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1.
Can J Surg ; 55(2): 99-104, 2012 Apr.
Article in English | MEDLINE | ID: mdl-22564521

ABSTRACT

BACKGROUND: Management of endoscopic retrograde cholangiopancreatography (ERCP)-associated duodenal perforation remains controversial. Some recommend surgery, while others recommend conservative treatment. METHODS: A retrospective chart review was conducted to identify patients treated at our institution for ERCP-related duodenal perforations. Study variables included indication for ERCP, clinical presentation, diagnostic procedures, time to diagnosis and treatment, location of injury, management, length of stay in hospital and survival. RESULTS: Between January 2000 and October 2009, 12 232 ERCP procedures were performed at our centre, and perforation occured in 11 patients (0.08%; 5 men, 6 women, mean age 71 yr). Six of the perforations were discovered during ERCP; 5 required radiologic imaging for diagnosis. Three perforations were diagnosed incidentally by follow-up ERCP. In 1 patient, perforation occurred 3 years after the procedure owing to a dislocated stent. Four of 11 perforations were stent-related; in 2 patients ERCP was performed in a nonanatomic situation (Billroth II gastroenterostomy). Free peritoneal perforation occurred in 4 patients; 1 was successfully managed conservatively. Four patients (36%) were treated surgically and none died. Five patients were managed conservatively with a successful outcome, and 2 patients died after conservative treatment (18%). Operative treatment included hepaticojejunostomy and duodenostomy (1 patient), suture of the perforation with T-drain (1 patient) and suture only (2 patients). The mean length of stay in hospital for all patients was 20 days. CONCLUSION: Post-ERCP duodenal perforations are associated with significant morbidity and mortality. Immediate surgical evaluation and close monitoring is needed. Management should be individually tailored based on clinical findings only.


Subject(s)
Cholangiopancreatography, Endoscopic Retrograde/adverse effects , Duodenal Diseases/etiology , Duodenal Diseases/therapy , Intestinal Perforation/etiology , Intestinal Perforation/therapy , Aged , Aged, 80 and over , Anti-Bacterial Agents/therapeutic use , Cholangiopancreatography, Endoscopic Retrograde/methods , Choledocholithiasis/diagnostic imaging , Choledocholithiasis/surgery , Cohort Studies , Duodenal Diseases/diagnosis , Female , Follow-Up Studies , Humans , Intestinal Perforation/diagnosis , Jaundice/diagnostic imaging , Jaundice/surgery , Laparotomy/methods , Length of Stay , Male , Middle Aged , Monitoring, Physiologic/methods , Pancreatic Neoplasms/diagnostic imaging , Pancreatic Neoplasms/surgery , Pancreatitis, Chronic/diagnostic imaging , Pancreatitis, Chronic/surgery , Parenteral Nutrition/methods , Patient Preference , Retrospective Studies , Risk Assessment , Severity of Illness Index , Treatment Outcome
2.
Gastrointest Endosc ; 59(6): 606-13, 2004 May.
Article in English | MEDLINE | ID: mdl-15114301

ABSTRACT

BACKGROUND: Studies suggest that heparin has anti-inflammatory effects that could prevent acute post-ERCP pancreatitis. The aim of this investigator-initiated, prospective, randomized, double-blind, multicenter study was to determine whether low-molecular-weight heparin can prevent acute post-ERCP pancreatitis. METHODS: Patients at increased risk for acute post-ERCP pancreatitis based on assessment of known risk factors were randomized to receive low-molecular-weight heparin (Certoparin 3000 IU subcutaneously) or placebo (saline solution 0.3 mL subcutaneously) the day before ERCP. The drug was given 2 hours before and 22 hours after ERCP. Documentation and follow-up included patient history, risk factors for acute post-ERCP pancreatitis, procedure-related data, assessment of pain (visual analogue scale, need for pain medication), laboratory findings before and after ERCP (0, 4, and 24 hours), as well as post-ERCP complications. The two-sided Fisher exact test was used for statistical comparison, and a p value < or =0.05 was considered significant. RESULTS: A total of 458 patients were enrolled in the study. Data from 10 patients could not be evaluated, leaving 221 patients in the low-molecular-weight heparin group and 227 in the placebo group (total 448 patients; 135 men, 313 women; mean age 58 [15] years). Low-molecular-weight heparin and placebo groups were comparable with regard to risk factors for acute post-ERCP pancreatitis (gender distribution, age <65 years, history of pancreatitis, pancreas divisum, disorders of sphincter of Oddi) and procedure-related data (difficult cannulation, diagnostic or therapeutic ERCP, needle-knife papillotomy, endoscopic sphincterotomy, biliary or pancreatic procedure, pancreatic contrast injection, success and final diagnosis of ERCP). Acute post-ERCP pancreatitis occurred in 8.5% (38/448), with one death resulting from severe pancreatitis. Low-molecular-weight heparin offered no benefit compared with placebo based on the frequency of acute post-ERCP pancreatitis (low-molecular-weight heparin, 18/221 vs. placebo, 20/227; p=0.87) and the severity of acute post-ERCP pancreatitis (low-molecular-weight heparin, 14 mild, 3 moderate, one severe; placebo, 18 mild, two moderate, 0 severe). The 24-hour serum amylase values and 24-hour pain scores did not differ significantly between the low-molecular-weight heparin group and the placebo group. Bleeding complications occurred in two patients, both in the low-molecular-weight heparin group (one mild, one moderate). CONCLUSIONS: Prophylactic subcutaneous administration of low-molecular-weight heparin does not prevent acute post-ERCP pancreatitis.


Subject(s)
Anti-Inflammatory Agents/therapeutic use , Cholangiopancreatography, Endoscopic Retrograde/adverse effects , Heparin, Low-Molecular-Weight/therapeutic use , Pancreatitis/prevention & control , Acute Disease , Aged , Anti-Inflammatory Agents/pharmacology , Confounding Factors, Epidemiologic , Double-Blind Method , Female , Heparin, Low-Molecular-Weight/pharmacology , Humans , Male , Middle Aged , Pancreatitis/etiology , Prospective Studies , Risk Factors
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