Endoscopic retrograde cholangiopancreatography-related adverse events: What is the role of surgery today?

Abstract

Endoscopic retrograde cholangiopancreatography (ERCP) plays a vital role in managing biliary and pancreatic diseases but carries a risk of severe complications that may require surgical intervention. This review focuses on the surgical management of key ERCP-related complications: Post-sphincterotomy bleeding, perforations, stent migration-induced perforations, and Dormia basket impaction. Although many complications can be managed endoscopically, surgery remains essential in refractory cases or when less invasive methods fail. Post-sphincterotomy bleeding, although often controlled endoscopically, may necessitate surgical ligation when hemorrhage persists. Perforations, classified by anatomical type, require tailored surgical approaches - primary repair for type I and biliary diversion with defect closure for types II and III. Stent migration-induced perforations, which may lead to peritonitis or abscess formation, often require surgery due to their variable clinical presentation and the lack of standardized management guidelines. Dormia basket impaction, although rare, may require advanced endoscopic techniques or laparoscopic retrieval if conservative measures prove ineffective. Early recognition, multidisciplinary collaboration, and individualized treatment strategies are pivotal in reducing morbidity and mortality. This review underscores evolving surgical approaches, emphasizing the importance of timely, patient-specific decisions to improve outcomes in severe ERCP-related complications.

Key Words: Endoscopic retrograde cholangiopancreatography complications; Surgical management; Post-sphincterotomy bleeding; Perforation; Stent migration; Dormia basket impaction

Core Tip: Surgical management of post-endoscopic retrograde cholangiopancreatography complications remains crucial despite advancements in endoscopic techniques. This review highlights rare but serious adverse events - post-sphincterotomy bleeding, perforation, stent migration, and Dormia basket impaction - emphasizing diagnostic strategies, therapeutic approaches, and surgical interventions when non-operative methods fail. Early recognition and tailored management, guided by the type of complication and the patient’s condition, are essential for improving outcomes. The review offers an updated, practical overview to assist clinicians in managing these challenging scenarios, particularly when surgery becomes the final - but life-saving - resort.

INTRODUCTION

Endoscopic retrograde cholangiopancreatography (ERCP) has revolutionised the field of gastroenterology by offering minimally invasive approaches for treating conditions such as choledocholithiasis, biliary strictures, and pancreaticobiliary malignancies. Despite its effectiveness, ERCP is not without complications; a range of adverse events, from minor to life-threatening, may occur during or after these procedures. Complications affect approximately 10% of patients, primarily due to technical issues or patient-related factors such as sphincter of Oddi dysfunction, anatomical variations, or a history of benign or malignant gastroduodenal surgery[1,2].

The most common adverse events associated with ERCP are pancreatitis, with an incidence ranging from 3.5% to 9.7%; infections, including cholecystitis and cholangitis, in 1.4% of cases; and bleeding, occurring in 0.3% to 9.6% of cases, which results in a negligible mortality rate (0.04%). On rare occasions, post-sphincterotomy bleeding (PSB) that does not respond to endoscopic or interventional radiological treatment may necessitate surgery (fewer than 10% of all cases)[3].

Perforations are relatively rare, occurring in 0.08% to 0.6% of ERCP procedures, but they represent one of the most serious complications; associated mortality may reach 0.06%[3,4]. Perforations can present as either extraluminal or intraluminal, with widely varying clinical manifestations and management strategies[5]. Several other complications, though rare, are documented in the international literature primarily as single case reports or short series, highlighting significant disparities in treatment approaches and outcomes. Biliary or pancreatic stents may migrate from their intended positions, potentially causing obstruction, infection, or even vascular injury. Stent migration can also result in visceral perforation[6]; however, such perforation remains a rare complication.

Dormia basket impaction - characterized by the entrapment of retrieval baskets within the biliary ducts or fracture of the traction wire - is an extremely rare complication that presents considerable challenges during extraction. It typically occurs in high-volume centres and often requires innovative techniques or surgical retrieval[7]. Among the complications encountered during ERCP, bleeding, perforation, perforation due to stent migration, and basket impaction present the most significant challenges. These complications demand prompt recognition and intervention, including surgical management[8]. If left untreated, they pose immediate risks to patient well-being and may lead to prolonged hospitalization, increased healthcare costs, and long-term sequelae.

Despite advances in endoscopic instrumentation, imaging modalities, and procedural techniques aimed at reducing these complications, their occurrence remains a significant concern in clinical practice. Moreover, the optimal management strategy of these complications - particularly those requiring surgical intervention - involves a wide range of often inconsistent treatments, reflecting the complexity and variability of individual cases. This narrative review aims to provide a comprehensive overview of ERCP-related complications that necessitate surgical intervention. It also examines the incidence, clinical manifestations, diagnostic strategies, and therapeutic approaches associated with these complications.

LITERATURE REVIEW

A comprehensive literature search was conducted to examine the surgical management of post-ERCP complications. The databases PubMed, Scopus, and Web of Science were utilised to identify relevant studies published up to May 2024. Keywords used in the search strategy included ‘post-ERCP complications’, ‘surgical management’, ‘perforations’, ‘post-sphincterotomy bleed’, ‘Dormia basket impaction’, and ‘stent migration’. Articles were selected based on their relevance, inclusion of surgical intervention details, and availability of outcome data. Both retrospective and prospective studies were considered. Review articles and case reports were also included due to the low incidence of post-ERCP complications requiring surgical intervention. Data extraction focused on types of complications, surgical management strategies, surgical techniques employed, postoperative outcomes, and mortality. All complications are summarised in Table 1.

Table 1 Overview of key aspects related to endoscopic retrograde cholangiopancreatography and its complications, including types, risk factors, clinical presentation, diagnostic approach, management strategies, and prognosis.

	Key points
Introduction	ERCP is a valuable but high-risk procedure, mainly for therapeutic purposes (e.g., bile duct stone extraction, stent placement)
Complication types	Includes pancreatitis (most common), bleeding (intraprocedural or postprocedural), perforation (duodenal, biliary tract), infection (cholangitis, cholecystitis, liver abscess), cardiopulmonary complications, post-sphincterotomy bleeding, perforation by stent migration, Dormia basket impaction
Risk factors	Patient-related (e.g., young age, sphincter of Oddi dysfunction), procedure-related (e.g., difficult cannulation, multiple attempts)
Clinical presentation	Varies by complication: Abdominal pain, fever, jaundice, anemisation, hypotension, signs of peritonitis
Diagnostic approach	Imaging: Ultrasound, CT, MRCP. Lab tests: blood count, CRP and inflammatory markers, amylase/lipase, liver function tests
Management strategies	Supportive care (fluids, analgesia), antibiotics for infection, endoscopic management. For severe cases (e.g., perforation, large bile leaks) surgical intervention
Prognosis	Most complications resolve with timely diagnosis and appropriate management. Severe cases require multidisciplinary care

This table provides a concise reference for understanding the challenges associated with endoscopic retrograde cholangiopancreatography and the importance of early detection and appropriate intervention. ERCP: Endoscopic retrograde cholangiopancreatography; CT: Computed tomography; MRCP: Magnetic resonance cholangiopancreatography; CRP: C-reactive protein.

DIAGNOSIS AND EARLY RECOGNITION

The diagnosis of ERCP-related complications requires a prompt and accurate approach. An initial thorough clinical assessment of the patient is essential, combined with laboratory test results and appropriate imaging strategies to provide a comprehensive evaluation of the patient’s condition[3]. From a laboratory perspective, several tests play a fundamental role in detecting ERCP-related complications. Serum amylase and lipase are essential for diagnosing post-ERCP pancreatitis, while a complete blood count helps identify leukocytosis or anaemia resulting from bleeding. Inflammatory markers such as C-reactive protein and erythrocyte sedimentation rate provide valuable information on the presence and severity of inflammation, as seen in cases of perforation. Additionally, liver function tests - including bilirubin, transaminases, alkaline phosphatase, and gamma-glutamyl transferase - are necessary to assess potential biliary obstruction or cholangitis. Among imaging studies, abdominal ultrasound often serves as the first step, as it enables the detection of fluid collections or bile duct dilation. However, for a more detailed assessment, contrast-enhanced abdominal computed tomography (CT) is crucial for identifying complications such as pancreatitis, perforation, bleeding, or stent migration[1,4]. Additionally, magnetic resonance cholangiopancreatography provides high-resolution images of the biliary and pancreatic ducts, making it particularly useful in cases of suspected strictures or bile leaks[3]. By integrating clinical evaluation, laboratory findings, and imaging techniques, early recognition of complications becomes possible, enabling timely intervention, improving prognosis, and optimising patient management.

PSB

PSB may occur during the procedure or as a delayed event. Advances in endoscopic techniques have significantly improved the management of this complication, making surgery a last-resort option. However, the optimal surgical technique remains poorly standardised. Management of PSB should follow a stepwise approach, beginning with less invasive methods and escalating to more complex surgical interventions if necessary[9]. Initially, balloon tamponade followed by the injection of diluted epinephrine (1:10000) should be promptly administered[10]. If epinephrine fails to achieve haemostasis, thermal therapies such as heater probes or monopolar coagulation may be employed. Should these methods prove ineffective, endoscopic clips can be used to control bleeding[11-14]. In cases of severe or refractory bleeding, fully covered self-expanding metal stents can serve as either rescue or primary therapy. These stents effectively control bleeding but require timely removal to avoid further complications such as migration and in-stent occlusion[15,16]. Fibrin glue and hemostatic powder have also demonstrated high success rates in achieving haemostasis in refractory cases. They offer a valuable option when other methods fail, even in cases of massive bleeding with poor visualisation of the bleeding site[17,18]. In cases of refractory PSB, angiographic embolisation achieves high haemostatic rates but is associated with significant mortality, particularly in patients with coagulopathy[19].

Open surgical ligation of the bleeding artery, although rarely required, should be reserved for situations in which embolisation attempts are unsuccessful[5,19]. Current literature does not extensively address the surgical management of PSB. A 2013 study by Dunne et al[19] reported on the interventional radiological management of PSB in a case series of 11 patients; one patient underwent surgical treatment after repeated embolization attempts failed to control bleeding from the inferior pancreaticoduodenal artery. The gastroduodenal artery is most frequently involved in PSB, followed by the superior and inferior pancreaticoduodenal arteries. Open surgical ligation - typically of the gastroduodenal artery - is required in approximately 10% of cases following failed embolisation[5,19,20]. Early intervention is crucial to achieve effective haemostasis (Figure 1).

Figure 1 Algorithmic approach to post-sphincterotomy bleeding, outlining the management strategies for complete sphincterotomy-related bleeding and massive bleeding. Treatment options include balloon tamponade, epinephrine injection, mechanical therapies (through-the-scope clip, metal stent), thermal therapy, angiography, embolisation, and surgical ligation when necessary. TTSC: Through-the-scope clip.

PERFORATIONS

Perforations occur in 0.4%[4] to 1.67% of ERCP procedures and carry a mortality rate of up to 8%[1]. Although rare, this complication often requires endoscopic management, with surgery becoming necessary in selected cases[4,21,22]. Howard et al[23] and Stapfer et al[24] proposed classification systems for ERCP-related perforations, categorising lesions by anatomical location and causal mechanism to guide treatment (Table 2). Stapfer’s widely adopted classification defines four types of perforations. Given their heterogeneity, optimal management remains debated and depends on the lesion type: (1) Type I requires defect closure; (2) Type III, bile diversion; (3) Type II, both closure and diversion; or (4) Type IV generally warrants conservative treatment (Figure 2).

Figure 2 Algorithmic approach to the management of endoscopic retrograde cholangiopancreatography-related perforations, outlining diagnostic and therapeutic strategies. Treatment options include endoscopic interventions (through the scope and over the scope clipping), conservative management (nasogastric/nasojejunal tube placement, antibiotics, and fasting), and advanced techniques such as endoscopic ultrasound-guided drainage or surgical intervention for severe cases. ERCP: Endoscopic retrograde cholangiopancreatography; TTS: Through the scope; OTS: Over the scope; NG: Nasogastric; NJ: Nasojejunal; EUS: Endoscopic ultrasound.

Table 2 Endoscopic retrograde cholangiopancreatography perforations.

Type of perforation	Stapfer (most used)	Howart	Incidence
Type I	Duodenal wall perforation (by endoscope)	Duodenal perforation remote from papilla	18%
Type II	Periampullary perforation (precut/sphincterotomy)	Periampullary retroperitoneal perforation	58%
Type III	Biliary or pancreatic duct perforation (by intraductal instrumentation)	Guidewire related perforation	13%
Type IV	Retroperitoneal gas alone	-	11%

Classification of endoscopic retrograde cholangiopancreatography-related perforations according to the Stapfer and Howart systems, including incidence rates. This table highlights the different types of perforations based on their anatomical location and mechanism of injury, providing a comparative perspective between the two classification methods.

Several endoscopic techniques are available for defect closure. Through-the-scope clips can be applied via a duodenoscope or a forward-viewing scope with a distal cap. Large defects may require multiple through-the-scope clips, the loop-and-clip technique, or over-the-scope clips. Early diagnosis and endoscopic treatment facilitate quicker resumption of oral intake and shorter hospital stays[21,22]. For type II or III perforations, biliary diversion with stent placement is effective. Fully covered self-expandable metal stents are preferred due to their superior pain relief, shorter hospital stays, and lower retroperitoneal abscess rates. Additional supportive measures include nil per os status, nasogastric or nasojejunal suction, and proton pump inhibitors to reduce fluid load at the perforation site, as well as drainage of retroperitoneal collections via percutaneous drainage or endoscopic ultrasound-guided internal drainage.

Although open surgery has become less common, non-operative management is not always sufficient. Surgical intervention is necessary if drainage fails, major leaks occur, or severe peritonitis and sepsis develop. Procedures include primary defect repair, abdominal wash, percutaneous drainage, or gastrojejunostomy, depending on the timing of perforation, patient condition, and defect characteristics. While primary surgery is required in about 5% of cases, 11% may need salvage surgery following failed non-surgical treatment[5]. Dahale et al[25] reported that type I lesions require open surgical intervention in 0.04% of cases. A 2017 systematic review found that delayed surgery (more than 24 hours post-ERCP) for type I injuries leads to more complex procedures and higher mortality[1]. Similarly, Samara et al[8] emphasised the importance of immediate evaluation by an experienced surgeon or endoscopist, highlighting the critical role of timing in treatment decisions. When conservative management fails, postoperative mortality for type I lesions reaches an alarming 75%.

For type II perforations diagnosed intraoperatively or post-procedure in non-septic patients with mild lumbar pain and minimal or no contrast extravasation, endoscopic or medical management with biliary stenting and/or clipping proves effective. Persistent retroperitoneal collections may require percutaneous or ultrasound-guided drainage. Surgery becomes necessary when initial strategies fail or in cases of severe sepsis, as delayed intervention increases mortality[5,23]. A posterior laparotomic approach benefits patients with prior partial gastrectomy and reconstruction by facilitating better drainage, reducing contamination, and minimising the risk of jejunal injury. Additionally, perforation of the afferent loop during duodenoscope cannulation necessitates prompt surgical intervention[26]. For type III injuries, conservative treatment succeeds in 95% of cases. However, surgery may be necessary in instances of persistent intra- or retroperitoneal collections, residual stones, or instrument entrapment in the biliary tract that cannot be managed endoscopically. The postoperative mortality rate following failed conservative management is 75% for type I lesions, 22% for type II, and 0% for type III.

PERFORATION DUE TO STENT MIGRATION

Following endoscopic biliary stent placement, dislocation and migration occur in approximately 8.5% of cases[27]. In some instances, the stent becomes lodged, leading to further complications such as luminal perforation of the gastrointestinal tract, which occurs in around 1% of cases[28]. As such, perforation due to biliary stent migration represents a significant complication, although it is not addressed in current guidelines. Plastic stents carry a higher risk of intestinal migration and perforation, with a mortality rate of up to 10.3%. Perforations most commonly occur in the duodenum, followed by the large intestine, small intestine, and bile duct. Surgical intervention is frequently required and remains the preferred treatment option[6].

Retroperitoneal perforation caused by stent migration is more common than intraperitoneal perforation, although the latter tends to be more severe. In most cases, the perforation occurs in a delayed fashion - days to weeks after placement - though, in rare cases, it can arise as early as 24 hours post-insertion[29]. The stent often migrates and remains within the intestinal lumen for extended periods, occasionally leading to complications such as pelvic abscess formation[30]. The treatment of stent-induced perforation depends on several factors: The patient’s general condition, the site of injury (duodenum, small or large bowel), the size and type of perforation (intraperitoneal or retroperitoneal), and the surgical and endoscopic expertise available at the centre. Conservative management and endoscopic treatment are appropriate for patients in stable condition with small intestinal wall defects and in the absence of large fluid collections and/or peritonitis. Surgical management is indicated for patients with peritonitis or retroperitoneal fluid collection - one of the typical consequences of perforation - alongside complications such as colovesical and colocutaneous fistula[31,32].

In a 2018 study[33], most patients underwent surgical treatments, which typically resulted in uneventful postoperative recovery and effective management of peritonitis and/or abscesses. Immediate surgical intervention, such as colostomy or primary anastomosis, remains the first-line treatment. However, endoscopic treatment is more appropriate when a covered or limited perforation is present without any evidence of peritonitis. The approach is also advisable if a distally migrated biliary stent is identified during a routine examination in patients with risk factors for perforation[34]. Intestinal perforation resulting from stent migration rarely necessitates complex surgery[35]. Therefore, proper follow-up and clear communication with the patient - particularly in the elderly population - are essential to prevent major complications such as mispositioning, rupture, migration, obstruction, and infection of stents[36].

BASKET IMPACTION

During an ERCP procedure, stones are typically removed using a Dormia basket or balloon catheter. This technique has a 90% success rate for extracting stones from the common bile duct. The Dormia basket comprises four radially arranged stainless steel wires positioned at 90 degrees, which open to capture the stone[37]. Basket impaction or wire rupture occurs in approximately 0.8% to 6% of cases, usually when the stone exceeds 20 mm in size, leading to the entrapment of both the basket and the stone[7,38,39].

Retention may result from the inability to manipulate the basket, either due to wire rupture in the Dormia basket itself or in a mechanical lithotripter. Basket impaction is defined as the inability to retrieve the basket and stone through the papillary orifice or to separate the stone from the basket within the biliary lumen. This complication can lead to cholangitis, pancreatitis, and migration; therefore, urgent resolution is essential. Due to its rarity, there is no universal consensus on the optimal removal technique.

The most common site of Dormia basket impaction is the ampulla of Vater. Several techniques have been described for managing this complication, including extracorporeal shock wave lithotripsy (ESWL), balloon dilation, use of a second Dormia basket, salvage mechanical lithotripsy, laser lithotripsy, rat tooth forceps, sphincterotomy extension, and open or laparoscopic surgery[38]. A more recent technique involves cholangioscope-guided electrohydraulic lithotripsy[40]. ESWL remains the most widely used treatment; however, additional endoscopy procedures are often required to remove the impacted basket and stone fragments and to achieve complete duct clearance. Not all centres, however, have the resources to utilise this technique[41].

Surgical intervention may be necessary when extraction of the basket and stone from the papillary orifice proves impossible. This step is generally reserved for cases in which disimpaction using ESWL, balloon dilation, or minimally invasive laparoscopic techniques has failed[7]. Laparoscopic common bile duct exploration can serve as an alternative treatment in such cases. The success of this approach depends on the surgeon’s expertise and the availability of appropriate equipment. Bile leakage due to retained stones - reported in 10% to 14% of cases - is the most common complication and often necessitates a subsequent ERCP[37,38]. Multiple studies indicate that primary closure following choledochotomy, as opposed to the placement of a Kehr tube after laparoscopic common bile duct exploration, reduces operating time, hospital stay, and the incidence of complications such as bile leakage, electrolyte imbalances, drain displacement, biliary peritonitis, infections, and fistulas. Therefore, primary closure is considered the preferred technique[37].

CONCLUSION

Early recognition and appropriate management of post-ERCP complications are essential to optimise patient outcomes and minimise morbidity. Although most complications can be managed conservatively through endoscopic or interventional radiological approaches, surgical intervention remains crucial in select, refractory cases. Advances in endoscopic technology and therapeutic strategies have continued to reduce the reliance on surgery; however, in rare instances, timely and tailored surgical management can be lifesaving. A multidisciplinary approach involving endoscopists, surgeons, and interventional radiologists is vital to achieving the best possible outcomes, particularly in complex or high-risk patients.