Prevention of complications after endoscopic retrograde cholangiopancreatography and papillosphincterotomy

Abstract

Aim. To improving the results of treatment of patients with obstructive jaundice on the basis of analysis of the causes of complications after endoscopic cholangiopancreatography and papillosphincterotomy. Methods. Conducted was an analysis of medical records of 703 patients with obstructive jaundice for the period 2006-2010. Results. Endoscopic retrograde cholangiopancreatography was performed in 542 patients. In 22 (4.06%) patients the study could not be performed due to anatomical features in the terminal portion of the common bile duct and in the descending section of the duodenum. If cases when it was necessary, cholangiopancreatography was accompanied by papillosphincterotomy. In total this procedure was conducted in 488 patients, including repeated procedures (2 to 4 times) - in 186 patients, and with concomitant lithoextraction - in 265 patients. The overall incidence of complications after endoscopic interventions for obstructive jaundice was 8.5% (46 cases) and the mortality rate was 1.1% (6 cases). Pancreatic necrosis developed in 7 (1.3%) cases, of which 3 (0.5%) with a lethal outcome, bleeding occured in 28 (5.7%) patients from the incision zone during papillosphincterotomy, perforation of the duodenum with a lethal outcome occurred in 1 (0.2%) case, jamming of the Dormia baskets occured in 10 (3.77%) patients, 2 (0.4%) of the cases had a lethal outcome. Adequate preparation for the procedure, adequate and effective premedication, sparing technique of endoscopic retrograde cholangiopancreatography and interventions on the major duodenal papilla, adequate and rational therapy after the diagnostic procedure and the operation are believed to be effective prevention measures of acute pancreatitis after endoscopic retrograde cholangiopancreatography and endoscopic papillosphincterotomy. Prevention of bleeding is mainly attributed to patient preparation: before the intervention it is necessary to examine the coagulation and clotting of blood, haemostatic agents should be administered before the operation and in complex cases papillosphincterotomy should be conducted in several stages with an interval of 3-6 days. For prevention of duodenal perforation the usage of a catheter cannula with an atraumatic distal end, and elimination of rough manipulations are recommended. In order to prevent jamming of the Dormia basket a thorough diagnosis is required, detection of large dense concretions on the background of stenosis of the terminal common bile duct should lead to refusal of conduction of lithoextraction. Conclusion. The use of endoscopic retrograde cholangiopancreatography and endoscopic papillosphincterotomy with adequate procedure performance in specialized endosurgical departments makes it possible to enhance the quality of diagnosis, reduce the incidence of complications and improve the results of treatment of patients with obstructive jaundice.