Gastroenterological Endoscopy. Группа авторов

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      10.6.1 Bleeding

      Bleeding is often associated with sphincterotomy, and occurs in 1.3% of ERCPs with a reported mortality rate of 0.05%.⁷⁸ Half are recognized during the procedure.^81,82 Most bleeding is mild to moderate in severity. Risk factors are related to: the patient’s condition, such as cholangitis before the procedure; coagulopathy, liver cirrhosis, or chronic renal failure; anatomical variants (peripapillary diverticulum, stone impaction, papillary stenosis, and Billroth II gastrectomy); or the technique used and the operator (low case volume of the unit or operator, needle knife sphincterotomy, sphincterotomy length, and “recut” of a previous sphincterotomy).^77,81,82,83

      Most patients can be managed by medical and endoscopic treatment.⁷⁷ Treatment of postsphincterotomy bleeding includes the use of epinephrine injection (0.1 mg/mL) for oozing-type bleeding.⁸⁴ Additional thermal methods, such as sphincterotome wire and electrocautery/heater probe use, can be used in the management of a visible vessel or a bleeding point.⁸⁵ Mechanical devices, such as TTS clips, although difficult to manipulate with a side-viewing scope, can be used as second-line treatment to control bleeding at the level of the sphincterotomy, avoiding its placement on the pancreatic orifice.⁸⁶ Balloon tamponade at the site of sphincterotomy has been described but its efficacy has not been established.⁸⁷

      The use of the Endocut Mode (Erbe, Inc., Germany), an automatically controlled cut/coagulation system, has become widely adopted and reduces the rate of minor bleeding.^88,89 Finally, for patients with altered anatomy or with coagulation disorders, balloon sphincteroplasty (endoscopic papillary balloon dilation) could be used since it reduces the risk of bleeding (but unfortunately increases the risk of pancreatitis when performed on an intact papilla).⁷⁷

      10.6.2 Perforation

      Perforation, although rare, is one of the most feared adverse events of ERCP, occurring in 0.6% of the procedures.^77,78 The most frequent is retroperitoneal duodenal perforation occurring at the site of sphincterotomy. Free peritoneal perforation of the duodenum or jejunum is rare and often associated with altered anatomy (Billroth II gastrectomy, duodenal stricture, or peridiverticular papilla). Perforation of the bile duct itself usually follows stricture dilation or traumatic wire insertion through a stricture.⁹⁰ Most patients with free peritoneal perforation will require surgery, whilst most patients with retroperitoneal duodenal perforation can be initially managed conservatively with nasogastric suction, hydration, and administration of broad-spectrum antibiotics. If possible, a nasobiliary catheter should be placed to ensure external biliary or pancreatic drainage. When retroperitoneal perforation is recognized during the procedure, this placement should be immediately attempted. Surgical or radiological drainage of retroperitoneal collections should be considered on a case-by-case basis, keeping in mind the severity of this complication with a reported mortality around 5%.^78,81,91,92

      ERCP-related perforation can largely be prevented by using a finely-tuned technique of sphincterotomy, always performed over a guidewire, ensuring correct orientation of the cutting wire during the course of the sphincterotomy. Incision should be performed step by step, avoiding a zipper cut, recognizing the anatomy of the papilla, and tailoring the size of the sphincterotomy to the size of distal common bile duct. In difficult cases or for removal of large stones, endoscopic balloon dilation of the papilla after a small or incomplete sphincterotomy is now a valid option.^93,94

      10.6.3 Infections

      Post-ERCP infections include cholangitis, cholecystitis, and “pancreatic sepsis” (which may refer to severe necrotic pancreatitis and/or infection of a pseudocyst). Cholangitis and sepsis occur in more than 85% of patients whose opacified bile ducts drain incompletely.⁹⁵ Post-ERCP acute cholecystitis has an incidence rate of < 0.5% and may be related to the injection of contrast medium into a poorly emptying gallbladder or to the occlusion of the cystic duct by a tumor, a stone, and/or a covered self-expandable stent.⁷⁷

      Properly disinfected endoscopes and use of sterile accessories are paramount in prevention. Drainage of any opacified obstructed structure is recommended and “diagnostic” opacification of an obstructed duct is strictly contraindicated. Antibiotic prophylaxis has proven effective in patients at risk of infective endocarditis, in patients known to have a pancreatic pseudocyst, or in patients displaying cholestasis or jaundice with enlarged bile ducts.^96,97 This prophylaxis should be prolonged if drainage is incomplete.

      10.6.4 Post-ERCP Pancreatitis

      Post-ERCP pancreatitis (PEP) remains the most prevalent cause of morbidity and mortality after ERCP. Although its incidence has decreased with improved techniques and indications as well as with prophylactic measures, it remains above 2% in large cohorts.^98,99 It is a clinical situation in which new postprocedural pancreatic pain is associated with at least a threefold increase in serum levels of amylase or lipase.¹⁰⁰ The severity of PEP is defined on the basis of the additional length of hospital stay needed to manage the condition (

Table 10.2). Different risk factors related to the operator case volume, to the procedure itself, and to patient susceptibility have been recognized in large prospective studies (

Box 10.1).^78,81 Severe PEP accounts for less than 10% of PEP cases¹⁰⁰; although risk factors for PEP have been identified, predictors of severity are lacking. The only drug prophylaxis for PEP that has proven efficient is intrarectal administration of 100 mg of diclofenac or indomethacin, and this has been adopted as standard therapy to be given for any ERCP performed on an intact papilla (or involving manipulations on the pancreatic duct).^98,101 In addition, it was recently shown that such prophylaxis should be given systematically before the procedure and not “on demand” according to the per-procedures findings or events.¹⁰² Over the past 20 years, two major endoscopic techniques for preventing PEP in high-risk patients have been developed: guidewire-directed biliary cannulation¹⁰³ and prophylactic pancreatic stent (PPS) insertion. Four meta-analyses of prospective, randomized trials comparing PEP rates with and without PPS insertion conclude that PPS not only reduces PEP rates but also decreases the rate of severe cases of PEP in high-risk patients.^104,105,¹⁰⁶ This finding was confirmed in the intention-to-treat analysis of studies investigating the risk of PEP development, which included patients in whom PPS insertion failed.¹⁰⁷ Nevertheless, PPS placement is associated with an adverse event rate of 4%,¹⁰⁷ mainly related to guidewire- or stent-induced pancreatic duct injuries. The additional benefit of PPS in average-risk ERCPs when NSAIDs are administered is unclear, and its use should be limited to higher risk cases, mainly when a manipulation of the pancreatic duct is performed, in case of precut or papillectomy or when acinarization is observed. Three- or five-centimeter-long 5 French PPS without internal (proximal) flange but with external (distal) flaps are considered the best choice.^108,109 PPS insertion is strongly recommended, despite the recognized complications, in patients who are at high risk of PEP (

Box 10.2).^98,110,111 Finally, the best way to prevent complications is not to perform the procedure, and recently, one of the most controversial indications, sphincter of Oddi dysfunction type III, associated with highest risk of PEP СКАЧАТЬ