Abstract Introduction Subcutaneous emphysema is a recognized complication of laparoscopic surgical procedures, with an incidence ranging from 0.43% to 2.34%; however, up to 77% of cases remain undiagnosed. Its occurrence following endoscopic retrograde cholangiopancreatography (ERCP) is rare but clinically significant, most often resulting from duodenal perforation. The risk increases with prolonged operative time and repeated cannulation attempts. This case highlights a catastrophic presentation of subcutaneous emphysema and associated complications following ERCP, emphasizing the importance of recognizing, managing, and counseling patients about even rare but potentially fatal outcomes of routine procedures. Case Presentation A 67-year-old man with a history of hypertension, compensated liver cirrhosis, heart failure with reduced ejection fraction, nephrolithiasis, and cholelithiasis presented to an outside hospital with acute abdominal pain. Imaging revealed choledocholithiasis and cholelithiasis. Magnetic resonance cholangiopancreatography confirmed the diagnosis, and ERCP was attempted using oxygen for insufflation. The procedure was aborted after multiple unsuccessful attempts to cannulate the peridiverticular papilla.Post-procedure, the patient developed diffuse subcutaneous emphysema extending from the head and neck to the lower extremities, including the scrotum. In the post-anesthesia care unit, he became hemodynamically unstable and required intubation. CT imaging of the chest, abdomen, and pelvis revealed extensive subcutaneous emphysema, pneumomediastinum, pneumopericardium, bilateral pneumothoraces, and pneumoperitoneum.Given the concern for perforation, the patient was transferred to our tertiary facility for cardiothoracic and gastrointestinal evaluation. Surgical teams suspected intestinal perforation; however, the patient was too unstable for operative repair. General surgery performed blowholes to decompress the subcutaneous air, which temporarily improved oxygenation. Despite aggressive management with inhaled nitric oxide and multiple vasopressors, the patient developed anuria and refractory shock. After multidisciplinary discussions, the family elected to pursue comfort care, and the patient passed away. Discussion Approximately 500,000 ERCPs are performed annually in the United States, with overall complication rates between 6% and 10%. Perforation is rare (1%) but carries a mortality rate of 16-18%. Subcutaneous emphysema following ERCP, although often benign when recognized early, can rapidly progress to pneumothorax, pneumomediastinum, or cardiovascular collapse. This case emphasizes the need for early recognition, appropriate imaging, and timely decompression in patients with post-procedural swelling or crepitus. It also reinforces the ethical responsibility of clinicians to counsel patients about even low probability but life-threatening complications inherent to diagnostic and therapeutic procedures. This abstract is funded by: None
Bendapudi et al. (Fri,) studied this question.