- Email: [email protected]
Bilateral pneumothoraces and subcutaneous emphysema after endoscopic sphincterotomy
papillary catheterization of the gallbladder followed by external shock wave lithotripsy and solvent infusion for the treatment of gallstone disease. Gastrointest Endosc 1992;38:19-22. 13. McCarthy JH, Miller GL, Laurence BH. Cannulation of the biliary tree, cystic duct and gallbladder using a hydrophilic polymer-coated steerable guide wire. Gastrointest Endosc 1990; 36:386-9.
14. ESWL and gallstone dissolution with MTBE via a naso-vesicular catheter. Endoscopy 1990;22:176-9. 15. Tamada K, Seki H, Sato K, et al. Efficacy of endoscopic retrograde cholecystoendoprosthesis (ERCCE) for cholecystitis. Endoscopy 1991;23:2-3.
Bilateral pneumothoraces and subcutaneous emphysema after endoscopic sphincterotomy
head of the pancreas. A pancreatic mass was not evident on CT. ERCP revealed a 10 mm, irregular, high-grade stenosis in the distal common bile duct with proximal dilation. Because of deformed duodenal anatomy, a long scope position was required. On initial attempts to cannulate the common bile duct with the sphincterotome, the catheter inadvertently lacerated the lateral duodenal wall. A small (approximately 7 mm) sphincterotomy was performed, and a 7F stent was placed across the stricture. The post-sphincterotomy cholangiogram showed no extravasation of contrast. When placing the stent, the patient's oxygen saturation decreased to 84 %. She was turned from the prone position and was noted to be dusky. In the recovery room she complained of chest pressure and increasing shortness of breath. Physical examination revealed an elderly female in acute respiratory distress with acrocyanosis. Her respirations were labored and shallow at a rate of 32/minute. Her blood pressure was 170/100 mm Hg and heart rate was 88 beats/min. Extensive subcutaneous emphysema was observed extending along the entire right chest wall to the neck, right arm and hand, and also up the left upper anterior thorax to the left shoulder. The breath sounds were markedly diminished in the right lung field and decreased to a lesser extent in the left upper lung field. The heart sounds were distant and without murmur. Abdominal examination revealed mild right upper quadrant tenderness without peritoneal signs.
Thomas Savides, Stuart Sherman, Barbara Kadell, Henry Cryer, Marvin Derezin,
MD MD MD MD MD
Perforation complicates endoscopic sphincterotomy in approximately 1 % of cases. 1, 2 Generally, the perforation occurs at the site of the sphincterotomy and results in retroperitoneal free air. The diagnosis is usually made (immediately) during the procedure by visualization of extravasated iodinated contrast material beyond the confines of the common bile duct lumen. 3-5 If the perforation is not recognized at immediate postsphincterotomy ductography, it should be suspected or recognized within a few hours of the procedure by the presence of abdominal pain, distension, fever, and leukocytosis as well as by x-ray evidence of retroperitoneal air. Occasionally, CT may be necessary to confirm the presence of a perforation. 6-8 We describe an unusual presentation of duodenal perforation occurring during endoscopic sphincterotomy in which retroperitoneal free air tracked into the mediastinum and caused bilateral pneumothoraces and subcutaneous emphysema. CASE REPORT
A 79-year-old woman presented with a I-week history of painless jaundice. Physical examination was notable for the absence of an abdominal mass. Laboratory results revealed a total bilirubin of 2.9 mg/dl (normal, <1.0 mg/dl), alkaline phosphatase 1112 IUIL (normal, <115 IUIL), AST 217 IUIL (normal, <37 IUIL), ALT 261 IUIL (normal, <40 IUIL). An abdominal ultrasonography showed intrahepatic and extrahepatic biliary dilation and a possible 3.5 cm mass near the From the Department of Medicine, Division of Gastroenterology, and the Departments of Surgery and Radiology, UCLA Medical Center, Los Angeles, California. Reprint requests: Stuart Sherman, MD, Division of Gastroenterology/Hepatology, Indiana University Medical Center, 550 North University Boulevard/Room 2300, Indianapolis, IN 46202-5250. 0016-5107/93/3906-0814$1.00 +.10
GASTROINTESTINAL ENDOSCOPY Copyright © 1993 by the American Society for Gastrointestinal Endoscopy
Figure 1. Chest radiograph showing bilateral pneumothoraces (arrows), pneumomediastinum, and subcutaneous
37/4/48409
emphysema.
814
GASTROINTESTINAL ENDOSCOPY
Figure 2. Abdominal film showing retroperitoneal free air (arrows).
The chest x-ray film revealed a pneumomediastinum, large bilateral pneumothoraces, and extensive subcutaneous emphysema (Fig. 1). Bilateral chest tubes were placed. Because of the concern of an esophageal perforation, an esophagram and UGI series were performed using water-soluble contrast material. Preliminary films revealed retroperitoneal air (Fig. 2). The esophagus and stomach were normal. Contrast extravasation was demonstrated at the junction of the second and third portions of the duodenum (Fig. 3). Chest and abdominal CT revealed extensive subcutaneous emphysema with pneumomediastinum and bilateral retroperitoneal free air with significantly more air in the right retroperitoneum. There also appeared to be localized extravasation of oral contrast posteriorly at the junction of the second and third portions of the duodenum consistent with a local perforation (Fig. 4). The patient underwent emergency exploratory laparotomy at which time a 2 cm laceration in the lateral aspect of the duodenum was identified with bile staining of the adjacent tissue. No perforation at the site of the sphincterotomy was seen. The duodenal laceration was repaired, and gastrostomy and jejunostomy tubes were placed. A mass was noted in the region of the distal bile duct and pancreatic head and was believed to be unresectable. The patient was discharged 12 days after the operation. She was readmitted to the hospital 3 weeks later with cholangitis and was treated with a percutaneously placed transhepatic biliary tube and antibiotics. She refused any further care and died a few months later. DISCUSSION
This is the first report (to our knowledge) of a case in which large bilateral pneumothoraces and massive VOLUME 39, NO.6, 1993
Figure 3. UGI series showing contrast extravasation at the junction of the second and third portions of the duodenum (arrows).
subcutaneous emphysema occurred after ERCP/endoscopic sphincterotomy-induced duodenal perforation. Colemont and colleagues9 reported a case of unilateral periorbital emphysema immediately after ERCP with sphincterotomy and biliary stent placement for malignant obstruction. Chest radiographs also showed an apical right pneumothorax and pneumomediastinum. The patient improved with conservative management. Tam et. al. lO reported a case of subcutaneous emphysema after ERCP with sphincterotomy and biliary stent placement for malignant obstruction. Chest radiographs revealed bilateral pleural effusions and pneumomediastinum. The patient improved with conservative therapy and underwent palliative surgery 8 days after the ERCP. Pneumomediastinum, pneumothoraces, and subcutaneous emphysema have also been reported after upper endoscopy and colonoscopy.1l-16 815
Figure 4. Abdominal CT scan showing retroperitoneal free air (small arrows) and leakage of contrast from the duodenal sweep (large arrow).
have caused increased air pressure in the duodenallumen resulting in such extensive air leakage. Management of retroperitoneal perforation after endoscopic sphincterotomy depends on the clinical status of the patient, but usually conservative treatment with antibiotics and nasogastric and/or nasobiliary drainage is adequate. 3-5 Surgery is necessary if the patient fails to respond to conservative therapy or develops an abscess, although some authors advocate early surgery for all perforations. 8 , 19, 20 Approximately 27 % to 40 % of retroperitoneal perforations require surgery, and the overall mortality rate is 12 % to 16 % .1, 2 Although our patient underwent emergency surgery, it is possible that a good outcome may have resulted from a more conservative approach. The patient did well after surgical repair of the perforation and died from complications of her underlying malignancy a few months later.
The explanation for pneumomediastinum, bilateral pneumothoraces, and massive subcutaneous emphysema after retroperitoneal perforation is as follows. The retroperitoneum is divided by the anterior and posterior renal fascia into three distinct compartments. These compartments communicate freely in their inferior aspects. Duodenal perforation results in air entering the right anterior pararenal space. This free air can travel inferiorly and communicate with the posterior pararenal compartment. The posterior pararenal compartment extends through the diaphragmatic hiatus and into the mediastinum. Free air can enter the mediastinum from the posterior pararenal compartment and subsequently result in bilateral pneumothoraces and cervical subcutaneous emphysema.!7,18 In this case, the perforation did not result from the sphincterotomy but rather from the cold sphincterotome that lacerated the lateral wall of the duodenum before the sphincterotomy. The duodenal wall may have perforated because of thinning of the duodenal tissue on the basis of the elderly age of the patient and scope torsion with the long scope position. The perforation resulted in air leakage into the retroperitoneum as documented by UGI series, CT scan, and laparotomy. The reason why this patient developed large bilateral pneumothoraces and massive subcutaneous emphysema rather than more localized retroperitoneal air may be related to the relatively early time during the procedure in which the perforation likely occurred. As pointed out by Cotton and colleagues, 1 the amount of air leakage may not reflect the size of the perforation as much as the extent and duration of manipulation performed after the perforation. 1 Repeated efforts to cannulate and perform sphincterotomy, as well as continued injection of air during the procedure, may
1. Cotton PB, Lehman G, Vennes J, et al. Endoscopic sphincterotomy complications and their management: an attempt at consensus. Gastrointest Endosc 1991;37:383-93. 2. Sherman S, Lehman GA. Complications of endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy: management and prevention. In: Barkin J, O'Phelan CA eds. Advanced therapeutic endoscopy. New York: Raven Press, 1990:201-10. 3. Dunham F, Bourgeois N, Gelin M, Jeanmart J, Toussaint J, Cremer M. Retroperitoneal perforation following endoscopic sphincterotomy: clinical course and management. Endoscopy 1982;14:92-6. 4. Byrne P, Leung JWC, Cotton PB. Retroperitoneal perforation during duodenal sphincterotomy. Radiology 1984;150:383-4. 5. Martin DF, Tweedle DEF. Retroperitoneal perforation during ERCP and endoscopic sphincterotomy: causes, clinical features, and management. Endoscopy 1990;22:174-5. 6. Kuhlman JE, Fishman EK, Milligan FD, Siegelmann SS. Complications of endoscopic retrograde sphincterotomy: computed tomographic evaluation. Gastrointest RadioI1989;14:127-32. 7. Harker L, Hutton L, Passi RB. Radiologic findings of retroperitoneal perforation after sphincterotomy. J Can Assoc Radiol 1986;37:169-72. 8. Sarr MG, Fishman EK, Milligan FD, Siegelman SS, Cameron JL. Pancreatitis or duodenal perforation after peri-Vaterian therapeutic endoscopic procedures: diagnosis, differentiation, and management. Surgery 1986;100:461-6. 9. Colemont LJ, Pelckmans PA, Moorkens GH, Maercke YMV. Unilateral periorbital emphysema: an unusual complication of endoscopic papillotomy. Gastrointest Endosc 1988;34:473-5. 10. Tam F, Prindiville T, Wolfe B. Subcutaneous emphysema as a complication of endoscopic sphincterotomy of the ampulla of Vater. Gastrointest Endosc 1989;35:447-9. 11. Girardi A, Piazza I, Giunta G, Pappagallo G. Retroperitoneal, mediastinal and subcutaneous emphysema as a complication of routine upper gastrointestinal endoscopy. Endoscopy 1990;22: 83-4. 12. Allan RN, Smallwood CJ. Pneumomediastinum and subcutaneous emphysema after perforation of the duodenum during gastroscopy. Br J Surg 1973;60:156-7. 13. Schmidt G, Borsch G, Wegener M. Subcutaneous emphysema and pneumothorax complicating diagnostic colonoscopy. Dis Colon Rectum 1986;29:136-8. 14. Bakker J, Kersen FV, Spruyt JB. Pneumopericardium and pneumomediastinum after polypectomy. Endoscopy 1991;23: 46-7. 15. Humphreys F, Hewetson KA, Dellipiani AW. Massive subcutaneous emphysema following colonoscopy. Endoscopy 1984;16: 160-1.
REFERENCES
816
GASTROINTESTINAL ENDOSCOPY
16. Amshel AL, Shonberg IL, Gopal KA. Retroperitoneal and mediastinal emphysema as a complication of colonoscopy. Dis Colon Rectum 1982;25:167-8. 17. Meyers MA. Radiological features ofthe spread and localization of extraperitoneal gas and their relationship to its source: an anatomical approach. Radiology 1974;111:17-26. 18. Maunder RJ, Pierson DJ, Hudson LD. Subcutaneous and mediastinal emphysema: pathophysiology, diagnosis, and management. Arch Intern Med 1984;144:1447-53.
19. Bell RCW, Stiegmann GV, Goff J, Reveille M, Norton L, Pearlman NW. Decision for surgical management of perforation following endoscopic sphincterotomy. Am Surg 1991;57:237-40. 20. Booth FVM, Doerr RJ, Khalafi RS, Luchette FA, Flint LM. Surgical management of complications of endoscopic sphincterotomy with precut papillotomy. Am J Surg 1990;159:132-6.
Massive gas spread through a duodenal perforation after endoscopic sphincterotomy Serge Evrard, Luis Mendoza, Didier Mutter, Denis Vetter, Jacques Marescaux,
MD MD MD MD MD
Endoscopic sphincterotomy is considered a common method of treatment of distal bile duct obstruction. The rate of significant complications after endoscopic sphincterotomy, such as perforation of the duodenal wall, pancreatitis, and hemorrhage, is about 10%, with an overall mortality rate of about 1.5 %.1 Subcutaneous emphysema, which seems to be exceptional, is probably the most spectacular of them. We report a case of massive subcutaneous emphysema, pneumomediastinum, pneumoperitoneum, and retropneumoperitoneum caused by a duodenal perforation, which appeared after an endoscopic sphincterotomy performed without special difficulties. CASE REPORT
A 75-year-old woman was admitted to our surgical unit for epigastric pain, nausea, fever to 38° C, and jaundice. The WBC was 12.6 K/mm 3• She had known gallbladder lithiasis for 30 years. The ultrasound examination showed the gallbladder to have thick walls and to contain many small stones; the common bile duct appeared to be normal. The diagnosis of cholangitis was evident. Under proper antibiotic coverage, an endoscopic sphincterotomy was performed. A peripapillary diverticulum was noted. The sphincterotome was passed without difficulty, and a I5-mm-long papillotomy was performed. A stone of 1 em in diameter was extracted from the From the Department of Surgery A and the Department of Hepatogastroenterology, Hopitaux Universitaires de Strasbourg, Strasbourg Cedex, France. Reprint requests: J. Marescaux, MD, Prof Surg., Department of Surgery A, Hopitaux Universitaires de Strasbourg, BP 426, 67091 Strasbourg Cedex, France. 0016-5107/93/3906-0817$1.00 +.10
GASTROINTESTINAL ENDOSCOPY Copyright © 1993 by the American Society for Gastrointestinal Endoscopy
37/4/46966
VOLUME 39, NO.6, 1993
Figure 1. Posteroanterior chest roentgenogram demonstrating massive subcutaneous emphysema and pneumomediastinum.
bile duct, and good passage of bile into the duodenum was noted. Nevertheless, extensive subcutaneous emphysema and a pneumomediastinum developed (Fig. 1), as did a retropneumoperitoneum and a pneumoperitoneum (Fig. 2). No clinical signs of peritonitis were seen. The treatment was conservative, consisting of no oral intake, intravenous fluids, and antibiotics. Recovery was uneventful. Some weeks later, a laparoscopic cholecystectomy was performed.
DISCUSSION
After sphincterotomy, retroduodenal perforation occurs in about 1 % of patients. 1 Intraperitoneal perforation is known to be extremely rare. In our case, we observed both an intraperitoneal and a retroperitoneal spread of gas. The presence of a peripapillary diverticulum is not known to represent a greater risk for perforation.! Reviewing the English medical literature, we found only three other cases of subcutaneous emphysema after endoscopic sphincterotomy, but all appeared in special circumstances: two after stent placement2,3 and one after a second difficult papillotomy procedure was carried out after failing to extract an impacted stone. 4 817
14. ESWL and gallstone dissolution with MTBE via a naso-vesicular catheter. Endoscopy 1990;22:176-9. 15. Tamada K, Seki H, Sato K, et al. Efficacy of endoscopic retrograde cholecystoendoprosthesis (ERCCE) for cholecystitis. Endoscopy 1991;23:2-3.
Bilateral pneumothoraces and subcutaneous emphysema after endoscopic sphincterotomy
head of the pancreas. A pancreatic mass was not evident on CT. ERCP revealed a 10 mm, irregular, high-grade stenosis in the distal common bile duct with proximal dilation. Because of deformed duodenal anatomy, a long scope position was required. On initial attempts to cannulate the common bile duct with the sphincterotome, the catheter inadvertently lacerated the lateral duodenal wall. A small (approximately 7 mm) sphincterotomy was performed, and a 7F stent was placed across the stricture. The post-sphincterotomy cholangiogram showed no extravasation of contrast. When placing the stent, the patient's oxygen saturation decreased to 84 %. She was turned from the prone position and was noted to be dusky. In the recovery room she complained of chest pressure and increasing shortness of breath. Physical examination revealed an elderly female in acute respiratory distress with acrocyanosis. Her respirations were labored and shallow at a rate of 32/minute. Her blood pressure was 170/100 mm Hg and heart rate was 88 beats/min. Extensive subcutaneous emphysema was observed extending along the entire right chest wall to the neck, right arm and hand, and also up the left upper anterior thorax to the left shoulder. The breath sounds were markedly diminished in the right lung field and decreased to a lesser extent in the left upper lung field. The heart sounds were distant and without murmur. Abdominal examination revealed mild right upper quadrant tenderness without peritoneal signs.
Thomas Savides, Stuart Sherman, Barbara Kadell, Henry Cryer, Marvin Derezin,
MD MD MD MD MD
Perforation complicates endoscopic sphincterotomy in approximately 1 % of cases. 1, 2 Generally, the perforation occurs at the site of the sphincterotomy and results in retroperitoneal free air. The diagnosis is usually made (immediately) during the procedure by visualization of extravasated iodinated contrast material beyond the confines of the common bile duct lumen. 3-5 If the perforation is not recognized at immediate postsphincterotomy ductography, it should be suspected or recognized within a few hours of the procedure by the presence of abdominal pain, distension, fever, and leukocytosis as well as by x-ray evidence of retroperitoneal air. Occasionally, CT may be necessary to confirm the presence of a perforation. 6-8 We describe an unusual presentation of duodenal perforation occurring during endoscopic sphincterotomy in which retroperitoneal free air tracked into the mediastinum and caused bilateral pneumothoraces and subcutaneous emphysema. CASE REPORT
A 79-year-old woman presented with a I-week history of painless jaundice. Physical examination was notable for the absence of an abdominal mass. Laboratory results revealed a total bilirubin of 2.9 mg/dl (normal, <1.0 mg/dl), alkaline phosphatase 1112 IUIL (normal, <115 IUIL), AST 217 IUIL (normal, <37 IUIL), ALT 261 IUIL (normal, <40 IUIL). An abdominal ultrasonography showed intrahepatic and extrahepatic biliary dilation and a possible 3.5 cm mass near the From the Department of Medicine, Division of Gastroenterology, and the Departments of Surgery and Radiology, UCLA Medical Center, Los Angeles, California. Reprint requests: Stuart Sherman, MD, Division of Gastroenterology/Hepatology, Indiana University Medical Center, 550 North University Boulevard/Room 2300, Indianapolis, IN 46202-5250. 0016-5107/93/3906-0814$1.00 +.10
GASTROINTESTINAL ENDOSCOPY Copyright © 1993 by the American Society for Gastrointestinal Endoscopy
Figure 1. Chest radiograph showing bilateral pneumothoraces (arrows), pneumomediastinum, and subcutaneous
37/4/48409
emphysema.
814
GASTROINTESTINAL ENDOSCOPY
Figure 2. Abdominal film showing retroperitoneal free air (arrows).
The chest x-ray film revealed a pneumomediastinum, large bilateral pneumothoraces, and extensive subcutaneous emphysema (Fig. 1). Bilateral chest tubes were placed. Because of the concern of an esophageal perforation, an esophagram and UGI series were performed using water-soluble contrast material. Preliminary films revealed retroperitoneal air (Fig. 2). The esophagus and stomach were normal. Contrast extravasation was demonstrated at the junction of the second and third portions of the duodenum (Fig. 3). Chest and abdominal CT revealed extensive subcutaneous emphysema with pneumomediastinum and bilateral retroperitoneal free air with significantly more air in the right retroperitoneum. There also appeared to be localized extravasation of oral contrast posteriorly at the junction of the second and third portions of the duodenum consistent with a local perforation (Fig. 4). The patient underwent emergency exploratory laparotomy at which time a 2 cm laceration in the lateral aspect of the duodenum was identified with bile staining of the adjacent tissue. No perforation at the site of the sphincterotomy was seen. The duodenal laceration was repaired, and gastrostomy and jejunostomy tubes were placed. A mass was noted in the region of the distal bile duct and pancreatic head and was believed to be unresectable. The patient was discharged 12 days after the operation. She was readmitted to the hospital 3 weeks later with cholangitis and was treated with a percutaneously placed transhepatic biliary tube and antibiotics. She refused any further care and died a few months later. DISCUSSION
This is the first report (to our knowledge) of a case in which large bilateral pneumothoraces and massive VOLUME 39, NO.6, 1993
Figure 3. UGI series showing contrast extravasation at the junction of the second and third portions of the duodenum (arrows).
subcutaneous emphysema occurred after ERCP/endoscopic sphincterotomy-induced duodenal perforation. Colemont and colleagues9 reported a case of unilateral periorbital emphysema immediately after ERCP with sphincterotomy and biliary stent placement for malignant obstruction. Chest radiographs also showed an apical right pneumothorax and pneumomediastinum. The patient improved with conservative management. Tam et. al. lO reported a case of subcutaneous emphysema after ERCP with sphincterotomy and biliary stent placement for malignant obstruction. Chest radiographs revealed bilateral pleural effusions and pneumomediastinum. The patient improved with conservative therapy and underwent palliative surgery 8 days after the ERCP. Pneumomediastinum, pneumothoraces, and subcutaneous emphysema have also been reported after upper endoscopy and colonoscopy.1l-16 815
Figure 4. Abdominal CT scan showing retroperitoneal free air (small arrows) and leakage of contrast from the duodenal sweep (large arrow).
have caused increased air pressure in the duodenallumen resulting in such extensive air leakage. Management of retroperitoneal perforation after endoscopic sphincterotomy depends on the clinical status of the patient, but usually conservative treatment with antibiotics and nasogastric and/or nasobiliary drainage is adequate. 3-5 Surgery is necessary if the patient fails to respond to conservative therapy or develops an abscess, although some authors advocate early surgery for all perforations. 8 , 19, 20 Approximately 27 % to 40 % of retroperitoneal perforations require surgery, and the overall mortality rate is 12 % to 16 % .1, 2 Although our patient underwent emergency surgery, it is possible that a good outcome may have resulted from a more conservative approach. The patient did well after surgical repair of the perforation and died from complications of her underlying malignancy a few months later.
The explanation for pneumomediastinum, bilateral pneumothoraces, and massive subcutaneous emphysema after retroperitoneal perforation is as follows. The retroperitoneum is divided by the anterior and posterior renal fascia into three distinct compartments. These compartments communicate freely in their inferior aspects. Duodenal perforation results in air entering the right anterior pararenal space. This free air can travel inferiorly and communicate with the posterior pararenal compartment. The posterior pararenal compartment extends through the diaphragmatic hiatus and into the mediastinum. Free air can enter the mediastinum from the posterior pararenal compartment and subsequently result in bilateral pneumothoraces and cervical subcutaneous emphysema.!7,18 In this case, the perforation did not result from the sphincterotomy but rather from the cold sphincterotome that lacerated the lateral wall of the duodenum before the sphincterotomy. The duodenal wall may have perforated because of thinning of the duodenal tissue on the basis of the elderly age of the patient and scope torsion with the long scope position. The perforation resulted in air leakage into the retroperitoneum as documented by UGI series, CT scan, and laparotomy. The reason why this patient developed large bilateral pneumothoraces and massive subcutaneous emphysema rather than more localized retroperitoneal air may be related to the relatively early time during the procedure in which the perforation likely occurred. As pointed out by Cotton and colleagues, 1 the amount of air leakage may not reflect the size of the perforation as much as the extent and duration of manipulation performed after the perforation. 1 Repeated efforts to cannulate and perform sphincterotomy, as well as continued injection of air during the procedure, may
1. Cotton PB, Lehman G, Vennes J, et al. Endoscopic sphincterotomy complications and their management: an attempt at consensus. Gastrointest Endosc 1991;37:383-93. 2. Sherman S, Lehman GA. Complications of endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy: management and prevention. In: Barkin J, O'Phelan CA eds. Advanced therapeutic endoscopy. New York: Raven Press, 1990:201-10. 3. Dunham F, Bourgeois N, Gelin M, Jeanmart J, Toussaint J, Cremer M. Retroperitoneal perforation following endoscopic sphincterotomy: clinical course and management. Endoscopy 1982;14:92-6. 4. Byrne P, Leung JWC, Cotton PB. Retroperitoneal perforation during duodenal sphincterotomy. Radiology 1984;150:383-4. 5. Martin DF, Tweedle DEF. Retroperitoneal perforation during ERCP and endoscopic sphincterotomy: causes, clinical features, and management. Endoscopy 1990;22:174-5. 6. Kuhlman JE, Fishman EK, Milligan FD, Siegelmann SS. Complications of endoscopic retrograde sphincterotomy: computed tomographic evaluation. Gastrointest RadioI1989;14:127-32. 7. Harker L, Hutton L, Passi RB. Radiologic findings of retroperitoneal perforation after sphincterotomy. J Can Assoc Radiol 1986;37:169-72. 8. Sarr MG, Fishman EK, Milligan FD, Siegelman SS, Cameron JL. Pancreatitis or duodenal perforation after peri-Vaterian therapeutic endoscopic procedures: diagnosis, differentiation, and management. Surgery 1986;100:461-6. 9. Colemont LJ, Pelckmans PA, Moorkens GH, Maercke YMV. Unilateral periorbital emphysema: an unusual complication of endoscopic papillotomy. Gastrointest Endosc 1988;34:473-5. 10. Tam F, Prindiville T, Wolfe B. Subcutaneous emphysema as a complication of endoscopic sphincterotomy of the ampulla of Vater. Gastrointest Endosc 1989;35:447-9. 11. Girardi A, Piazza I, Giunta G, Pappagallo G. Retroperitoneal, mediastinal and subcutaneous emphysema as a complication of routine upper gastrointestinal endoscopy. Endoscopy 1990;22: 83-4. 12. Allan RN, Smallwood CJ. Pneumomediastinum and subcutaneous emphysema after perforation of the duodenum during gastroscopy. Br J Surg 1973;60:156-7. 13. Schmidt G, Borsch G, Wegener M. Subcutaneous emphysema and pneumothorax complicating diagnostic colonoscopy. Dis Colon Rectum 1986;29:136-8. 14. Bakker J, Kersen FV, Spruyt JB. Pneumopericardium and pneumomediastinum after polypectomy. Endoscopy 1991;23: 46-7. 15. Humphreys F, Hewetson KA, Dellipiani AW. Massive subcutaneous emphysema following colonoscopy. Endoscopy 1984;16: 160-1.
REFERENCES
816
GASTROINTESTINAL ENDOSCOPY
16. Amshel AL, Shonberg IL, Gopal KA. Retroperitoneal and mediastinal emphysema as a complication of colonoscopy. Dis Colon Rectum 1982;25:167-8. 17. Meyers MA. Radiological features ofthe spread and localization of extraperitoneal gas and their relationship to its source: an anatomical approach. Radiology 1974;111:17-26. 18. Maunder RJ, Pierson DJ, Hudson LD. Subcutaneous and mediastinal emphysema: pathophysiology, diagnosis, and management. Arch Intern Med 1984;144:1447-53.
19. Bell RCW, Stiegmann GV, Goff J, Reveille M, Norton L, Pearlman NW. Decision for surgical management of perforation following endoscopic sphincterotomy. Am Surg 1991;57:237-40. 20. Booth FVM, Doerr RJ, Khalafi RS, Luchette FA, Flint LM. Surgical management of complications of endoscopic sphincterotomy with precut papillotomy. Am J Surg 1990;159:132-6.
Massive gas spread through a duodenal perforation after endoscopic sphincterotomy Serge Evrard, Luis Mendoza, Didier Mutter, Denis Vetter, Jacques Marescaux,
MD MD MD MD MD
Endoscopic sphincterotomy is considered a common method of treatment of distal bile duct obstruction. The rate of significant complications after endoscopic sphincterotomy, such as perforation of the duodenal wall, pancreatitis, and hemorrhage, is about 10%, with an overall mortality rate of about 1.5 %.1 Subcutaneous emphysema, which seems to be exceptional, is probably the most spectacular of them. We report a case of massive subcutaneous emphysema, pneumomediastinum, pneumoperitoneum, and retropneumoperitoneum caused by a duodenal perforation, which appeared after an endoscopic sphincterotomy performed without special difficulties. CASE REPORT
A 75-year-old woman was admitted to our surgical unit for epigastric pain, nausea, fever to 38° C, and jaundice. The WBC was 12.6 K/mm 3• She had known gallbladder lithiasis for 30 years. The ultrasound examination showed the gallbladder to have thick walls and to contain many small stones; the common bile duct appeared to be normal. The diagnosis of cholangitis was evident. Under proper antibiotic coverage, an endoscopic sphincterotomy was performed. A peripapillary diverticulum was noted. The sphincterotome was passed without difficulty, and a I5-mm-long papillotomy was performed. A stone of 1 em in diameter was extracted from the From the Department of Surgery A and the Department of Hepatogastroenterology, Hopitaux Universitaires de Strasbourg, Strasbourg Cedex, France. Reprint requests: J. Marescaux, MD, Prof Surg., Department of Surgery A, Hopitaux Universitaires de Strasbourg, BP 426, 67091 Strasbourg Cedex, France. 0016-5107/93/3906-0817$1.00 +.10
GASTROINTESTINAL ENDOSCOPY Copyright © 1993 by the American Society for Gastrointestinal Endoscopy
37/4/46966
VOLUME 39, NO.6, 1993
Figure 1. Posteroanterior chest roentgenogram demonstrating massive subcutaneous emphysema and pneumomediastinum.
bile duct, and good passage of bile into the duodenum was noted. Nevertheless, extensive subcutaneous emphysema and a pneumomediastinum developed (Fig. 1), as did a retropneumoperitoneum and a pneumoperitoneum (Fig. 2). No clinical signs of peritonitis were seen. The treatment was conservative, consisting of no oral intake, intravenous fluids, and antibiotics. Recovery was uneventful. Some weeks later, a laparoscopic cholecystectomy was performed.
DISCUSSION
After sphincterotomy, retroduodenal perforation occurs in about 1 % of patients. 1 Intraperitoneal perforation is known to be extremely rare. In our case, we observed both an intraperitoneal and a retroperitoneal spread of gas. The presence of a peripapillary diverticulum is not known to represent a greater risk for perforation.! Reviewing the English medical literature, we found only three other cases of subcutaneous emphysema after endoscopic sphincterotomy, but all appeared in special circumstances: two after stent placement2,3 and one after a second difficult papillotomy procedure was carried out after failing to extract an impacted stone. 4 817