A 67 y.o. man presented with obstructive jaundice. CT examination of abdomen and pelvis revealed a biliary obstruction at the ampulla, with sudden cut off of the distal common bile duct (CBD) in absence of gallstone disease.
He was referred to a gastroenterologist, who recommended an endoscopic retrograde cholangiopancreatography (ERCP) and an endoscopic ultrasound (EUS) of the pancreas.
The ERCP revealed diffuse dilation of the CBD down to the level of the papilla, without stones. Biopsies of the papilla did not demonstrate any cancer.
Given the inconclusive diagnosis, a EUS was recommended. The EUS revealed a likely malignant process in the area of the ampulla, but was complicated by a duodenal perforation. The perforation was immediately recognized, a surgeon was notified, broad spectrum antibiotics were started. A STAT CT of the abdomen and pelvis revealed extensive retroperitoneal emphysema extending through the right inguinal canal into the right upper thigh, into the extraperitoneal subdiaphragmatic spaces, as well as in the right mediastinum. Some of the ingested oral contrast, as well air, was also noted in the retroperitoneal space along the psoas muscle. There was no evidence of intraperitoneal air.
The patient was brought emergently to the operating room with a diagnosis of duodenal perforation and ampullary mass (most likely a pancreatic cancer) and a Whipple surgery was performed.
The post-operative course was characterized by the development of multiple abscesses in the retroperitoneal space. A CT obtained on post-operative day (POD) #7 revealed fluid and air collections along the right psoas muscle, which needed to be drained through an interventional radiology procedure. In the following days, multiple additional procedures became necessary for drainage of this abscess along the right psoas. Additionally, the post-operative course was further complicated by a dehiscence of the hepatico-jejunostomy, which mandated a take-back to the operating room on POD #11, and by a dehiscence of the duodeno-jejunostomy, which required a take-back to the operating room on POD #18.
The remaining post-operative course was characterized by persistent retroperitoneal and abdominal infections. Eventually the patient was discharged to a rehab, off antibiotics, more than 4 months after his PD. Because of his prolonged convalescence, he remained to weak and sick to undergo systemic chemotherapy. The patient died from pancreatic cancer 45 months after the initial surgery.
I have the following questions. Was the EUS indicated? In what instances a perforation of the duodenum during EUS would constitute negligence? Was the prognosis of the patient affected by the perforation?
Files:
No questions yet!
Do you believe there might have been medical error?
. Duodenal perforation is a recognized risk of ERCP. Diagnosis of pancreas cancer means this patient had a median survival of around 24 months; consequently, his prolonged complicated course likely did not limit his lifespan
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Without duodenal perforation this patient could have had an elective tumor resection with expeditious recovery
What makes you a good expert for this case?
Multiple years of experience practicing surgical oncology
How often do you encounter cases similar to this one in your practice?
I rarely encounter cases similar to this one in my practice
Want to open a case or submit response?
Comments from similar speciality or otherwise pertinent to the case may also be accepted.