperitoneum in the paraduodenal space. Surgical intervention (diagnostic laparoscopy) was planned. The patient was positioned supine on the operating table, with the operating and camera surgeon standing on the right side, the monitor placed on the left side. Four 5-mm and one 10-mm laparoscopic ports were placed in the upper abdomen. The left lobe of the liver was retracted anteriorly with a 5-mm flexible retractor. Air was entrapped inside the omentum and retroperitoneum over the hepatic flexure, right kidney, and duodenal area (Figure 1). This air was let out by opening the plane between the layers of omentum. No bilious fluid was present in the peritoneal cavity, so the retroperitoneum was approached by dividing the duodenum and was kocherized with scissors. A localized collection of bilious fluid was adjacent to the second part of the duodenum (Figure 2). This fluid was sucked out, revealing a large 2x2-cm perforation with prolapsing mucosa identified on the lateral surface of the distal second part of the duodenum (Figure 3). Because the edges were not friable, we decided to perform primary closure with intracorporeal sutures. This was achieved in 2 layers, by first taking continuous sutures using 3.0 Vicryl, and then a layer of interrupted seromuscular sutures using 3.0 Ethibond Excel (Figure 4). Thorough peritoneal toilet was performed using the irrigation-suction device. Two drain tubes (size 24F) were placed, one in the vicinity of the second part of the duodenum and the other in the peritoneal cavity. All the port sites were closed.


Laparoscopic management of a retroperitoneal duodenal perforation following ERCP for periampullary cancer.

Palanivelu C, Jategaonkar PA, Rangarajan M, Anand NV, Senthilnathan P - JSLS (2008 Oct-Dec)

On laparoscopy, air trapped within the omentum and retroperitoneum.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC3015994&req=5

Figure 1: On laparoscopy, air trapped within the omentum and retroperitoneum.
Mentions: The patient was a 60-year-old lady with acute abdominal pain referred to our hospital. She underwent ERCP for obstructive jaundice due to a periampullary tumor, with a plan to biopsy the tumor and stent the common bile duct. During the procedure, the (distal) second part of the duodenum was perforated, confirmed by visualizing the abdominal cavity with the scope passed through the perforation. The patient was then referred to our institution within 5 hours for further management. She was admitted with signs of acute abdomen. Intravenous fluids were administered, and a nasogastric tube was inserted. Intravenous antibiotics were administered (magnamycin-4gm/day + ornidazole-1g/day). Blood and urine investigations were performed, which showed leukocytosis, hyperbilirubinemia, and altered liver enzymes. A plain abdominal x-ray and ultrasonogram (USG) were normal, while a CT scan showed air and fluid in the retroperitoneum in the paraduodenal space. Surgical intervention (diagnostic laparoscopy) was planned. The patient was positioned supine on the operating table, with the operating and camera surgeon standing on the right side, the monitor placed on the left side. Four 5-mm and one 10-mm laparoscopic ports were placed in the upper abdomen. The left lobe of the liver was retracted anteriorly with a 5-mm flexible retractor. Air was entrapped inside the omentum and retroperitoneum over the hepatic flexure, right kidney, and duodenal area (Figure 1). This air was let out by opening the plane between the layers of omentum. No bilious fluid was present in the peritoneal cavity, so the retroperitoneum was approached by dividing the duodenum and was kocherized with scissors. A localized collection of bilious fluid was adjacent to the second part of the duodenum (Figure 2). This fluid was sucked out, revealing a large 2x2-cm perforation with prolapsing mucosa identified on the lateral surface of the distal second part of the duodenum (Figure 3). Because the edges were not friable, we decided to perform primary closure with intracorporeal sutures. This was achieved in 2 layers, by first taking continuous sutures using 3.0 Vicryl, and then a layer of interrupted seromuscular sutures using 3.0 Ethibond Excel (Figure 4). Thorough peritoneal toilet was performed using the irrigation-suction device. Two drain tubes (size 24F) were placed, one in the vicinity of the second part of the duodenum and the other in the peritoneal cavity. All the port sites were closed.

Bottom Line: Although it is proven to be efficient and relatively safe, complications do occur (1.8%).Both surgical and non-surgical management have been reported, each with its specific indications.Laparotomy is the preferred approach, though now laparoscopy is a viable and effective alternative, because it provides the benefits of minimal access, such as reduced pain and early ambulation.

View Article: PubMed Central - PubMed

Affiliation: GEM Hospital & Postgraduate Institute, Coimbatore, India.

ABSTRACT

Introduction: Endoscopic retrograde cholangiopancreatography (ERCP) is a fairly common procedure being performed in several centers worldwide. Although it is proven to be efficient and relatively safe, complications do occur (1.8%). We present a patient with ERCP-induced retroperitoneal perforation of the duodenum treated laparoscopically at our institution.

Case report: The patient is a 60-year-old female who underwent ERCP for obstructive jaundice due to periampullary carcinoma, during which the perforation occurred. Laparoscopy was performed 5 hours later and the perforation sutured primarily.

Results: The operating time was 125 minutes. On the fourth postoperative day, the patient developed a retroperitoneal collection, confirmed by computed tomographic scan. Re-look laparoscopy was performed and the fluid drained. She recovered completely and was discharged on the eighth postoperative day.

Conclusion: Duodenal perforation following ERCP is rare, with an incidence of 1.8%. Both surgical and non-surgical management have been reported, each with its specific indications. Our patient needed surgery, because the perforation was large and a retroperitoneal collection was present. Laparotomy is the preferred approach, though now laparoscopy is a viable and effective alternative, because it provides the benefits of minimal access, such as reduced pain and early ambulation.

Show MeSH
Related in: MedlinePlus