Murphy’s Law in ERCP complications

Murphy’s Law: Anything that can go wrong will go wrong.

This is appropriate for the occurrence and treatment of ERCP complications.

It enlightens us with the principles we shall stick to in the treatment of complications of ERCP. Firstly, to prevent its occurrence from every possibility that has the tendency. Secondly, always keep yourself in a rational mood.

Changhai Digestive Disease and Gastrointestinal Endoscopy Week& Conference of Digestive System Endoscope of Shanghai Medical Association & 22nd Chinese Symposium on Endoscopic Ultrasonography has been held last week in China.  What impressed us is that ERCP nursing training course , a book with full practical experience and understanding of theory , written by the nursing team of endoscopy center of Oriental Hepatobiliary, affiliated surgery hospital to the Second Military Medical University , was brought to us.

Today we pick up the pearl from the ERCP forum and give some reference on the perforation treatment of ERCP complications.

1. Risk factors for ERCP perforation

Anatomic reason

- Upper gastrointestinal stenosis/diverticulum (especially the upper duodenal Angle)

- After Bill-roth II surgery or Roux-en-y surgery, the intestinal tract is angular or narrow.

Associated with disease

- Diverticular papilla with large stone

- Bile duct stenosis, improper timing of dilatation or internal diameter selection

Operation related

- Needle knife pre-cut with improper depth

- Violent action in stone extraction

- Laser lithotripsy

- Emergent lithotripsy near the papilla

-EUS-BD /PD, etc

2. Relationship between perforation and operator

ERCP student: type I perforation (duodenal ball descending junction)

Junior ERCP physician: type II perforation (precut related, EST related)

Senior ERCP physician:

- Difficulty in guide wire selection intubation

- Difficulty in stone extraction

- Gastrointestinal reconstruction

- EUS-BD /PD

3. Indications of perforation

4. Perforation treatment

Effect: Intraoperative treatment > early treatment after operation > late treatment after operation

The treatment methods as below: the decompression tube was placed at the perforation location and the jejunal nutrient tube was implanted.

Type I: perforation closure by the use of titanium clips and nylon loops

Type II: perforation closure by metal covered stent with titanium clip for fixation, associated with gastrointestinal decompression

Type III: implant the nasal biliary stent or plastic stent