Gastroenterological Endoscopy. Группа авторов
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Название: Gastroenterological Endoscopy

Автор: Группа авторов

Издательство: Ingram

Жанр: Медицина

Серия:

isbn: 9783131470133

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СКАЧАТЬ biliary sphincterotomy.112

       Patient-related factors

      • Female gender

      • Young age

      • History of suspected sphincter of Oddi dysfunction

      • History of pancreatitis, recurrent or post-ERCP pancreatitis

       Procedure-related factors

      • Difficult or multiple cannulation attempts

      • Multiple pancreatic contrast injections

      • Pancreatic acinarization

      • Precut sphincterotomy

      • Endoscopic papillary balloon dilation

      • Sphincter of Oddi manometry

      • Distal common bile duct diameter ≤ 10 mm

      • Procedures not involving stone removal

      Source: Adapted with permission from Woods KE, Willingham FF. World J Gastrointest Endosc. 2010; 2(5): 165–78.

       Definitive

      • Pancreatic sphincterotomy for sphincter of Oddi dysfunction/acute recurrent pancreatitis

      • Ampullectomy

       Highly recommended

      • Difficult biliary cannulation, involving instrumentation or injection of the pancreatic duct

      • Pancreatic sphincterotomy (major and minor)

      • Aggressive instrumentation of the pancreatic duct (cytology brushing, biopsies)

      • Balloon dilatation of an intact biliary sphincter (balloon sphincteroplasty)

      • Prior PEP

      • Precut sphincterotomy starting at the papillary orifice

      Source: Adapted with permission from Devière J. Gastrointest Endosc Clin N Am. 2011; 21(3): 499–510.

      PEP is mild to moderate in >90% of the cases.98,100 PEP is managed as with pancreatitis from other etiologies.

      10.7 Other Techniques

      Over the last 10 years, the therapeutic capabilities of endoscopy have been extended to techniques involving the passage of instruments through the GI tract or of endoscopes into the submucosal space. Most of these techniques are still in development, and all of these should be done in high-volume centers with extensive technical experience. Some of these procedures, however, have become part of the routine armamentarium in large endoscopy units, such as EUS-guided celiac block/neurolysis for refractory pancreatic pain, EUS-guided cyst drainages, and POEM for achalasia. The major potential complications associated with these techniques are summarized.

      10.7.1 EUS-Guided Celiac Block/Neurolysis

      This technique used for managing pain related to pancreatic cancer or chronic pancreatitis is usually used in cases not manageable with usual drug therapy. It consists of injecting absolute ethanol or corticoids at the bifurcation between the aorta and the celiac trunk. Usually, the needle is flushed with local anesthetic, which is injected initially. This reduces the transient exacerbation of pain (reported in up to 30% of cases) but also confirms the injection takes place outside the stomach and is not intravascular. Indeed, intramural injection may lead to necrosis of the gastric wall and abscess formation (especially when neurolysis is performed), while damage to a vessel can induce bleeding or rare spinal cord injury. Another delayed complication, almost unpreventable, is diarrhea. This occurs in 3 to 5% of the cases, and is often transient and managed symptomatically.113,114

      10.7.2 EUS-Guided Drainage of Pancreatic Fluid Collections

      Endotherapy has become accepted as a gold standard for management of symptomatic pancreatic pseudocysts and acute fluid collections.115 Complications related with this technique may occur during the procedure or delayed. Periprocedural complications include bleeding, of which the incidence has been dramatically reduced with the use of linear EUS endoscopes to perform the procedure, and leakage of the pseudocyst contents. If a bleeding occurs during the procedure, it is most often due to puncture of a vessel. A coagulation device (Cystotome, Cook Endoscopy, Winston-Salem, North Carolina, United States; Endoflex, Voerde, Germany) can be used and the procedure completed by the placement plastic stents or SEMSs, which will also has a tamponade effect.116 However, there are no established indications for SEMS placement for pseudocyst drainage. Recently developed short, biflanged stents (Axios, Boston Scientific, Marlborough, Massachusetts, United States; Nagi stent, Taewoong, Seoul, Korea; Spaxus stent, Taewoong, Seoul, Korea) are useful for drainage of pseudocysts and necrosis and facilitating access to pancreatic necrosis for direct necrosectomy. They may be associated with severe complications, mainly vascular injuries.117 Leakage following placement usually occurs either by loss of guidewire access after puncture or by misdeployment or slippage into the peritoneal cavity when the collection is not bulging into the GI tract. If such a leak occurs, the first priority is to regain access to the residual cavity and provide adequate decompression.

      Delayed bleeding may also occur within a few days after the procedure. In this case, it is most often due to a pseudoaneurysm, and the initial therapeutic approach should be an interventional angiography.

      Finally, a late complication is recurrence of the collection after stent removal. It is most often due to the presence of a disconnected pancreatic duct.118 Magnetic resonance pancreatography (if possible with secretin) is recommended before any decision to remove the transmural stents. If ductal disconnection is present, stents (exclusively plastic, not SEMS) should remain in place indefinitely.

      10.7.3 Peroral Endoscopic Myotomy

      POEM, and more largely any intervention requiring access to the submucosal space (also called third space endoscopy to differentiate it from the luminal and extraluminal cavities), including esophageal or pyloric myotomies but also resection of submucosal tumors, has become a standard procedure in tertiary specialized centers. These techniques offer new possibilities of treatment, potentially more effective than surgery in selected cases. They are, however, associated with specific complications. In one of the largest series to date,119 (1,680 patients treated with POEM), major complications occurred in 55 (3.3%) patients, including 13 (0.8%) postoperative mucosa breach, 3 (0.2%) delayed bleeding, 8 (0.5%) hydrothorax, 25 (1.5%) pneumothorax that required thoracic tube placement, and 6 (0.4%) other complications. Four patients required ICU admission and 14 (0.8%) stayed more than 10 days in the hospital. The rate of major complications decreased over time and СКАЧАТЬ