[APP (Amberg-perforation-project) - development and evaluation of an interdisciplinary, systematic approach for endoscopic management of iatrogenic perforation in a German secondary referral center].

BACKGROUND

Recently, there has been a significant change in the management of iatrogenic gastrointestinal perforation from surgery towards primary endoscopic therapy.

MATERIAL AND METHODS

All perforations occurring in all consecutive endoscopies from 1/1/2014 to 12/31/2017 in our hospital (Klinikum St. Marien Amberg, Germany) were recorded, evaluated and followed up prospectively. In-house SOPs were designed and communicated with all physicians within our hospital. Endoscopic closure of the perforation was primarily attempted, always in consent with the abdominal surgeon.

RESULTS

In total, we observed 24 perforations in 18 627 consecutive endoscopies (0.13 %). There were also 24 cases of free extraluminal gas without perforation (12 post-polypectomy-syndromes und 12 post-ERCP with papillotomy). Diagnosis of perforation could be established within 12 hours in 95.8 % (23/24) (in 20 cases during endoscopy). Initial therapeutic approach was surgical in 3 cases, conservative in 3 cases and interventional-endoscopic closure of perforation in 17 cases (4 × Clips, 10 × OTSC, 3 × SEMS). In 1 case, no therapy was performed. Mortality was 4.2 % (1/24). In 3 cases, the patient had to be operated on secondary to endoscopic therapy. In summary, surgical therapy was necessary in 6 of 24 cases (25 %). Interventional-endoscopic therapy was successful technically in 94.1 % (16/17) and clinically in 87.5 % (14/16).

DISCUSSION

Primary interventional-endoscopic closure of iatrogenic gastrointestinal perforation is a safe and successful option in the everyday practice of a secondary referral hospital. The most important factor is prevention of delay until closure of perforation. Also, interdisciplinary consensus between endoscopist and surgeon is essential. Based on our own data, we developed and introduced a system for documentation and management of all endoscopic complications in endoscopy called "KEMS", which could be successfully integrated in our IT-system.