Duodenal Perforations After Endoscopic Retrograde Cholangiopancreatography

Dear Editor:

This letter is in regard to the article published in your journal from the month of June, entitled “Duodenal perforations after endoscopic retrograde cholangiopancreatography” by Dr. Armas Ojeda et al.¹ First of all, we would like to congratulate the authors for the article about their experience as well as their clear, detailed report.

However, we would like to touch on a specific related aspect. In the classification by Stapfer et al.,² perforations are divided into types i–iv, which is not mentioned in the article. Type 4 perforations are due to the use of compressed air to maintain intraluminal visualisation during endoscopic retrograde cholangiopancreatography (ERCP) and are not true perforations. They are seen as retroperitoneal or subcutaneous air and do not usually require surgical treatment as they normally respond very well to conservative treatment. Therefore, in the series presented, there are no type IV perforations. However, 3 cases of subcutaneous emphysema are observed, and in 5 patients with supposed type II perforations, no such perforations were found during surgery. Thus, it is probable that some of the patients classified as having type iiperforations actually had type ivperforations.

Coincidentally, we have recently presented our experience at the Andalusian Association of Surgeons Conference held in Torremolinos, Malaga, from June 17 to 19, 2015.³ Our series included 11 patients diagnosed with post-ERCP between June 2010 and June 2014, which represents 0.6% of all ERCP procedures done. In 5 patients (3 type IV and 2 type II), conservative treatment resulted in good patient progress in 100% of the cases. The other 6 patients were treated surgically (one type i, 4 type ii and one type iii), with a mortality rate of 50%, which was probably related with an overly delayed diagnosis that led to a poor patient condition. In our experience, therefore, we believe that there are 2 fundamental factors in the prognosis and treatment of post-ERCP perforations: the time transpired, as early treatment and diagnosis are vital; and the type of perforation, using the most widely accepted classification by Stapfer et al., as we have previously mentioned.

Conflict of Interests

The authors have no conflict of interests.