Management of perforation after endoscopic retrograde cholangiopancreatography

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP)-related perforation is an infrequent complication. It is associated with significant morbidity and mortality. The present study is an evaluation of experience with management and outcomes of ERCP-related perforations and a review of relevant literature.
METHODS: Between January 2008 and January 2015, a total of 9383 ERCPs were performed in endoscopy unit. A total of 29 perforations (0.33%) were identified and retrospectively reviewed.
RESULTS: Of the 29 patients, 18 were female and 11 patients were male, with mean age of 70.5 years (range 33–99 years). According to Stapfer’s classification, the 29 patients with ERCP related perforations included 5 type 1 perforations, 14 type 2 perforations, 7 type 3 perforations, and 3 cases of type 4 perforation. In total, 15 of 29 patients with ERCP perforation were operated on. Nine (60%) of those who underwent surgery were discharged uneventful, but 6 (40%) patients died due to postoperative complications and/or associated comorbidities. Seven (24.1%) of 29 patients had undergone endoscopic treatment and 5 of the 7 were discharged from the hospital without any problems; however, peritonitis occurred in 2 patients whose initial endoscopic treatment failed. The first of these 2 patients underwent surgery and was discharged uneventfully, but second patient, who refused surgery, died due to sepsis. Six patients were successfully treated with conservative management. Surgery could not be performed in the remaining 2 patients, who died of sepsis following peritonitis; 1 refused surgery, the other had sudden cardiopulmonary arrest during induction of general anesthesia. Mean hospital stay was 13.2 days (range: 2–57 days). In all, 9 (31%) patients died during period of the study.
CONCLUSION: ERCP-related perforation is uncommon complication, but an extremely serious condition. Early diagnosis and prompt management are most important to reduce associated significant morbidity and mortality rates. The most appropriate treatment course should be determined on case-by-case basis.

Endoskopik retrograd kolanjiopankreatikografiye baðlý perforasyonlarýn tedavisi

AMAÇ: Endoskopik retrograd kolanjiopankreatikografiye (ERKP) baðlý perforasyonlar az görülmelerine karþýlýk yüksek morbidite ve mortalite oranlarýna sahiptir. Bu çalýþmada ERKP’ye baðlý perforasyonlarýn tedavisi ve sonuçlarýmýza ait tecrübelerimizi deðerlendirmeyi ve ilgili literatürün gözden geçirilmesini amaçladýk.
GEREÇ VE YÖNTEM: Ocak 2008 ve Ocak 2015 yýllarý arasýnda Ýzmir Katip Çelebi Üniversitesi, Atatürk Eðitim ve Araþtýrma Hastanesi Endoskopi Ünitesi’nde toplam 9383 ERKP iþlemi yapýldý. Bu hastalarýn 29’unda (%0.33), ERKP’ye baðlý perforasyon tespit edildi ve bu hastalara ait veriler geriye dönük olarak deðerlendirildi.
BULGULAR: Yirmi dokuz hastanýn 18’i kadýn, 11’i erkek hasta olup, ortalama yaþ 70.5 (33–99 yaþlar arasý) idi. Stapfer sýnýflandýrmasýna göre 5 hastada tip 1, 14 hastada tip 2, 7 hastada tip 3 ve 3 hastada da tip 4 perforasyon saptandý. Toplam olarak, 15 hastaya cerrahi tedavi uygulandý; bunlardan 9’u (%60) sorunsuz olarak taburcu edilirken, 6 (%40) hasta ameliyat sonrasý komplikasyonlardan dolayý öldü. Yirmi dokuz hastanýn 7’sinde (%24.1) ise baþlangýçta endoskopik tedavi uygulandý ve bu hastalardan beþi sorunsuz olarak taburcu edildi. Ancak endoskopik tedavi iki hastada baþarýsýz oldu. Peritonit geliþen bu 2 hastadan ilki, cerrahi tedavi sonrasý sorunsuz olarak taburcu edildi. Cerrahi tedaviyi kabul etmeyen diðer hasta ise sepsis nedeni ile öldü. Altý hasta konservatif týbbi tedavi ile baþarýlý bir þekilde tedavi edildi. Peritonit sonrasý geliþen sepsis nedeniyle hayatýný kaybeden 2 hastadan ilkinde hasta ve yakýnlarýnýn cerrahi tedaviyi reddetmesi nedeniyle, diðer hastada ise, anestezinin indüksiyon evresinde ani geliþen kardiyopulmoner arrest sonucu cerrahi tedavi yapýlamadý. Çalýþmamýzda ortalama hastanede kalma süresi 13.2 gün (2–57), ölen hasta sayýsý ise dokuz (%31) idi.
TARTIÞMA: Endoskopik retrograd kolanjiopankreatikografiye baðlý perforasyonlar nadir görülmesine karþýlýk yüksek mortalite oranlarý yol açabilmesi nedeni ile son derece önemli bir klinik durumdur. Erken taný ve tedavi mortalite ve morbidite oranlarýnýn azaltýlmasýnda çok önemlidir. En uygun tedavi yöntemi, hastanýn bireysel özellikleri ve klinik durumu göz önünde bulundurularak verilmelidir.