Yang Jian-feng, Zhang Xiao, Zhang Xiao-feng
Department of Gastroenterology, The First People's Hospital of Hangzhou, Hangzhou, China.
Zhonghua Wei Chang Wai Ke Za Zhi. 2012 Jul;15(7):682-6.
To summarize the experience with duodenal perforations to determine a systematic management approach.
A total of 11 250 patients who received endoscopic retrograde cholangiopancreatography(ERCP) in The First People's Hospital of Hangzhou from January 2005 to December 2011 and 15(0.13%) patients developed duodenal perforation. The clinical data of these 15 cases were analyzed.
There were 6 males and 9 females. The age ranged from 45 to 87 years. Seven patients developed perforation after sphincterotomy of the duodenal papilla. Five patients perforated due to the endoscope, and 3 due to guide wire and net basket. All the patients presented varying degree of abdominal pain and distention. CT scan of the upper abdomen showed peripancreatic and retroperitoneal air or fluid. Diagnosis was confirmed in 7 patients using abdominal X-ray. Eight patients developed postoperative abdominal pain and distention, subcutaneous emphysema, and fever 3 hours to 5 days after surgery, and diagnosis was confirmed using plain abdominal X-ray or upper abdominal CT scan. Nine patients were managed conservatively, 4 of whom were diagnosed within 3 hours after perforation and were managed by endoscopic metal clip and nasobiliary drainage and no abdominal abscesses developed. The length of hospital stay ranged from 10 to 15 days. Five patients were diagnosed 10 hour to 5 days after perforation, of whom 2 had intestinal fistula, 4 had abscess, and one died, the length of hospital stay ranged from 15 to 105 days. Six patients were managed surgically, 4 received surgery within 4 to 8 hours after perforation and no abscess developed, and the length of hospital stay ranged from 18 to 21 days. The other 2 patients were operated at 24 hours and 30 hours after perforation respectively, one of whom had recurrent intra-abdominal bleeding after surgery and one died from intra-abdominal abscess and multiple organ failure.
For duodenal perforations related to ERCP, early diagnosis can be made by prompt intraoperative identification and postoperative CT scan. Endoscopic metal clip and nasobiliary drainage should be considered aside from surgical intervention.
总结十二指肠穿孔的经验，以确定系统的管理方法。
2005年1月至2011年12月期间，杭州市第一人民医院共有11250例患者接受了内镜逆行胰胆管造影术（ERCP），其中15例（0.13%）发生十二指肠穿孔。分析这15例患者的临床资料。
男性6例，女性9例。年龄在45至87岁之间。7例患者在十二指肠乳头括约肌切开术后发生穿孔。5例因内镜穿孔，3例因导丝和网篮穿孔。所有患者均出现不同程度的腹痛和腹胀。上腹部CT扫描显示胰周和腹膜后有气体或液体。7例患者通过腹部X线确诊。8例患者术后3小时至5天出现腹痛、腹胀、皮下气肿和发热，通过腹部平片或上腹部CT扫描确诊。9例患者采取保守治疗，其中4例在穿孔后3小时内确诊，采用内镜金属夹和鼻胆管引流治疗，未发生腹腔脓肿。住院时间为10至15天。5例患者在穿孔后10小时至5天确诊，其中2例发生肠瘘，4例有脓肿，1例死亡，住院时间为15至105天。6例患者接受手术治疗，4例在穿孔后4至8小时内接受手术，未发生脓肿，住院时间为18至21天。另外2例患者分别在穿孔后24小时和30小时接受手术，其中1例术后腹腔内反复出血，1例死于腹腔脓肿和多器官功能衰竭。
对于与ERCP相关的十二指肠穿孔，可通过术中及时识别和术后CT扫描进行早期诊断。除手术干预外，应考虑内镜金属夹和鼻胆管引流。
