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Vol. 45. Issue 3.
Pages 209-210 (March 2022)
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Vol. 45. Issue 3.
Pages 209-210 (March 2022)
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Pyriform sinus perforation as a rare complication of endoscopic retrograde cholangiopancreatography
La perforación del seno piriforme como una rara complicación de la colangiopancreatografía retrógrada endoscópica
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Vincent Zimmera,b,
Corresponding author
vincent.zimmer@gmx.de

Corresponding author.
, Basel Al-Kadahc, Ernst-Peter Muesd
a Department of Medicine, Marienhausklinik St. Josef Kohlhof, Neunkirchen, Germany
b Department of Medicine II, Saarland University Medical Center, Saarland University, Homburg, Germany
c Department of Otorhinolaryngology, Saarland University Medical Center, Saarland University, Homburg, Germany
d Department of General and Visceral Surgery, Marienhausklinik St. Josef Kohlhof, Neunkirchen, Germany
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A 78-year-old female underwent endoscopic retrograde cholangiopancreatography (ERCP) for bile leakage at day 2 after laparoscopic cholecystectomy (post hoc-histology myofibroblastic tumor). After initial minimal resistance during duodenoscope introduction, ERCP confirmed cystic duct leakage. Therefore, a minimal-incision papillotomy with 10-Fr double pigtail stenting was performed. Immediately following the procedure, a cervical and right thoracic emphysema was noted, which was replicated on X-ray studies, however without evidence of free abdominal and/or retroperitoneal air. (Fig. 1A) Urgent computed tomography confirmed these findings and suggested hypopharynx perforation underlying the exuberant emphysema. (Fig. 1B) A limited contrast swallow using water-soluble gastrografin unequivocally proved a small pyriform sinus perforation. (Fig. 1C, arrow) The patient underwent a cautious CO2-insufflated EGD for guidewire placement for gently positioning a nasogastric tube. The patient was successfully treated conservatively with broad-spectrum antibiotics, initial enteral feeding and soft meals for 7 days. Duodenoscope insertion during repeat ERCP 6 weeks later was likewise performed over an endoscopically placed guidewire.

Figure 1.

(A) Chest X-ray demonstrating exuberant thoraco-abdominal and neck emphysema. Note lack of free abdominal and/or retroperitoneal air. (B) CT scans likewise illustrating diffuse neck emphysema suggestive of hypopharyngeal perforation. (C) Limited contrast swallow using water-soluble gastrografin confirmative of a small pyriform sinus perforation.

(0.14MB).

ERCP-related perforation traditionally centers around duodenal and/or periampullary/intraductal localizations as reflected by e.g. the widely embraced Stapfer classification.1 By contrast, perforation along the duodenoscope insertion route is more uncommon, and may particularly involve the esophagus and/or hypopharyngeal structures.2 For the latter close interdisciplinary cooperation with ear-nose-throat (ENT) specialists is crucial to decide on the best individual treatment with small sinus pyriformis perforations often amenable to conservative treatment.3

Conflict of interest

Nothing to declare.

References
[1]
K.D. Johnson, A. Perisetti, B. Tharian, R. Thandassery, P. Jamidar, H. Goyal, et al.
Endoscopic retrograde cholangiopancreatography-related complications and their management strategies: a “scoping” literature review.
Dig Dis Sci, 65 (2020), pp. 361-375
[2]
Y.M. Kim, P.J.Y.H. Youn.
Iatrogenic pyriform sinus perforation during endoscopic ultrasonography.
Int J Gastrointest Interv, 8 (2019), pp. 59-61
[3]
J. Zenga, D. Kreisel, V.M. Kushnir, J.T. Rich.
Management of cervical esophageal and hypopharyngeal perforations.
Am J Otolaryngol, 36 (2015), pp. 678-685
Copyright © 2020. Elsevier España, S.L.U.. All rights reserved
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