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Systematic review

Vol. 150 No. 1314 (2020)

Systematic review of pneumothoraces after endoscopic retrograde cholangiopancreatography

  • Lehmann Virgilio
  • Keller Walther
  • Egger Bernhard
DOI
https://doi.org/10.4414/smw.2020.20199
Cite this as:
Swiss Med Wkly. 2020;150:w20199
Published
03.04.2020

Summary

AIMS OF THE STUDY

Pneumothoraces after endoscopic retrograde cholangiopancreatography (ERCP) are an uncommon but potentially lethal complication. Little evidence is available on their epidemiology, diagnosis and therapy. We aimed to evaluate current practices and provide recommendations.

METHOD

We systematically reviewed articles from PubMed, Embase, OVID-Medline and the Cochrane Library.

RESULTS

Forty-four publications reported pneumothoraces after ERCP in 49 patients (74% females). Twenty-one patients (43%) had atypical gastrointestinal anatomy, including peri-ampullary diverticula (n = 8), surgical or endoscopic alterations (n = 7), local tumours (n = 3), ulcerations (n = 2) and ectopic papilla (n = 1). Precut (14%) or standard (39%) sphincterotomies were performed. Cannulation was unsuccessful in six ERCPs. Pneumothoraces occurred bilaterally (45%), on the right (37%) or left side (6%), or no side was stated (12%). Nineteen tension pneumothoraces occurred. Perforations were mainly caused by the sphincterotome, peri-ampullary (41%), or the endoscope, distant from the papilla of Vater (23%). Pneumothoraces were sometimes diagnosed only after hospital discharge (14%). Eighteen patients underwent surgical therapy with drainage, repair and/or bypass. Conservative treatment included antibiotics and bowel rest. Most pneumothoraces were drained; 14% resolved without pleural drainage. Overall mortality was 4%. The mean hospital stay was 9.8 days.

CONCLUSIONS

A post-ERCP pneumothorax should be considered when subcutaneous emphysema, cardiovascular instability or respiratory distress occurs. Thoraco-abdominal computed tomography facilitates identification and therapy tailoring. Because of possible late or discrete onset, patients should be monitored carefully.

References

  1. Loperfido S Angelini G Benedetti G Chilovi F Costan F De Berardinis F Major early complications from diagnostic and therapeutic ERCP: a prospective multicenter study. Gastrointest Endosc. 1998;48(1):1–10.https://doi.org/10.1016/S0016-5107(98)70121-X
  2. Jeurnink SM Poley JW Steyerberg EW Kuipers EJ Siersema PD. ERCP as an outpatient treatment: a review. Gastrointest Endosc. 2008;68(1):118–23.https://doi.org/10.1016/j.gie.2007.11.035
  3. Moher D Liberati A Tetzlaff J Altman DG PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Int J Surg. 2010;8(5):336–41.https://doi.org/10.1016/j.ijsu.2010.02.007
  4. Stapfer M Selby RR Stain SC Katkhouda N Parekh D Jabbour N Management of duodenal perforation after endoscopic retrograde cholangiopancreatography and sphincterotomy. Ann Surg. 2000;232(2):191–8.https://doi.org/10.1097/00000658-200008000-00007
  5. Murad MH Sultan S Haffar S Bazerbachi F. Methodological quality and synthesis of case series and case reports. BMJ Evid Based Med. 2018;23(2):60–3.https://doi.org/10.1136/bmjebm-2017-110853
  6. Higgins J, Thomas J, Chandler J, Cumpston M, Li T, Page M, et al. Cochrane Handbook for Systematic Reviews of Interventions version 6.0 (updated July 2019). Cochrane. 2019. Available from www.training.cochrane.org/handbook.
  7. Al-Ashaal YI Hefny AF Safi F Abu-Zidan FM. Tension pneumothorax complicating endoscopic retrograde cholangiopancreatography: case report and systematic literature review. Asian J Surg. 2011;34(1):46–9. Published online April 26, 2011.https://doi.org/10.1016/S1015-9584(11)60018-3
  8. Bartosz C Kovach A Forssell K Winter M Kothari S Ullah A Needle Knife Sphincterotomy for Biliary Access at ERCP: Experience At Two United States Academic Tertiary Referral Centers: 288. Am J Gastroenterol. 2014;109:S88. doi:.https://doi.org/10.14309/00000434-201410002-00288
  9. Colemont LJ Pelckmans PA Moorkens GH Van Maercke YM. Unilateral periorbital emphysema: an unusual complication of endoscopic papillotomy. Gastrointest Endosc. 1988;34(6):473–5.https://doi.org/10.1016/S0016-5107(88)71440-6
  10. Doerr RJ Kulaylat MN Booth FV Corasanti J. Barotrauma complicating duodenal perforation during ERCP. Surg Endosc. 1996;10(3):349–51. Published online March 01, 1996.https://doi.org/10.1007/BF00187390
  11. Ferrara F Luigiano C Billi P Jovine E Cinquantini F D’Imperio N. Pneumothorax, pneumomediastinum, pneumoperitoneum, pneumoretroperitoneum, and subcutaneous emphysema after ERCP. Gastrointest Endosc. 2009;69(7):1398–401.https://doi.org/10.1016/j.gie.2008.08.004
  12. Fujii L Lau A Fleischer DE Harrison ME. Successful nonsurgical treatment of pneumomediastinum, pneumothorax, pneumoperitoneum, pneumoretroperitoneum, and dubcutaneous emphysema following ERCP. Gastroenterol Res Pract. 2010;2010:289135. Published online June 14, 2010.https://doi.org/10.1155/2010/289135
  13. García-Cano J Ferri-Bataller R Gómez-Ruiz CJ. Common bile duct perforation sealed with a metal fully-covered stent. Rev Esp Enferm Dig. 2016;108(8):495–6. Published online August 25, 2016.
  14. Garmon EH Contreras E Conley J. Tension pneumothorax and widespread pneumatosis after endoscopic retrograde cholangiopancreatography. Anesthesiology. 2013;119(3):699.https://doi.org/10.1097/ALN.0b013e31827bcdba
  15. Goddard AG McConomy B Bathla G Furqan M Silverman WB. Air leakage in multiple compartments after endoscopy. Cleve Clin J Med. 2016;83(10):705–7. Published online October 12, 2016.https://doi.org/10.3949/ccjm.83a.15168
  16. Greilich NB Gasanova I Farrell B Joshi GP. The diagnosis and management of patient with delayed symptoms from a tracheal tear. A A Case Rep. 2016;6(8):230–3.https://doi.org/10.1213/XAA.0000000000000289
  17. Gya D Sali A Angus D. Subcutaneous emphysema and pneumothorax following endoscopic sphincterotomy. Aust N Z J Surg. 1989;59(11):900–2.https://doi.org/10.1111/j.1445-2197.1989.tb07038.x
  18. Han M-L Wu Y-M Liu K-L Su W-C Wang H-P. Tension pneumothorax after an ERCP in a patient with hepatic hydrothorax and sealed-off perforated duodenal ulcer. Gastrointest Endosc. 2008;68(4):771–2, discussion 772.https://doi.org/10.1016/j.gie.2008.03.007
  19. Hui C-K Lai K-C Yuen M-F Lam S-K. Tension pneumothorax complicating ERCP in a patient with a Billroth II gastrectomy. Gastrointest Endosc. 2001;54(2):254–6.https://doi.org/10.1067/mge.2001.114962
  20. Iyilikci L Akarsu M Duran E Sarikaya HB Biyikli B. Duodenal perforation and bilateral tension pneumothorax following endoscopic sphincterotomy. J Anesth. 2009;23(1):164–5.https://doi.org/10.1007/s00540-008-0710-7
  21. Keber T Mojškerc K Makuc J. Bilateral Pneumothorax and Subcutaneous Emphysema following Endoscopic Retrograde Cholangiopancreatography with Sphincterectomy. Signa Vitae. 2015;10(2):192–201. doi:.https://doi.org/10.22514/SV102.122015.13
  22. Keskin K Başkurt M Aktürk F Conkbayır C. A rare cause of chest pain mimicking myocardial infarction. Turk Kardiyol Dern Ars. 2014;42(5):472–4.https://doi.org/10.5543/tkda.2014.27163
  23. Kocaman O Sipahi M Cubukçu A Baykara ZN Hülagü S. Porous diaphragm syndrome after ERCP in a patient with bile duct stricture. Turk J Gastroenterol. 2009;20(2):157–8. Published online June 17, 2009.
  24. Kogure H Watabe H Yamada A Isayama H Tsujino T Nagano R Su1456 Therapeutic ERCP Using Short Double-Balloon Enteroscopy in Patients With Surgically Altered Anatomy. Gastrointest Endosc. 2011;73(4):AB271. doi:.https://doi.org/10.1016/j.gie.2011.03.509
  25. Lagoudianakis EE Tsekouras D Papadima A Genetzakis M Pattas M Giannopoulos P Pneumothorax complicating endoscopic sphincterotomy successfully treated conservatively. Acta Gastroenterol Belg. 2006;69(3):342–4. Published online December 16, 2006.
  26. Linssen VD Tan ACITL Schouten JA. Massive subcutaneous emphysema, unilateral pneumothorax, pneumomediastinum and pneumoperitoneum after endoscopic retrograde cholangiopancreatography. Netherlands Journal of Critical Care. 2013;17(4):16–8.
  27. Lopes TL Clements RH Wilcox CM. Laparoscopy-assisted ERCP: experience of a high-volume bariatric surgery center (with video). Gastrointest Endosc. 2009;70(6):1254–9.https://doi.org/10.1016/j.gie.2009.07.035
  28. Lutchmansingh D Ryu C Amzuta I. The Path Less Traveled: Bilateral Pneumothoraces as a Complication of Endoscopic Retrograde Cholangiopancreatography. Chest. 2013;144(4):494A. doi:.https://doi.org/10.1378/chest.1671537
  29. Makni A Chebbi F Ben Safta Z. Pneumoretroperitoneum, bilateral pneumothorax and emphysema following endoscopic biliary sphincterotomy. Acta Chir Belg. 2012;112(4):307–9.https://doi.org/10.1080/00015458.2012.11680844
  30. Markogiannakis H Toutouzas KG Pararas NV Romanos A Theodorou D Bramis I. Bilateral pneumothorax following endoscopic retrograde cholangiopancreatography: a case report. Endoscopy. 2007;39(Suppl 1):E195. doi:.https://doi.org/10.1080/00015458.2012.11680844
  31. Morley AP Lau JYW Young RJ. Tension pneumothorax complicating a perforation of a duodenal ulcer during ERCP with endoscopic sphincterotomy. Endoscopy. 1997;29(4):332.https://doi.org/10.1055/s-2007-1004205
  32. Neofytou K Petrou A Savva C Petrides C Andreou C Felekouras E Pneumothorax following ERCP: Report of two cases with different pathophysiology. Case Rep Med. 2013;2013:206564.https://doi.org/10.1155/2013/206564
  33. Ozgonul A Cece H Sogut O Demir D Kurkcuoglus IC. Pneumoperitoneum, pneumoretroperitoneum and bilateral pneumothorax caused by ERCP. J Pak Med Assoc. 2010;60(1):60–1. Published online January 09, 2010.
  34. Plönes T Reuland A-K Passlick B. Bilateral pneumothoraces, pneumomediastinum and subcutaneous emphysema as a rare complication of endoscopic cholangiopancreatography. BMJ Case Rep. 2012;2012(dec03 1):bcr2012007412.https://doi.org/10.1136/bcr-2012-007412
  35. Rappaport DE Solano JJ Edlow JA. Bilateral pneumothoraces as a complication of endoscopic retrograde cholangiopancreatography. J Emerg Med. 2017;52(4):573–5.https://doi.org/10.1016/j.jemermed.2016.11.023
  36. Samies N 3rd Reidman D Franga D. Diffuse subcutaneous emphysema after endoscopic retrograde cholangiopancreatography with subsequent pneumothorax and pneumomediastinum. Am Surg. 2015;81(2):E67–9.
  37. Sampaziotis F Wiles A Shaukat S Dickinson RJ. Bilateral pneumothorax and subcutaneous emphysema following endoscopic retrograde cholangiopancreatography: a rare complication. Diagn Ther Endosc. 2010;2010:894045. Published online August 11, 2010.https://doi.org/10.1155/2010/894045
  38. Savides T Sherman S Kadell B Cryer H Derezin M. Bilateral pneumothoraces and subcutaneous emphysema after endoscopic sphincterotomy. Gastrointest Endosc. 1993;39(6):814–7.https://doi.org/10.1016/S0016-5107(93)70273-4
  39. Scarlett PY Falk GL. The management of perforation of the duodenum following endoscopic sphincterotomy: a proposal for selective therapy. Aust N Z J Surg. 1994;64(12):843–6.https://doi.org/10.1111/j.1445-2197.1994.tb04561.x
  40. Schepers NJ van Buuren HR. Pneumothorax following ERCP: report of four cases and review of the literature. Dig Dis Sci. 2012;57(8):1990–5. Published online March 31, 2012.https://doi.org/10.1007/s10620-012-2150-3
  41. Schiavon LL Rodrigues RA Nakao FS Di Sena VO Ferrari AP Libera ED Jr. Subcutaneous emphysema, pneumothorax and pneumomediastinum following endoscopic sphincterotomy. Gastroenterol Res. 2010;3(5):216–8. Published online September 20, 2010.https://doi.org/10.4021/gr232w
  42. Schilling M Sailer AS Heinz G Kutilek M. Intrathorakale Perforation von Gallenwegsstents bei St. p. Lebertransplantation. RoFo Fortschr Geb Rontgenstr Nuklearmed. 2014;186(9):887–8.https://doi.org/10.1055/s-0033-1356313
  43. Seymann GB Savides T Richman KM. Massive subcutaneous emphysema after endoscopic retrograde cholangiopancreatography. Am J Med. 2010;123(9):e15–6.https://doi.org/10.1016/j.amjmed.2009.12.040
  44. Shen T-C Chen C-P Chen C-H. An elderly woman with air leakage. Intern Med. 2015;54(5):533–4.https://doi.org/10.2169/internalmedicine.54.3652
  45. Shimatani M Matsushita M Takaoka M Koyabu M Ikeura T Kato K Effective “short” double-balloon enteroscope for diagnostic and therapeutic ERCP in patients with altered gastrointestinal anatomy: a large case series. Endoscopy. 2009;41(10):849–54.https://doi.org/10.1055/s-0029-1215108
  46. Song SY Lee KS Na KJ Ahn BH. Tension pneumothorax after endoscopic retrograde pancreatocholangiogram. J Korean Med Sci. 2009;24(1):173–5. Published online March 10, 2009.https://doi.org/10.3346/jkms.2009.24.1.173
  47. Brueck M Bandorski D Rauber K Lotterer E. [Pneumoretroperitoneum and bilateral pneumothorax after endoscopic biliary sphincterotomy]. Dtsch Med Wochenschr. 2010;135(17):853–6.https://doi.org/10.1055/s-0030-1253667
  48. Menéndez P Padilla D Villarejo P García A. Neumoperitoneo, neumoretroperitoneo, neumotórax bilateral, neumomediastino y enfisema subcutáneo secundario a CPRE. Rev Gastroenterol Peru. 2012;32(1):94–7. [Spanish].
  49. Valkovský J Vrána J Šmíd J Kraus J Kovala P Kremer M Neobvyklá komplikace ERCP. Gastroenterologie a Hepatologie. 2014;68:209–11. Czech. doi:http://redakce.ambitmedia.cz/index.php/gh/article/view/410
  50. Ko CW Lee SP. Epidemiology and natural history of common bile duct stones and prediction of disease. Gastrointest Endosc. 2002;56(6, Suppl):S165–9.https://doi.org/10.1016/S0016-5107(02)70005-9
  51. Williams EJ Taylor S Fairclough P Hamlyn A Logan RF Martin D Risk factors for complication following ERCP; results of a large-scale, prospective multicenter study. Endoscopy. 2007;39(9):793–801.https://doi.org/10.1055/s-2007-966723
  52. Enns R Eloubeidi MA Mergener K Jowell PS Branch MS Pappas TM ERCP-related perforations: risk factors and management. Endoscopy. 2002;34(4):293–8.https://doi.org/10.1055/s-2002-23650
  53. Cotton PB Lehman G Vennes J Geenen JE Russell RCG Meyers WC Endoscopic sphincterotomy complications and their management: an attempt at consensus. Gastrointest Endosc. 1991;37(3):383–93.https://doi.org/10.1016/S0016-5107(91)70740-2
  54. Bhat M Romagnuolo J da Silveira E Reinhold C Valois E Martel M Randomised clinical trial: MRCP-first vs. ERCP-first approach in patients with suspected biliary obstruction due to bile duct stones. Aliment Pharmacol Ther. 2013;38(9):1045–53.https://doi.org/10.1111/apt.12481
  55. Chen Q Jin P Ji X Du H Lu J. Management of difficult or failed biliary access in initial ERCP: A review of current literature. Clin Res Hepatol Gastroenterol. 2019;43(4):365–72.https://doi.org/10.1016/j.clinre.2018.09.004
  56. Maunder RJ Pierson DJ Hudson LD. Subcutaneous and mediastinal emphysema. Pathophysiology, diagnosis, and management. Arch Intern Med. 1984;144(7):1447–53.https://doi.org/10.1001/archinte.1984.00350190143024
  57. Hartin DJ Kendall R Boyle AA Atkinson PRT. Case of the month: Buffalo chest: a case of bilateral pneumothoraces due to pleuropleural communication. Emerg Med J. 2006;23(6):483–6.https://doi.org/10.1136/emj.2005.030981
  58. Howard TJ Tan T Lehman GA Sherman S Madura JA Fogel E Classification and management of perforations complicating endoscopic sphincterotomy. Surgery. 1999;126(4):658–63, discussion 664–5.https://doi.org/10.1016/S0039-6060(99)70119-4
  59. Paspatis GA Dumonceau J-M Barthet M Meisner S Repici A Saunders BP Diagnosis and management of iatrogenic endoscopic perforations: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement. Endoscopy. 2014;46(8):693–711.https://doi.org/10.1055/s-0034-1377531
  60. Leigh-Smith S Harris T. Tension pneumothorax--time for a re-think? Emerg Med J. 2005;22(1):8–16.https://doi.org/10.1136/emj.2003.010421
  61. Machado NO. Management of duodenal perforation post-endoscopic retrograde cholangiopancreatography. When and whom to operate and what factors determine the outcome? A review article. JOP. 2012;13(1):18–25.