Arabpour Erfan, Sadeghi Amir, Shojaee Sajad, Tabatabaie Negin, Khoshdel Sina, Pouladi Amirreza, Abdehagh Mohammad, Zali Mohammad Reza
Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
Basic and Molecular Epidemiology of Gastrointestinal Disorders Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
Indian J Gastroenterol. 2025 Jun 13. doi: 10.1007/s12664-025-01788-2.
Endoscopic retrograde cholangiopancreatography (ERCP)-related perforations (EPs) are rare but serious adverse events, with a reported frequency of 0.4% to 0.6% and mortality rates reaching 8%. The lack of a uniform classification system for injury patterns and evidence-based management guidelines poses significant challenges in clinical decision-making. This systematic review evaluates therapeutic approaches and outcomes of EPs using the Stapfer classification to address these gaps.
We conducted a systematic review of studies that utilized the Stapfer classification to categorize EPs into four types, ranked by severity: type I (lateral/medial duodenal wall perforation), type II (periampullary injuries), type III (bile duct injuries) and type IV (retroperitoneal air alone). The study protocol was registered in PROSPERO (ID CRD42023473841).
Among 287 patients from 18 eligible studies, type-I perforations were associated with significantly higher mortality (adjusted OR = 3.17, 95% CI 1.45-6.99). Surgical management did not significantly increase mortality risk compared to non-operative treatment (adjusted OR = 1.99, 95% CI 0.66-6.00) but was linked to prolonged hospital stays (coefficient 8.58, 95% CI 2.71-14.46). In contrast, perforation type did not significantly influence hospitalization duration (coefficient - 0.64, 95% CI - 4.04 to 2.76).
Our findings underscore the need for individualized treatment strategies based on perforation type and patient-specific factors. While the Stapfer classification aids in risk stratification, the heterogeneity of current evidence limits generalizability. Large-scale prospective studies are essential to establish standardized management protocols.
内镜逆行胰胆管造影术（ERCP）相关穿孔（EP）是罕见但严重的不良事件，报告发生率为0.4%至0.6%，死亡率达8%。缺乏统一的损伤模式分类系统和基于证据的管理指南给临床决策带来了重大挑战。本系统评价采用斯塔弗分类法评估EP的治疗方法和结局，以填补这些空白。
我们对利用斯塔弗分类法将EP分为四种类型（按严重程度排序：I型（十二指肠侧壁/内侧壁穿孔）、II型（壶腹周围损伤）、III型（胆管损伤）和IV型（仅腹膜后积气））的研究进行了系统评价。研究方案已在国际前瞻性注册系统（ID CRD42023473841）登记。
在18项符合条件的研究中的287例患者中，I型穿孔的死亡率显著更高（调整后的OR = 3.17，95%CI 1.45 - 6.99）。与非手术治疗相比，手术治疗并未显著增加死亡风险（调整后的OR = 1.99，95%CI 0.66 - 6.00），但与住院时间延长有关（系数8.58，95%CI 2.71 - 14.46）。相比之下，穿孔类型对住院时间没有显著影响（系数 - 0.64，95%CI - 4.04至2.76）。
我们的研究结果强调了基于穿孔类型和患者个体因素制定个体化治疗策略的必要性。虽然斯塔弗分类法有助于风险分层，但当前证据的异质性限制了其普遍性。大规模前瞻性研究对于建立标准化管理方案至关重要。
