Gastroenterological Endoscopy. Группа авторов

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      10.1 Introduction

      An endoscopic complication can be defined as an adverse event that requires a deviation from the initial plan for diagnosis and/or treatment, and this adverse event can be qualified as severe when it prolongs hospitalization and/or results in an unscheduled hospital admission.¹ The frequency of endoscopic complications is likely to increase in proportion to the indications and complexity of therapeutic procedures. The best way to prevent complication is to carefully analyze procedural indications and avoid unnecessary invasive examinations. Gastrointestinal (GI) endoscopy is a discipline evolving quickly within a multidisciplinary environment with paradigm changes such as the development of alternative, noninvasive diagnostic techniques, for example, magnetic resonance cholangiopancreatography (MRCP), which has entirely replaced diagnostic endoscopic retrograde cholangiopancreatography (ERCP) for imaging the biliopancreatic tract. With an increasing complexity of endoscopic procedures, the need for extensive knowledge of techniques and accessories has become paramount, and it is now clear that many of these procedures must be concentrated in specialized referral centers. Acquiring and maintaining experience in a multidisciplinary environment is essential to select the best procedure for a specific indication and to consequently reduce the risk of adverse events. Now that therapeutic endoscopy offers even more alternatives to open surgery, it is also important to disseminate information about the outcomes of these procedures in order to avoid inappropriate therapeutic approaches to manage known or suspected complications. For example, postprocedural management following submucosal and transmural endotherapy may result in imaging findings of incidental free air that may be inappropriately managed with aggressive surgery.²

      Preprocedural patient education and informed consent (see Chapter 3) are paramount. Standardization of treatment, organization of the therapeutic endoscopy team and its training, and adherence to guidelines are also essential in order to minimize, prevent, and adequately manage adverse events. The most frequent complications of diagnostic and therapeutic endoscopy are reviewed in this chapter. Different modalities of medical, endoscopic, and surgical management are also considered.

      10.2 General Considerations

      10.2.1 Cardiopulmonary and Sedation-Related Events

      A cornerstone for proper performance of endoscopy is that the selection, and the monitoring of sedation should commensurate with the planned procedure. Cardiopulmonary adverse events account for up to 50% of severe morbidity and mortality related to GI endoscopy.^3,4 These adverse events range from clinically insignificant oxygen desaturation to clinical dysrhythmias, oversedation, aspiration pneumonia, respiratory failure, myocardial infarction, and shock. Many of these adverse events are linked to inappropriate sedation levels considering the type of procedure and the status of the patient, but they may also be associated with other adverse events such as bleeding, sepsis, and perforation.

      Before undertaking moderate sedation (see Chapter 4), the patient’s medical and surgical history, baseline medications with a particular focus on antithrombotic agents, and drug allergies must be assessed. The American Society of Anesthesiologists (ASA) score is a useful predictor of procedural sedation risk. Other risk factors include age, type of anesthesia, inpatient status, emergency procedure, and trainee involvement. Patients should not temporarily discontinue their cardiovascular medications except for antithrombotic agents when high-risk bleeding procedure is performed (see

Table 10.1),⁵ and this decision should be undertaken with advice from other specialists (cardiology, neurology, etc.) in patients at high risk for thrombosis.

      Pharyngeal anesthesia is usually recommended when no or minimal sedation is administered. It should be used with caution or avoided in nonintubated patients with suspected gastric outlet obstruction or gastroparesis, and in the presence of active upper GI bleeding as it increases the risk of aspiration pneumonia.³ Pre-oxygenation of patients with ischemic cardiovascular disease, as well as administration of supplemental oxygen during the procedure to avoid ischemic events, is recommended. All patients must be monitored using pulse oximetry before, during, and after the examination and continued until full recovery. Managing and avoiding cardiopulmonary adverse events requires competency in basic life support, knowledge of the patient’s underlying medical status, and pharmacological properties of the drugs used and their reversal agents.

      10.2.2 Infection

      Although rare,⁶ infections can result from the transmission of microorganisms through the endoscope from one patient to another or (even more rarely) through reprocessed devices, from the translocation of bacteria from the endogenous digestive flora through a tear or perforation in the mucosa, from contamination of a sterile compartment by patient’s GI flora (i.e., typically during ERCP in the presence of obstructed ducts and inadequate drainage), or by the transmission of microorganisms from patients to personnel of the endoscopy unit (and vice versa).

      All reported cases of patient-to-patient transmitted infections were due to failure СКАЧАТЬ