Endoscopic retrograde cholangiopancreatography at a regional hospital of the IMSS, 2002-2011 127 Table 1 Post-ERCP complication criteria Mild Moderate Severe Hemorrhage Clinical evidence of bleeding (not Transfusion 4 units with no Transfusion 5 units or surgery. just endoscopic); Drop in need for surgery. hemoglobin 3 g with no need for transfusion. Perforation Possibility or suspicion of contrast Perforation established, Medical treatment for more than material leakage treated with fluids requiring treatment for more 10 days or surgical intervention. or suction for at least 3 days. than 4 and up to 10 days. Pancreatitis Clinical presentation of pancreatitis, Pancreatitis requiring Pancreatitis requiring amylase 3 times its normal value hospitalization for 4 to 10 days. hospitalization for more than 10 in the first 24 postoperative hours days or hemorrhagic pancreatitis. requiring hospitalization for 2 to 3 days. Cholangitis Fever 38º at 24 to 48 hrs. Fever requiring hospitalization Septic shock or surgery. 3 days, endoscopic treatment, or percutaneous intervention. Adapted and modified from: Cotton PB et al.16 Table 2 Characteristics of patients that underwent ERCP Table 3 Etiology of patients that underwent ERCP Variable n=1145 % Variable n=1145 % Women 693 60,5 Choledocholithiasis 359 31,4 Age (years) Neoplasia 208 18,2 80 104 9,1 Cholangiocarcinoma 77 37,0 65-80 317 27,7 Bismuth I 67 87,0 50-65 297 25,9 50 427 37,3 Bismuth II 6 7,8 Jaundice 688 60,1 Bismuth III 1 1,2 Abnormal LFTs 718 62,7 Bismuth IV 3 3,9 Biliary lithiasis by ultrasound 137 12,0 Postoperative ductus choledocus 13 1,1 ligature Biliary dyskinesia 2 0,2 History of pancreatitis 30 2,6 LFTs: Liver function tests. after the procedure. In very few cases, follow-up coincided with the patient’s admission to the emergency room or with a direct communication from the patient’s relatives. Age and endoscopic cut (precut/sphincterotomy) were In relation to etiology, choledocolithiasis and pancreatic factors associated with complications in this study. The oddsand biliary tumor frequency was 31,4% (n=359) and 18,2% ratio for complication risk in the group of patients that re-(n= 208), respectively, and cholangiocarcinoma represented ceived treatment was 1,4 (95% CI: 1,02-5,43, p=0,045).37,0% (n=77) of the tumor total. Therapeutic endoscopy re-presented 51,0% of the total of studies performed. It is im-portant to mention the therapeutic use of ERCP at ourhospital in postoperative lesions of the biliary tract, sincewe had thirteen cases (1,1%) (table 3). A total of 23,8% (n=271) of the patients were smokers, the Table 4 Post-ERCP complicationsman-to-woman ratio was 1,8:1,0, and 1,2% (n=17) of the Variable n=1145 %patients presented with periampullary diverticula, makingaccess to the biliary tract difficult (9/17, 52,94%). Hemorrhage 14 1,2 The study complication frequency was 2,1% (n=24). He- Acute pancreatitis 6 0,5morrhage was the most common finding and was self-limi- Respiratory distress 3 0,3ted in the majority of cases. Injection of norepinephrine at Cholangitis 1 0,11:10.000 and blood transfusion were required in onlyone case (table 4). Follow-up was carried out at the outpa- Total 24 2,1tient service of the Gastroenterology Department 30 days
128 G.A. Reyes-Moctezuma et alDiscussion ConclusionsThis cohort analysis is the first of its kind to be carried out in In conclusion, this study characterized a large series of en-Northeastern Mexico. From a total of 1.145 patients that doscopic procedures (ERCP) in a regional hospital of the Ins-underwent ERCP at this hospital unit over a 10-year period, tituto Mexicano del Seguro Social, in which the frequencythe frequency of complications observed in the present stu- and number of complications and contributing risk factorsdy was 2,1%, and they were associated with precut and were reported. Careful patient selection is important be-sphincterotomy17. It should be mentioned that the complica- cause by combining the abovementioned information withtion frequency found in our study was lower than that reported the technical ability of the therapeutic endoscopist, compli-i n di f f e re nt pa r t s o f t h e w o r l d . We b e l i eve t h i s cations will be reduced. We suggest that ERCP be performedis due to the fact that 49,0% of the procedures were diag- only by highly qualified endoscopists.nostic. We have used precut more frequently over the lastfew years and it is very likely that once the number of com- Financial disclosureplications has been analyzed, it will be used even more.Another factor that perhaps influenced our complication No financial support was received in relation to this article.percentage is the fact that no residents participated in the pro-cedures and they were always performed by 2 endoscopists; Conflict of Interestof course this possibility would need to be confirmed The authors declare that there is no conflict of interest.through controlled studies. The order of frequency of com-plications in published reports is: pancreatitis, hemorrhage,cholangitis, and perforation16. In the present study, hemorr- Acknowledgementshage (n=14) was the most frequent complication, followed We wish to thank all the medical and nonmedical colleaguesby pancreatitis (n=6), respiratory distress (n=3), and cholan- at the endoscopy unit for their help in collecting the datagitis (n=1). Our 3 cases of respiratory distress (0,3%) alerted that allowed us to write this article.us to the necessity of opportune management, given thathaving different anesthesiologists working with us duringthe procedure is a characteristic of our hospital. The drug that Referencesis predominantly used is a combination of propofol and fen-tanyl, which could possibly contribute to the presentation 1. Yarmuch. J G, Navarrete MF, Lembach HJ, Molina JC.of this complication4. Rendimiento de la Colangiopancreatografía por resonancia ma- The definition of hemorrhage varies, and hemoglobin figu- gnética respecto a la Colangiopancreatografía endoscópica ret-res from 2-3 g/dL are accepted; this is significant when rograda en el diagnóstico de coledocolitiasis. Rev Chilena deblood transfusion is required18. In our study population there Cirugía 2008; 60: 122-6.were 14 cases (1,2%) in which 93,0% of the patients presen- 2. Laokpessi A, Bouillet P, Sautereau D, et al. Value of magnetic resonance cholangiography in the preoperative diagnosis ofted with mild hemorrhage and only one patient (7,0%) pre- common bile duct stones. Am J Gastroenterol 2001;96: 2354-9.sented with moderate hemorrhage according to international 3. Shanmugam V, Beattie GC, Yule SR, et al. Is magnetic reso-criteria16, requiring blood transfusion without surgery. This nance cholangiopancreatography the new gold standard in bil-patient had the significant history of taking nonsteroidal iary imaging? Br J Radiol. 2005;78:888-93.anti-inflammatory drugs, stressing the importance of ca- 4. Rex DK, Deenadayalu VP, Eid E, et al. endoscopist- Directed Ad-rrying out a rigorous and detailed anamnesis of our patients. ministration of Propofol: A Worldwide safety Experience. Gas- Pancreatitis frequency published in prospective studies is troenterology 2009; 137:1229-37.from 1,3% to 7,6%19-21 and in our study it was 0,5%. As mentioned 5. Christoforidis E, Goulimaris I, Kanellos I, et al. Post-endoscopicabove, this could increase when a greater number of thera- retrograde cholangiopancreatography pancreatitis and hypera-peutic endoscopies are performed, because precut and sphinc- mylasemia: patient-related and operative risk factors. Endos- copy 2002;34:286-92.terotomy are the risk factors for its presentation22-25. Another 6. Christensen M, Matzen P, Schulze S, et al. Complications offactor that raises the number of complications is the ampulla of ERCP: a prospective study Gastrointest Endosc 2004;60:721-31.Vater dilatation and the technical difficulty in cannulizing 7. Freeman ML. Adverse outcomes of ERCP. Gastrointest Endoscand gaining access to the biliary tract26-31, given that the 2002;56(6 Suppl): S273-82.type and frequency of complications described in the literature 8. Mallery JS, Baron TH, Dominitz JA, et al. Complications of ERCPvary up to 10,0%32-33. Gastrointest Endosc 2003;57:633-8. Due to methodological problems as well as to diverse de- 9. Consulted 27 October 2008. http://www.endonurse.com/arti-finitions, complication frequency is not yet completely cles/ins-outs-ercp.htmldetermined and fluctuates from 1,3% to 10,0%, with a mor- 10. Katz D, Nikfarjam M, Sfakiotaki A, Christophi C. Selective Endo-tality of 2,0% to 4,0%. It must be clearly stated that ERCP is scopic Cholangiography for the Detection of Common Bile Duct Stones in Patients with Cholelithiasis. Endoscopy 2004;36:1145-9.a complex procedure with significant morbidity and mortali- 11. Saccomani G, Durante V, Magnolia MR et al. Combined endo-ty that should be performed by qualified endoscopists with scopic treatment for cholelithiasis associated with choledocholith-experience at the therapeutic level in order to reduce the iasis. Surg Endosc 2005;19:910-4.percentage of complications34-35. There were no fatal outco- 12. Ganci C, Chan C, Bobadilla J, et al. Management of choledo-mes in our study and the endoscopic studies were perfor- cholithiasis found during laparoscopic cholecystectomy: amed by highly competent personnel. strategy based on the use postoperative endoscopic retrograde
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