Ülkü SARITAŞ, İbrahim GÖREN, Altuğ ŞENOL

Terapotik ERCP komplikasyonları için risk faktörleri: Tek merkezli prospektif çalışma

Tanı ve tedavi amaçlı ERCP'nin pankreatit başta olmak üzere kolanjit, kanama, perforasyon ve kardiyorespiratuvar komplikasyonları vardır. Bu çalışmanın amacı tedavi amaçlı ERCP komplikasyonları ve bunlar üzerine etkili risk faktörlerini belirlemektir. Bu amaçla tek merkezde aynı endoskopist tarafından gerçekleştirilen ardışık 100 ERCP işleminde, işleme bağlı erken komplikasyonların sayı ve şiddeti ile işlem öncesi, sırası ve sonrasında kaydedilen çok sayıda klinik ve laboratuvar parametrenin değerlendirildiği prospektif bir çalışma planlandı. Yüz hastadan ikisinde daha önce geçirilmiş mide operasyonu ve Bilroth-II tipi gastrojejunostomi ve 2 hastada duodenum tümörü nedeniyle papile ulaşılamadığından ERCP yapılamadı. Geriye kalan 96 hastadan 86 sında selektif koledok kanulasyonu, 9 hastada ön kesiyi takiben koledok kanulasyonu ve 1 hastada perkütan-endoskopik kombine girişim ile koledok kanulasyonunu takiben terapotik ERCP gerçekleştirildi. Bir hastada pankreatit, kolanjit ve kanama, 1 hastada kolanjit, 1 hastada pankreatit ve 2 hastada kanama olmak üzere toplam 5 (%5.2) hastada 7 (%7.29) komplikasyon görüldü. Komplikasyonlar hafif ve orta şiddette olup mortalite yoktu. Komplikasyon gelişen hastaların hepsi kadındı ve ikisinde kalıntı koledok taşı vardı. Kadın cinsiyet ve kalıntı koledok taşı terapotik ERCP komplikasyonları üzerine etkili risk faktörleri olarak saptandı. Koledok taşında EST yi takiben koledok temizliği yapıldıktan sonra opak madde verilerek kontrol kolanjiografi çekildiğinde opak örtmesine bağlı küçük taşlar gözden kaçabilir ve ilk 24 satte oddideki ödeme bağlı spontan düşüş olamayacağından bizim 1 hastamızda olduğu gibi pankreatit, kolanjit ve kanamaya neden olabilir. Bu nedenle işlem bittikten sonra hastaları sırtüstü çevirip kalıntı koledok taşı açısından skopi ile kontrol yapılmalı ve taş varsa spontan düşüş beklenmeden tekrar duodenoskopla girilerek işlem tamamlanmalıdır. Sonuç olarak endoskopistin deneyimi dahil çok sayıda teknik ve hastayla ilgili faktör ERCP ile ilgili komplikasyon oranını artırmaktadır. Endoskopistin yeterli deneyim kazanması, yüksek riskli hastaların belirlenerek mümkünse ERCP'den vazgeçilmesi veya işlemden kaynaklanan risk faktörlerinin azaltılması ve tanısal ERCP yerine mümkün olduğu kadar invaziv olmayan görüntüleme yöntemlerinin kullanılması ERCP ile ilişkili komplikasyonları azaltacaktır.

Anahtar Kelimeler:

ERCP, pankreatit, perforasyon, kolanjit

Risk factors for complications of therapeutic ERCP: A single center prospective study

Other than pancreatitis, diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP) can result in several complications - primarily cholangitis, bleeding, perforation and cardio-respiratory side effects. In this study, we investigated complications of therapeutic ERCP and the risk factors associated with these complications. We did a retrospective study on 100 patients who had undergone ERCP procedure by the same endoscopist and evaluated data regarding clinical and laboratory parameters obtained pre-, during and soon after the ERCP procedure. ERCP could not be done in two patients because of previous gastric operation and Billroth II type gastrojejunostomy and in another two patients who had obstructing duodenum tumor which prevented reaching the papilla. We did selective choledochal cannulation in 86 of 96 patients; nine cases had undergone precut sphincterotomy before selective cannulation, and in one case, percutaneous and endoscopic combined method had been used to cannulate the common bile duct. Totally, seven (7.29%) complications in five patients (5.2%) were observed as follows: one patient had pancreatitis, cholangitis and bleeding; one had cholangitis; one had pancreatitis and bleeding and two had bleeding. There was no mortality, though mild and moderate procedure-related morbidities were noted. All the patients who developed complications were female and two had had residual common bile duct stone. The female gender and residual bile duct stone were determined to be the main risk factors in therapeutic ERCP. After sphincterotomy and cleaning of the common bile duct, the cholangiographic images can miss small stones due to contrast material, and during the first 24 hours, the Oddi edema can prevent spontaneous passage of the residual stone. Thus, as was seen in one of our patients, pancreatitis, cholangitis and bleeding can develop in these cases. Thus, patients should be checked with scopes and in the case of a residual stone, extraction should be completed without delay rather than waiting for spontaneous release. In conclusion, specific patient- and procedure- related factors, including operator experience, can increase the risk of ERCP-related complications. Precise identification of risk factors for complications of ERCP is essential to recognize high-risk cases in which ERCP should be avoided if possible. Furthermore, use of noninvasive imaging modalities instead of diagnostic ERCP and performance of ERCP by an experienced endoscopist will decrease ERCP-related complications.

Keywords:

ERCP, pancreatitis, perforation, cholangitis,

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