Endoscopic retrograde cholangiopancreatography-related duodenal perforations: A systematic review and meta-analysis of management and outcomes

Background and ObjectivesEndoscopic retrograde cholangiopancreatography (ERCP)-related perforations (EPs) are rare but serious adverse events, with a reported frequency of 0.4% to 0.6% and mortality rates reaching 8%. The lack of a uniform classification system for injury patterns and evidence-based management guidelines poses significant challenges in clinical decision-making. This systematic review evaluates therapeutic approaches and outcomes of EPs using the Stapfer classification to address these gaps.MethodsWe conducted a systematic review of studies that utilized the Stapfer classification to categorize EPs into four types, ranked by severity: type I (lateral/medial duodenal wall perforation), type II (periampullary injuries), type III (bile duct injuries) and type IV (retroperitoneal air alone). The study protocol was registered in PROSPERO (ID CRD42023473841).ResultsAmong 287 patients from 18 eligible studies, type-I perforations were associated with significantly higher mortality (adjusted OR = 3.17, 95% CI 1.45-6.99). Surgical management did not significantly increase mortality risk compared to non-operative treatment (adjusted OR = 1.99, 95% CI 0.66-6.00) but was linked to prolonged hospital stays (coefficient 8.58, 95% CI 2.71-14.46). In contrast, perforation type did not significantly influence hospitalization duration (coefficient - 0.64, 95% CI - 4.04 to 2.76).ConclusionsOur findings underscore the need for individualized treatment strategies based on perforation type and patient-specific factors. While the Stapfer classification aids in risk stratification, the heterogeneity of current evidence limits generalizability. Large-scale prospective studies are essential to establish standardized management protocols.