Patient Receives Emergency Surgery After Duodenum is Perforated

This case takes place in Maine and involves a middle aged female patient with a past history of Crohn’s Disease and a surgical history of multiple prior abdominal surgeries. The patient underwent an elective procedure to remove a stone in her bile duct. The surgery was complicated by the patient’s anatomy, looping of the endoscope, and post sphincterotomy perforation and bleeding. Intraoperatively, the surgeon noted that he caused a small serosal tear adjacent to the sphincterotomy, and as a result attempts to extract the stone from the bile duct were abandoned. The operative notes state that the surgeon had perforated the patient’s duodenum during the surgery. Attempts at endoscopic closure were unsuccessful and the patient was taken emergently to the OR in order to repair the injury to the duodenum.

Question(s) For Expert Witness

1.) Do you perform ERCP procedures on patient's with PMH of multiple abdominal surgeries/abnormal anatomy? If so, how often?

2.) While risk of perforation is known and expected, would it be reasonable to assume that a physician should promptly repair (clip) a perforation rather than attempting to extract the stone?

Expert Witness Response E-007716

I have performed thousands of ERCP's on patients with similar past histories. Anatomy is variable and unimportant, although some anatomic variation can make the procedure more challenging. Perforation is a risk of endoscopy and specifically of sphicterotomy. Many times perforation will not be recognized at the time of ERCP. If it is, closure with clips can be attempted but may not prevent the need for surgery. Extracting the stone is preferable and might still be attempted even if the perforation is recognized.