Gastroenterological Endoscopy. Группа авторов

injection, electrocautery (coagulation forceps or tip of the snare), endoloop, and clips. The use of cautery should be performed with caution owing to the thinness of the colonic wall. Immediate bleeding may be prevented by the use of pure coagulation for pedunculated polyps,⁷² epinephrine injection, clipping, or closing the stalk with an endoloop. No prophylactic measures have proved to be efficient in preventing delayed bleeding.⁷³ Bleeding occurring during EMR or ESD is preferably managed by coagulation.⁷⁴

      10.5.4 Unusual Complications

      Very rare adverse events associated with colonoscopy include glutaraldehyde-induced colitis (probably due to endoscope mishandling during reprocessing) and extracolonic trauma such as splenic rupture and liver hematoma due to excessive abdominal pressure exerted during difficult insertion.^75,76

      10.6 ERCP

      ERCP has changed the paradigm of management of biliopancreatic diseases but is also one of the most demanding endoscopic procedures. In addition to adverse events common with upper GI endoscopic procedures, specific adverse events related to biliopancreatic manipulations include bleeding, perforation, infection, and pancreatitis⁷⁷ (see

Table 10.2). According to a retrospective review of 21 studies, including 16,855 patients, the incidence rate of ERCP-related complications was 6.85% (1.67% were severe complications), with a mortality rate of 0.33%.⁷⁸ These findings were confirmed in two prospective studies, including 7,252 patients, with an overall complication rate of 5.3% and mortality rate of 0.34%.^79,80 Important factors modulating the risk of complications are the indication for ERCP and the case volume of the operator, which could be responsible for a two- to threefold increase in the rate of severe complications.⁸¹ For these reasons, the need for concentrating these procedures in high-volume centers has become more and more obvious over the last two decades.

      10.6.1 Bleeding

      Bleeding is often associated with sphincterotomy, and occurs in 1.3% of ERCPs with a reported mortality rate of 0.05%.⁷⁸ Half are recognized during the procedure.^81,82 Most bleeding is mild to moderate in severity. Risk factors are related to: the patient’s condition, such as cholangitis before the procedure; coagulopathy, liver cirrhosis, or chronic renal failure; anatomical variants (peripapillary diverticulum, stone impaction, papillary stenosis, and Billroth II gastrectomy); or the technique used and the operator (low case volume of the unit or operator, needle knife sphincterotomy, sphincterotomy length, and “recut” of a previous sphincterotomy).^77,81,82,83

      Most patients can be managed by medical and endoscopic treatment.⁷⁷ Treatment of postsphincterotomy bleeding includes the use of epinephrine injection (0.1 mg/mL) for oozing-type bleeding.⁸⁴ Additional thermal methods, such as sphincterotome wire and electrocautery/heater probe use, can be used in the management of a visible vessel or a bleeding point.⁸⁵ Mechanical devices, such as TTS clips, although difficult to manipulate with a side-viewing scope, can be used as second-line treatment to control bleeding at the level of the sphincterotomy, avoiding its placement on the pancreatic orifice.⁸⁶ Balloon tamponade at the site of sphincterotomy has been described but its efficacy has not been established.⁸⁷

      The use of the Endocut Mode (Erbe, Inc., Germany), an automatically controlled cut/coagulation system, has become widely adopted and reduces the rate of minor bleeding.^88,89 Finally, for patients with altered anatomy or with coagulation disorders, balloon sphincteroplasty (endoscopic papillary balloon dilation) could be used since it reduces the risk of bleeding (but unfortunately increases the risk of pancreatitis when performed on an intact papilla).⁷⁷

      10.6.2 Perforation

      Perforation, although rare, is one of the most feared adverse events of ERCP, occurring in 0.6% of the procedures.^77,78 The most frequent is retroperitoneal duodenal perforation occurring at the site of sphincterotomy. Free peritoneal perforation of the duodenum or jejunum is rare and often associated with altered anatomy (Billroth II gastrectomy, duodenal stricture, or peridiverticular papilla). Perforation of the bile duct itself usually follows stricture dilation or traumatic wire insertion through a stricture.⁹⁰ Most patients with free peritoneal perforation will require surgery, whilst most patients with retroperitoneal duodenal perforation can be initially managed conservatively with nasogastric suction, hydration, and administration of broad-spectrum antibiotics. If possible, a nasobiliary catheter should be placed to ensure external biliary or pancreatic drainage. When retroperitoneal perforation is recognized during the procedure, this placement should be immediately attempted. Surgical or radiological drainage of retroperitoneal collections should be considered on a case-by-case basis, keeping in mind the severity of this complication with a reported mortality around 5%.^78,81,91,92

      ERCP-related perforation can largely be prevented by using a finely-tuned technique of sphincterotomy, always performed over a guidewire, ensuring correct orientation of the cutting wire during the course of the sphincterotomy. Incision should be performed step by step, avoiding a zipper cut, recognizing the anatomy of the papilla, and tailoring the size of the sphincterotomy to the size of distal common bile duct. In difficult cases or for removal of large stones, endoscopic balloon dilation of the papilla after a small or incomplete sphincterotomy is now a valid option.^93,94

      10.6.3 Infections

      Post-ERCP infections include cholangitis, cholecystitis, and “pancreatic sepsis” (which may refer to severe necrotic pancreatitis and/or infection of a pseudocyst). Cholangitis and sepsis occur in more than 85% of patients whose opacified bile ducts drain incompletely.⁹⁵ Post-ERCP acute cholecystitis has an incidence rate of < 0.5% and may be related to the injection of contrast medium into a poorly emptying gallbladder or to the occlusion of the cystic duct by a tumor, a stone, and/or a covered self-expandable stent.⁷⁷

      Properly disinfected endoscopes and use of sterile accessories are paramount in prevention. Drainage of any opacified obstructed structure is recommended and “diagnostic” opacification of an obstructed duct is strictly contraindicated. Antibiotic prophylaxis has proven effective in patients at risk of infective endocarditis, in patients known to have a pancreatic pseudocyst, or in patients displaying cholestasis or jaundice with enlarged bile ducts.^96,97 This prophylaxis should be prolonged if drainage is incomplete.

      10.6.4 Post-ERCP Pancreatitis

      Post-ERCP pancreatitis (PEP) remains the most prevalent cause of morbidity and mortality after ERCP. Although its incidence has decreased with improved techniques and indications as well as with prophylactic measures, it remains above 2% in large cohorts.^98,99 It is a clinical situation in which new postprocedural pancreatic pain is associated with at least a threefold increase in serum levels of amylase or lipase.¹⁰⁰ The severity of PEP is defined on the basis of the additional length of hospital stay needed to manage the condition (

Table 10.2). Different risk factors related to the operator case volume, to the procedure itself, and to patient susceptibility have been recognized in large prospective studies (

Box 10.1).^78,81 Severe PEP accounts for