Ulus Travma Acil Cerrahi Derg. 2023; 29(3): 443-447 | DOI: 10.14744/tjtes.2022.28923

Endoskopik retrograd kolanjiyopankreatografi sonrasý portal ven yaralanmasý: Olgu sunumu

Pýnar Taþar, Sadýk Ayhan Kýlýçturgay
Bursa Uludað Üniversitesi Týp Fakültesi, Genel Cerrahi Anabilim Dalý, Bursa

Endoskopik retrograd kolanjiyopankreatografi (ERCP), çeþitli pankreatikobilier bozukluklarýn taný ve tedavisinde yaygýn olarak kullanýlan bir prose-dür olmuþtur. Yaygýn olarak güvenli bir prosedür olarak kabul edilmesine raðmen, ERCP morbidite ve nadiren mortalite ile iliþkilidir. En sýk görülen komplikasyonlar arasýnda akut pankreatit, kanama ve duodenal perforasyon bulunur. Portal ven kanülasyonu, ERCP’nin nadir bir komplikasyonudur. Biz, ERCP ve sfinkterotomi sýrasýnda portal vene endoskopik biliyer stent yerleþtirilmesi olgusunu tanýmladýk. Elli dört yaþýnda kadýn hastaya kronik taþlý kolesistit ön tanýsý ile laparoskopik kolesistektomi yapýldý. Ameliyat sonrasý dördüncü gün sarýlýk ve kaþýntý þikayeti ile acil servise baþvurdu. MRCP’de intrahepatik ve ekstrahepatik safra yollarý dilate ve ana safra kanalýnda 7.5x5.5 mm’lik bir taþ vardý. ERCP ile sfinkterotomi yapýldý, taþlar çýkarýldý ve ardýndan 10F 7 cm stent yerleþtirildi. ERCP’nin dördüncü gününde ateþ ve total bilirubin düzeyi 5 mg/dl’de sebat eden hastaya kolanjitik apse ve/veya ERCP komplikasyonu düþünülerek abdominopelvik bilgisayarlý tomografi (BT) çekildi. BT’de koledok içindeki stentin proksimal ucu-nun ana portal vene girdiði ve ucunun tromboze olduðu izlendi. Bu nedenle ameliyathane þartlarýnda stentin endoskopik olarak çýkarýlmasýna karar verildi. Anestezi indüksiyonunun ardýndan stent gastroenteroloji ekibi tarafýndan endoskopik olarak çýkarýldý. Stent çýkarýlýrken hastanýn karýn boþluðu laparoskopik olarak eksplore edildi. Anestezi sýrasýnda hemodinamik instabilite geliþmeyen ve transfüzyon gerektirmeyen hasta, klinik takibinde bir kez melenasý oldu. Hasta düþük molekül aðýrlýklý heparin ve oral sefalosporin ile taburcu edildi ve poliklinik kontrolü önerildi. Kontrolleri sýrasýnda aralýklý ateþ þikayeti olan hastaya yapýlan portal vendeki trombozu deðerlendirmek için Doppler USG yapýldý. Doppler USG’de ana portal vende ve dallarýnda tromboze bir görünüm saptandý. Genel durumu iyi olan, karýn aðrýsý olmayan hastada, yüksek doz düþük molekül aðýrlýklý heparine geçile-rek gastroenteroloji ve genel cerrahi poliklinik kontrolünde takibe alýndý. Nadir görülen hayatý tehdit eden bu komplikasyon özellikle iþlem sýrasýnda ve/veya hastanýn klinik takibinde daima akýlda tutulmalýdýr.

Anahtar Kelimeler: Endoskopik retrograd kolanjiyopankreatografi, kolanjit, komplikasyon; portal ven kanülasyonu; tromboz.

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Portal vein injury following endoscopic retrograde cholangiopancreatography: A case report

Pýnar Taþar, Sadýk Ayhan Kýlýçturgay
Department of General Surgery, Bursa Uludað University Faculty of Medicine, Bursa-Türkiye

Endoscopic retrograde cholangiopancreatography (ERCP) has been a widely used procedure in the diagnosis and treatment of various pancreaticobiliary disorders. Although widely considered a safe procedure, ERCP is associated morbidity and occasional mortality. The most common complications include acute pancreatitis, hemorrhage, and duodenal perforation. Portal vein cannulation is a rare complication of ERCP. We described a case of placement of an endoscopic biliary stent in the portal vein during ERCP and sphinc-terotomy. A 54-year-old female patient underwent laparoscopic cholecystectomy with a pre-diagnosis of chronic cholecystitis with gallstones. She visited emergency unit with the complaint of jaundice and itching on the 4th post-operative day. On the magnetic res-onance cholangiopancreatography, the intrahepatic and the extrahepatic bile ducts were dilated and a 7.5×5.5 mm stone at common bile duct. Sphincterotomy was performed by ERCP, the stones were removed, and then a 10F 7 cm stent was installed. Abdominopelvic computed tomography (CT) was performed on the 4th day of ERCP in the patient whose fever and total bilirubin levels persisted at 5 mg/dL, considering cholangitic abscess and/or ERCP complication. On the CT, the proximal end of the stent in the common bile duct was observed to enter into the main portal vein and the tip was observed to be thrombosed. Therefore, it was decided to remove the stent endoscopically under operating room conditions. After the anesthesia induction, the stent was endoscopically removed by the gastroenterology team. The abdominal cavity of patient was explored laparoscopically in the during of stent removal. The patient did not experience hemodynamic instability and did not require transfusion during anesthesia but had melena once on the clinical follow-up. The patient was discharged with low molecular weight heparin and oral cephalosporin and was advised to return for polyclinic control. Doppler ultrasonography (USG) was performed to evaluate the thrombosis of the portal vein in the patient who had intermittent fever during the controls. Doppler USG revealed a thrombosed appearance in the main portal vein and its branches. The patient, who was in good general condition and had no abdominal pain, was switched to high-dose low molecular weight heparin and followed under the control of the gastroenterology and general surgery outpatient clinic. This rare life-threatening complication should always be kept in mind especially during the procedure and/or in the clinical follow-up of the patient.

Keywords: Cholangitis, complication; endoscopic retrograde cholangiopancreatography; portal vein cannulation; thrombosis.

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