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Okano et al. Mini-invasive Surg 2021;5:29 https://dx.doi.org/10.20517/2574-1225.2021.15 Page 5 of 9

[25]
placing a covered metallic stent [Figure 4]. Similar actions are performed in cases of papillary or bile duct
perforation by a basket forceps that is associated with common bile duct stone removal. Generally, papillary
perforations and bile duct perforations are caused by treatment devices, and they can usually be alleviated
[26]
by bile duct drainage, gastric tube placement, and antibiotics administration . Post-ERCP, free air should
be checked for, as well as fluid collection in the retroperitoneal space and ascites on an abdominal computed
tomography (CT). Surgical treatment should be considered in cases where progression of symptoms such as
fever and abdominal pain, elevated inflammatory response, and an increasing trend of retroperitoneal space
fluid collection and ascites on CT are observed.

Duodenal perforation
Duodenal perforation occurs normally during scope insertion into the descending duodenum and
stretching procedures. Since adhesions of the duodenum due to previous abdominal surgeries or cancer
invasion may cause perforations, it is important to perform ERCP with an awareness of preventing
duodenal perforation, such as performing ERCP without the stretching procedure. Clip closure with a clip
[27]
can be performed for duodenal perforations with additional conservative treatment . Recently, the efficacy
[28]
of over-the-scope clip for perforations during pancreaticobiliary endoscopy has been reported . Duodenal
perforations are usually direct injuries of the intestinal wall due to endoscopy and have large perforation
hole. Hence, careful consideration is required for the indication of endoscopic closure, and surgical closure
of the injury should be considered first.

ERCP-RELATED TREATMENT ISSUES
Acute cholangitis
Sepsis may occur after emergency ERCP for acute obstructive septic cholangitis. To avoid an increase in the
pressure within the bile duct, ERCP should be performed initially with a small amount of contrast agent and
then with endoscopic nasobiliary drainage or biliary stent drainage alone. Lithiasis treatment should be
performed following cholangitis control.

Furthermore, during drainage for malignant hilar obstruction, it is preferable to not perform bile duct
contrast imaging on the other side of the bile duct expected for drainage, so as to prevent cholangitis . It is
[29]
important to preoperatively determine the bile duct expected for drainage in advance by CT or magnetic
resonance cholangiopancreatography. Although there are reports that unilateral drainage has lower risk for
cholangitis than bilateral drainage [30-31] , examination on a case-by-case basis is necessary as the obstruction
state will differ depending on the case.

Acute cholecystitis
Acute cholecystitis is a complication that may occur after metallic stent placement [32-33] . The risk is
particularly high in cases where a tumor extends to the cystic duct and where the cystic duct is obstructed
by a covered metallic stent. Furthermore, the risk has been reported with the presence of stones in the
gallbladder and the filling of the gallbladder with contrast during the examination ; adequate attention
[14]
should be taken to prevent excessive contrast. If there is no improvement with conservative therapy,
percutaneous transhepatic gallbladder aspiration or percutaneous transhepatic gallbladder drainage should
be considered. In the case of cholecystitis due to a covered metallic stent, removal of the stent and replacing
with a plastic stent or uncovered metallic stent should be considered.

Stent migration
Migration of plastic stents into the bile duct has been observed. Proximal stent migration was reported in
approximately 5% of cases in an initial report . Malignant strictures, larger diameter stents, and shorter
[34]
[34]
stents were significantly associated with proximal biliary stent migration . In case of proximal migration, a