Department of HPB Surgery & Liver Transplantation, Institute of Liver & Biliary Sciences, New Delhi, 110070, India.
Department of Gastrointestinal Surgery & Liver Transplantation, G B Pant Institute of Post Graduate Medical Education and Research, New Delhi, India.
Surg Endosc. 2020 Jan;34(1):77-87. doi: 10.1007/s00464-019-06733-x. Epub 2019 Mar 11.
Perforation is a rare but serious adverse event of endoscopic retrograde cholangiopancreatography (ERCP). The aim of this study was to determine the predictors of morbidity and mortality after surgical management of ERCP-related perforation (EP).
The records of patients with EP requiring surgical intervention at a tertiary referral center in a 12-year period (2004-2016) were retrospectively analyzed for demography, indications for ERCP, risk factors, timing and type of surgical repair, post-operative course, hospital stay, and outcome. Multiple logistic regression was used to identify the parameters predicting survival.
Of 25,300 ERCPs, 380 (1.5%) had EP. Non-operative management was successful in 330 (86.8%) patients. 50 (13.2%) patients were operated for EP. Out of 50, the perforation was detected during ERCP (intra-procedure) in 32 patients (64%). In 30 patients (60%), the surgery was performed within 24 h of ERCP. Twenty patients underwent delayed surgery (after 24 h of ERCP) following the failure of initial non-operative management. The delayed surgery after an unsuccessful medical treatment had a detrimental effect on morbidity, mortality and hospital stay. Post-operative duodenal leak was the only independent predictor of 90-day mortality (p = 0.02, OR = 9.1, 95% CI 1.52-54.64). Addition of T-tube duodenostomy (TTD) to the primary repair for either type I or type II perforations increased post-operative duodenal leak (type I, p = 0.048 and type II; p = 0.001) and mortality (type I, p = 0.009 and type II, p = 0.045).
Although EP is a rare event, it has a serious impact on morbidity and mortality. Delaying of surgery following failed non-operative management worsens the prognosis. Addition of TTD to the repair is not helpful in these patients.
内镜逆行胰胆管造影术（ERCP）相关穿孔（EP）是一种罕见但严重的不良事件。本研究旨在确定手术治疗 ERCP 相关穿孔（EP）后发病率和死亡率的预测因素。
回顾性分析了一家三级转诊中心在 12 年期间（2004-2016 年）因 EP 而需要手术干预的患者的记录，以了解人口统计学、ERCP 指征、危险因素、手术修复的时机和类型、术后过程、住院时间和结果。使用多变量逻辑回归来确定预测生存率的参数。
在 25300 例 ERCP 中，有 380 例（1.5%）发生 EP。330 例（86.8%）患者经非手术治疗成功。50 例（13.2%）患者因 EP 而行手术治疗。在 50 例患者中，32 例（64%）在 ERCP 期间（术中）发现穿孔。在 30 例患者（60%）中，手术在 ERCP 后 24 小时内进行。在初始非手术治疗失败后，有 20 例患者进行了延迟手术（ERCP 后 24 小时后）。初次非手术治疗失败后进行延迟手术对发病率、死亡率和住院时间有不利影响。术后十二指肠漏是 90 天死亡率的唯一独立预测因素（p=0.02，OR=9.1，95%CI 1.52-54.64）。对于 I 型或 II 型穿孔，在初次修复中添加 T 型管十二指肠造口术（TTD）会增加术后十二指肠漏（I 型，p=0.048；II 型，p=0.001）和死亡率（I 型，p=0.009；II 型，p=0.045）。
尽管 EP 是一种罕见的事件，但它对发病率和死亡率有严重影响。非手术治疗失败后延迟手术会使预后恶化。在这些患者中，添加 TTD 到修复中没有帮助。
