Endoscopic treatment of ERCP-related duodenal perforation

Duodenal perforation following ERCP is an unusual but severe adverse event. Prompt recognition improves clinical outcomes including mortality, thus endoscopists should have a low threshold to consider perforation in those with abdominal pain, hemodynamic perturbation, and atypical fluoroscopy findings. Classification of perforations as retroperitoneal/periampullary vs free/remote from the papilla is important as the former can be managed nonoperatively in most cases. Nonsurgical therapy typically includes medical therapy supplemented by placement of fully covered self-expandable stents in the bile duct and through-the-scope endoscopic clips over the defect. New endoscopic technology including full thickness suturing devices, over-the-scope clips, fibrin injection, and vacuum therapy may increase the proportion of patients with duodenal perforation who may be amenable to minimally invasive treatment.