Bostancı Özgür, Battal Muharrem, Yazıcı Pınar, Demir Uygar, Alkım Canan
Department of General Surgery, Şişli Etfal Training and Research Hospital, İstanbul, Turkey.
Department of Gastroenterology, Şişli Etfal Training and Research Hospital, İstanbul, Turkey.
Turk J Surg. 2018 Jan 3;34(1):24-27. doi: 10.5152/turkjsurg.2017.3820. eCollection 2018.
The best therapeutic approach for endoscopic retrograde cholangiopancreatography-related perforations remains controversial; while some authors suggest routine conservative management, others advocate mandatory surgical exploration. We aimed to evaluate our clinical experience of perforations during endoscopic sphincterotomy.
A retrospective chart review from January 2010 to October 2015 identified 20 patients with endoscopic retrograde cholangiopancreatography-related perforations. Data collection included demographics, time to diagnosis, type of perforation, treatment strategy, surgical procedure, complications, hospital stay, and outcome. All patients were classified into two groups on the basis of radiological and operative findings.
Only five patients underwent surgical treatment, whereas 15 patients were managed conservatively. The mean time to diagnosis was 7.8 hrs (range: 1 to 36 hrs). In patients who underwent surgical treatment, the types of perforations included type I and III in one patient each and type II in three patients. Surgical procedures included laparoscopic and open cholecystectomy with t-tube drainage in two patients each and primary repair of duodenal injury with hepaticojejunostomy in one patient. Among conservatively managed patients, eight, four, and three had type II, type III, and type IV injuries, respectively. Of these 15 patients, 60% (n=9) underwent percutaneous procedures. The mean length of hospital stay was similar for conservatively and surgically treated patients (12 vs. 12.4 days, respectively, p=0.790). One patient (5%) with type I injury died of multiorgan deficiency.
With close close clinical follow-up, medical treatment can be beneficial for most patients, and surgical procedures should be reserved for patients with type I (definite) and type II/III injuries; in patients with these clinical parameters, conservative management will likely be unsuccessful.
内镜逆行胰胆管造影术相关穿孔的最佳治疗方法仍存在争议；一些作者建议采用常规保守治疗，另一些人则主张进行强制性手术探查。我们旨在评估内镜括约肌切开术中穿孔的临床经验。
回顾性分析2010年1月至2015年10月期间20例内镜逆行胰胆管造影术相关穿孔患者的病历。收集的数据包括人口统计学资料、诊断时间、穿孔类型、治疗策略、手术方式、并发症、住院时间和结局。所有患者根据影像学和手术结果分为两组。
仅5例患者接受了手术治疗，而15例患者接受了保守治疗。平均诊断时间为7.8小时（范围：1至36小时）。接受手术治疗的患者中，穿孔类型包括I型和III型各1例，II型3例。手术方式包括2例患者行腹腔镜和开腹胆囊切除术并置T管引流，1例患者行十二指肠损伤一期修复并肝空肠吻合术。在保守治疗的患者中，分别有8例、4例和3例为II型、III型和IV型损伤。在这15例患者中，60%（n = 9）接受了经皮操作。保守治疗和手术治疗患者的平均住院时间相似（分别为12天和12.4天，p = 0.790）。1例I型损伤患者（5%）死于多器官功能衰竭。
通过密切的临床随访，药物治疗对大多数患者可能有益，手术应保留给I型（明确）和II/III型损伤的患者；对于具有这些临床参数的患者，保守治疗可能不会成功。
