From the Guidelines
Retroperitoneal free air after ERCP should be managed with careful assessment and possible closure with through-the-scope clips (TTSCs) or placement of a fully covered self-expandable metal stent (SEMS) into the bile duct across the ampulla, as identified perforations of this type at the time of ERCP may be amenable to endoscopic closure. The management of retroperitoneal free air after Endoscopic Retrograde Cholangiopancreatography (ERCP) is crucial to prevent complications and ensure patient safety. According to the AGA clinical practice update on endoscopic management of perforations in the gastrointestinal tract, expert review 1, type 2 periampullary (retroperitoneal) perforations can be subtle and easily missed, emphasizing the need for careful assessment of the gas pattern on fluoroscopy and consideration of computed tomography scan if there is concern for such a perforation. Key considerations in management include:
- Careful assessment of the gas pattern on fluoroscopy to identify potential perforations
- Requesting a computed tomography scan if there is concern for a retroperitoneal perforation
- Endoscopic closure with TTSCs or placement of a fully covered SEMS into the bile duct across the ampulla if feasible
- Monitoring for signs of infection, peritonitis, or sepsis, and considering surgical intervention if necessary, although this is rarely needed. The approach to management should prioritize minimizing complications and promoting spontaneous healing, as supported by the latest clinical practice update 1.
From the Research
Management of Retroperitoneal Free Air after ERCP
The management of retroperitoneal free air after Endoscopic Retrograde Cholangiopancreatography (ERCP) depends on several factors, including the size and location of the perforation, the patient's overall health, and the presence of any underlying medical conditions.
- The primary approaches to treat retroperitoneal infections, which can be a complication of ERCP, include controlling the source of infection, rational use of antibiotic agents, and nutritional interventions 2.
- In cases of retroperitoneal perforation after ERCP, the "5R model" of management can be followed: recognize, react, reach out, repent, and revisit 3.
- Most perforations of the gastrointestinal tract during ERCP can be managed nonoperatively, especially if they are retroperitoneal and occur during sphincterotomy 4.
- Patients with remote perforation or altered foregut anatomy usually require surgical intervention 4.
- The presence of air or fluid in the retroperitoneal space after ERCP, particularly in the right anterior pararenal space and perirenal space, can indicate periampullary perforation 5.
- Digital fluoroscope detection of retroperitoneal free air or contrast medium leakage can facilitate the diagnosis of ERCP-related perforations 6.
Diagnostic Approaches
- Computed tomography (CT) is primarily used to diagnose retroperitoneal infection 2.
- Digital fluoroscopy can detect retroperitoneal free air or contrast medium leakage, facilitating the diagnosis of ERCP-related perforations 6.
- Endoscopy may not always detect perforations immediately, and subsequent digital fluoroscopy may be necessary 6.
Treatment Options
- Nonoperative management, including conservative treatment and trans-arterial embolization to control bleeding, can be effective for some patients with retroperitoneal perforation after ERCP 4, 6.
- Surgical intervention may be necessary for patients with remote perforation, altered foregut anatomy, or those who do not respond to nonoperative management 4, 6.
- Minimally invasive drainage technologies, such as ultrasound/CT-guided puncture and drainage, can shorten the treatment cycle and disease burden for patients with retroperitoneal infections 2.