ERCP perforasyonlarýnda erken ve gecikmiþ tanýnýn mortalite ile karþýlaþtýrýlmasý: Yüksek hacimli hasta deneyimi

AMAÇ: Endoskopik retrograt kolanjiyopankreatografi (ERCP) perforasyonu nadir görülen, fakat mortalitesi yüksek seyredebilen bir komplikasyondur. Bu çalýþmada, cerrahi veya týbbi tedavi edilen ERCP perforasyonlarýna insidans, klinik veriler ve taný zamanýna göre klinik deðerlendirme yapýldý. ERCP perforasyonlarýnýn azaltýlabilmesi için klinik özelliklerinin ortaya konulmasý, literatür ile karþýlaþtýrýlmasý ve mortalitenin azaltýlmasý hedeflendi.
GEREÇ VE YÖNTEM: Bu klinik geriye dönük çalýþmada 8 yýlda yapýlan tüm ERCP iþlemleri (n=8676) içinde 51 perforasyon saptandý. Erken taný konulan [Grup 1: 40], geç taný konulan [Grup 2: 11] gruplar primer tanýlarý, ERCP öncesi kan ve biyokimyasal incelemeleri, perforasyon tipi, tedavi yöntemi, klinik özellikleri, yatýþ süresi, mortalite yönünden karþýlaþtýrýldý. Ek olarak ERCP sýrasýnda papillotomi, stent yerleþtirilmesi, koledok dilatasyonu, ERCP iþlemi sayýsý yönünden karþýlaþtýrýldý.
BULGULAR: Hastanemizde ERCP perforasyonu oraný %0.59’du. Hastalarýn çoðunluðu koledokolitiazis ve periampuller tümörlerdi. Hastalarýn yaþý 62.78±17.13 (24–89); %56.9'u (n=29) kadýndý. En sýk stapfer tip II perforasyonlar (%49) görüldü. Ancak mortalitenin %62.5’i stapfer tip I’di. Toplam mortalite %13.72 (n=7) idi. Cerrahi tedavi edilen hastalarýn (n=24) yatýþ süresi (13.38±10.09 gün) daha fazla idi. Týbbi tedavi edilenlere (%74.1) daha çok koledok stenti yerleþtirilmiþti (p=0.039). Grup 1, ERCP sýrasýnda görsel olarak veya kontrast madde kaçaðý (13/40) ile veya þüphe nedeniyle tomografi ile tespit edildi. Grup 2 hastalarýn Pre-ERCP lökosit seviyesi daha yüksekti (p=0.044). Acil cerrahi gereksinimi %72.7 ve mortalite %36.4 idi. Perforasyonunun erken ve geç farkedilmesi arasýnda mortalite açýsýndan farklýlýk belirlendi (p=0.014).
TARTIÞMA: Erken taný konulanlarda, tip I perforasyonlar hariç, daha az cerrahi gereksinim olmuþtur. Tip II perforasyonlar, akut karýn ve sepsis bulgularý yok ise, çoðunlukla non-operatif güvenli bir þekilde tedavi edilebilmektedir. Erken taný ve tedavi mortaliteyi azaltmaktadýr.

Comparison of early and delayed diagnosis of mortality in ERCP perforations: A high-volume patient experience

BACKGROUND: Although ERCP (Endoscopic retrograde cholangiopancreatography) perforation is a rare complication, it results in high morbidity and mortality. In this study, clinical evaluation was performed concerning the incidence, clinical data and time of diagnosis for ERCP perforations that were either surgically or medically treated. To reduce the ERCP perforations and related mortality, in this study, we aimed to reveal the clinical features and compare them with the literature.
METHODS: In this clinical retrospective study, 51 perforations were detected in 8676 ERCP procedures performed in the past eight years in our hospital. We compared the two groups: early diagnosed patients [Group 1: n=40] and the delayed diagnosed patients [Group 2: n=11] concerning primary diagnosis, blood and biochemical tests before ERCP, perforation type, treatment method, clinical features, length of stay, and mortality. These groups were compared concerning stent placement, papillotomy choledochal dilatation and the number of ERCP procedures.
RESULTS: The ERCP perforation rate in our hospital was 0.59%. The majority of patients who underwent ERCP procedures was due to the choledocholithiasis and periampullary tumors. The mean age was 62.78±17.13 (24–89 years old) and 56.9% of the patients (n=29) were women. Stapfer type II perforations (49%) were the most common type of perforation. However, 62.5% of the total mortality occurred in patients with type I perforation. The overall mortality rate was 13.72% (n=7). The duration of hospitalization (13.38±10.09 days) was higher in the patients who were treated surgically (n=24). Choledochal stents were utilized mostly in the medically treated patients (74.1%) (p=0.039). The patients in Group 1 were detected visually by the operator during the ERCP by leakage of contrast substance (13/40) or by abdominal tomography due to clinical suspicion. Patients in Group 2 had higher pre-ERCP leukocyte levels (p=0.044). The urgent surgery requirement in Group 2 was 72.7%, while the mortality rate was 36.4%. Significant mortality difference was observed between the early and late detection of perforations, indicating a higher rate in Group 2 (p=0.014).
CONCLUSION: In the patients who were diagnosed early, fewer surgical interventions were required, except for the type I perforations. Type II perforations can often be safely treated non-surgically if there are no signs of acute abdomen and sepsis. Early diagnosis and treatment significantly reduce ERCP-related mortality.