Surgical endoscopy · 2026
Initial non-surgical versus upfront surgical management of ERCP-related perforations by Stapfer type: a systematic review and meta-analysis.
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Jamileh Eyad, Farooq Omar, Xamza Mohamed, Subar Daren, Lambert Joel
Аннотация
BACKGROUND: ERCP-related perforation is uncommon but potentially fatal, and optimal initial management remains uncertain across Stapfer subtypes. We compared initial non-surgical management with upfront surgery overall and by Stapfer type, retaining patients requiring rescue surgery within their original strategy.
METHODS: Databases were searched to 30 June 2026. Treatment success was standardised as survival to discharge without operative rescue after initial non-surgical management and survival to discharge after upfront surgery. Random-effects risk ratios (RRs) were pooled overall and by Stapfer type; certainty was assessed using GRADE.
RESULTS: Twenty-three retrospective studies included 681 perforations. In 15 reconstructable cohorts, initial-strategy success was 227/273 (83.2%) after initial non-surgical management and 75/89 (84.3%) after upfront surgery (RR 0.97, 95% CI 0.81-1.17; I2 = 25%). Mortality was 16/273 (5.9%) vs. 14/89 (15.7%) (RR 0.53, 95% CI 0.25-1.15). Length of stay was heterogeneous and clinically inconclusive (MD 1.03 days, 95% CI - 3.35 to 5.40; I2 = 83%; prediction interval - 11.24 to 13.30). Type I success (RR 1.04, 95% CI 0.77-1.41) and mortality (RR 1.47, 95% CI 0.56-3.86) were non-significant. Contemporary endoscopic closure succeeded in 10/10 highly selected Type I cases (100%; exact 95% CI 69.2-100.0%), but was too small to establish superiority. Type II success (RR 0.69, 95% CI 0.41-1.16) and mortality (RR 1.44, 95% CI 0.23-8.90) were also non-significant. Type III and IV non-surgical success was 46/49 (93.9%) and 34/34 (100%). Rescue surgery occurred in 14.3, 12.9, 5.4, and 0% of Types I-IV. Certainty was very low.
CONCLUSION: Very-low-certainty evidence suggests management should be tailored to Stapfer subtype, physiological stability and source control, with prompt operative rescue when non-surgical management fails.
METHODS: Databases were searched to 30 June 2026. Treatment success was standardised as survival to discharge without operative rescue after initial non-surgical management and survival to discharge after upfront surgery. Random-effects risk ratios (RRs) were pooled overall and by Stapfer type; certainty was assessed using GRADE.
RESULTS: Twenty-three retrospective studies included 681 perforations. In 15 reconstructable cohorts, initial-strategy success was 227/273 (83.2%) after initial non-surgical management and 75/89 (84.3%) after upfront surgery (RR 0.97, 95% CI 0.81-1.17; I2 = 25%). Mortality was 16/273 (5.9%) vs. 14/89 (15.7%) (RR 0.53, 95% CI 0.25-1.15). Length of stay was heterogeneous and clinically inconclusive (MD 1.03 days, 95% CI - 3.35 to 5.40; I2 = 83%; prediction interval - 11.24 to 13.30). Type I success (RR 1.04, 95% CI 0.77-1.41) and mortality (RR 1.47, 95% CI 0.56-3.86) were non-significant. Contemporary endoscopic closure succeeded in 10/10 highly selected Type I cases (100%; exact 95% CI 69.2-100.0%), but was too small to establish superiority. Type II success (RR 0.69, 95% CI 0.41-1.16) and mortality (RR 1.44, 95% CI 0.23-8.90) were also non-significant. Type III and IV non-surgical success was 46/49 (93.9%) and 34/34 (100%). Rescue surgery occurred in 14.3, 12.9, 5.4, and 0% of Types I-IV. Certainty was very low.
CONCLUSION: Very-low-certainty evidence suggests management should be tailored to Stapfer subtype, physiological stability and source control, with prompt operative rescue when non-surgical management fails.