Risk factors and techniques affecting surgical outcome of therapeutic endoscopic retrograde cholangiopancreatography difficulties

Abstract

Objective: To analyze the therapeutic endoscopic retrograde cholangiopancreatography (ERCP) difficulties and complications experienced by a general surgeon and identify risk factors and technique affecting surgical outcome.

Material and method: A retrospective review was carried out in 88 consecutive ERCP operated with four different indications on patients in Nakornping General Hospital by a surgeon trained from Nippon Medical School, Japan.

Results: The patients average age was 57.2 years. Fifty-four patients had common bile duct stone and 43 of them were successfully removed. Endoscopic sphincterotomy (EST) was the most frequent procedure needed to combine with the stone extraction (23 in 43). Twenty-two distal common bile duct obstructions unable to be diagnosed by ultrasound or computed tomography were operated on and found to be unvarying proportion of tumor, stone or stricture. Among these 6 biopsy and 12 treatments were concurrently made. Eight bile fistula and four cholangitis were indicated for endoscopic drainage. Only one serious bleeding was complicated. Two perforations were discovered in the present series and none required laparotomy repair of duodenum. Eighteen of the 88 failed to be operated on and most of them were within first four-month learning curve. Duodenal diverticulum was a common failure factor. The pre-procedure unknown diagnosis relates to an insignificant risk 2.4 times complications of the known (RR = 2.4, p = 0.31). Three patients (3.4%), all over 70 years old, succumbed late after ERCP due to sepsis and myocardial infarction, compared to those age under 70 is a significant risk factor (p = 0.059). Age over 50 seems to result in a higher pancreatitis complication (3 versus none under 50) but not statistically significant (p = 0.405).

Conclusion: Skill and synchronous assistance are important factors for success of ERCP but a more unpredictable outcome and complications were encountered for the preoperative undiagnosable obstructive jaundice. Hot and slow sphincterotomy would minimize the bleeding complication. Duodenal diverticulum and those operated on for late obstruction were risk factors in patients with EST perforations. Pondering to be minimally by invasive, advanced age still contributes to a higher complication and mortality risk in the surgical treatment of ERCP.