Systematic review of pneumothoraces after endoscopic retrograde cholangiopancreatography

Pneumothoraces after endoscopic retrograde cholangiopancreatography (ERCP) are an uncommon but potentially lethal complication. Little evidence is available on their epidemiology, diagnosis and therapy. We aimed to evaluate current practices and provide recommendations. We systematically reviewed articles from PubMed, Embase, OVID-Medline and the Cochrane Library. Forty-four publications reported pneumothoraces after ERCP in 49 patients (74% females). Twenty-one patients (43%) had atypical gastrointestinal anatomy, including peri-ampullary diverticula (n = 8), surgical or endoscopic alterations (n = 7), local tumours (n = 3), ulcerations (n = 2) and ectopic papilla (n = 1). Precut (14%) or standard (39%) sphincterotomies were performed. Cannulation was unsuccessful in six ERCPs. Pneumothoraces occurred bilaterally (45%), on the right (37%) or left side (6%), or no side was stated (12%). Nineteen tension pneumothoraces occurred. Perforations were mainly caused by the sphincterotome, peri-ampullary (41%), or the endoscope, distant from the papilla of Vater (23%). Pneumothoraces were sometimes diagnosed only after hospital discharge (14%). Eighteen patients underwent surgical therapy with drainage, repair and/or bypass. Conservative treatment included antibiotics and bowel rest. Most pneumothoraces were drained; 14% resolved without pleural drainage. Overall mortality was 4%. The mean hospital stay was 9.8 days. A post-ERCP pneumothorax should be considered when subcutaneous emphysema, cardiovascular instability or respiratory distress occurs. Thoraco-abdominal computed tomography facilitates identification and therapy tailoring. Because of possible late or discrete onset, patients should be monitored carefully.