Stapfer type II perforations, defined by periampullary injury with retroperitoneal leakage, represent the most frequent form of ERCP-related perforation. Despite their clinical relevance, optimal management remains debated. The aim of this study was to evaluate the clinical success of endoscopic treatment of Stapfer type II perforations, including cannulation success, early perforation recognition rate, and the need for surgery or percutaneous drainage.

This retrospective study included patients diagnosed with Stapfer type II perforation between 2019 and 2025 at a high-volume tertiary referral center. Type II perforation was defined as retroperitoneal free air detected intra-procedurally or confirmed post-procedurally on contrast-enhanced CT. When perforation was recognized during ERCP, FcSEMS was placed in the same session. Patients diagnosed after ERCP underwent repeat ERCP within 24 hours, and FcSEMS was deployed if technically feasible. Endoscopic clinical success was defined as the avoidance of surgical exploration. In two patients with failed cannulation, percutaneous transhepatic biliary drainage (PTBD) was performed, followed by rendezvous-assisted FcSEMS placement.

Between 2019 and 2025, a total of 14,576 ERCPs and 8,094 sphincterotomies were performed. Sphincterotomy-related Stapfer type II perforation developed in 24 patients (0.29%). The median age was 61.5 years (range 23–90), and 16 patients (66.6%) were female. The most frequent indication for ERCP was common bile duct stones in 16 patients (66.6%). Perforation was recognized during the index procedure in 20 patients (83.3%), while 4 patients (16.7%) were diagnosed post-procedurally by CT. Standard sphincterotomy was the cannulation technique attempted in 13 patients (54.2%). Cannulation was successful in 22 patients (91.7%). In two patients with unsuccessful cannulation, PTBD followed by rendezvous-assisted stent placement was performed. Due to post-procedural recognition of perforation (n=4) or failed initial cannulation requiring PTBD (n=2), a total of 6 patients (25%) underwent a repeat ERCP within 24 hours. FcSEMS was successfully placed in 23 patients (95.8%). One patient (4.2%) with primary sclerosing cholangitis-related dominant stricture was treated with nasobiliary drainage because stent placement was not technically possible. Retroperitoneal fluid collection developed in 8 patients (33.3%), 6 of whom were in the group requiring a second-session procedure. None of the patients required percutaneous drainage or surgical intervention. No mortality occurred in the entire cohort. All patients demonstrated rapid clinical improvement following endoscopic therapy, and no stent-related adverse events such as migration or occlusion were recorded during follow-up.

FcSEMS placement is a highly effective treatment modality for Stapfer type II ERCP perforations. In all technically suitable patients, FcSEMS should be deployed immediately once perforation is recognized. In cases of failed cannulation, PTBD-assisted rendezvous enables successful stent placement and prevents the need for surgery. When perforation is diagnosed post-procedurally, early repeat ERCP and prompt FcSEMS deployment within 24 hours are critical to prevent clinical deterioration. Early recognition and timely treatment appear to reduce the likelihood of developing retroperitoneal fluid collections, which were predominantly observed in patients requiring delayed intervention. Our findings support the early, systematic use of FcSEMS for Stapfer type II perforations and highlight the importance of immediate detection, successful cannulation, and rapid biliary decompression to optimize outcomes and avoid invasive procedures.