The importance of early recognition in management of ERCP-related perforations.

BACKGROUND: Iatrogenic perforations related to endoscopic retrograde cholangiopancreatography (ERCP) are rare events, carrying with it a mortality of up to 8%. Given the rarity of this adverse event, there remains limited data and continued uncertainties when choosing therapeutic strategies. Our aims were to evaluate the management of ERCP-related perforations and compare outcomes based on timing of recognition. METHODS: The endoscopic databases of two tertiary care centers were interrogated to identify consecutive adult patients who sustained ERCP-related perforation over a 10-year period from 2006 to 2016. Electronic medical records were reviewed to extract demographic data, perforation type, management strategies, clinical data, and patient outcomes. RESULTS: 14,045 ERCP's were performed during our 10-year study period. Sixty-three patients (average age 62.3 ± 2.38 years, 76% female) with ERCP-related perforations were included. Stapfer I perforations were found in 14 (22.2%) patients, Stapfer II in 24 (38.1%), and Stapfer III and IV perforations were identified in 16 (25.4%) and 9 (14.28%), respectively. Forty-seven (74.6%) perforations were recognized immediately during the ERCP, whereas 16 (25.4%) were recognized late. Endoscopic therapy was attempted in 35 patients in whom perforations were identified immediately, and was technically successful in 33 (94.3%). In all, 4 (1 immediate/ 3 delayed) patients required percutaneous drainage and 9 (5 immediate/ 4 delayed) surgery. Length of hospital stay, ICU admission were significantly shorter and incidence of SIRS was significantly lower when perforation was recognized immediately. CONCLUSIONS: Immediate recognition of ERCP-related perforations leads to more favorable patient outcomes; with lower incidence of SIRS, less need for ICU level care, and shorter hospital stay.

A systematic review of the management and outcome of ERCP related duodenal perforations using a standardized classification system.

INTRODUCTION: The incidence of duodenal perforation after ERCP ranges from 0.09% to 1.67% and mortality up to 8%. METHODS: This systematic review was registered in Prospective Register of Systematic Reviews, PROSPERO. Stapfer classification of ERCP-related duodenal perforations was used. RESULTS: The systematic search yielded 259 articles. Most frequent post-ERCP perforation was Stapfer type II (58.4%), type I second most frequent perforation (17.8%) followed by Stapfer type III in 13.2% and type IV in 10.6%. Rate of NOM was lowest in Stapfer type I perforations (13%), moderate in type III lesions (58.1%) and high in other types of perforations (84.2% in type II and 84.6% in IV). In patients underwent early surgical treatment (<24 h from ERCP) the most frequent operation was simple duodenal suture with or without omentopexy (93.7%). In patients undergoing late surgical treatment (>24 h from ERCP) interventions performed were more complex. In type I lesions post-operative mortality rate was higher in patients underwent late operation (>24 h). In type I lesions, failure of NOM occurred in 42.8% of patients. In type II failure of NOM occurred in 28.9% of patients and in type III there was failure of NOM in only 11.1%, none in type IV. Postoperative mortality after NOM failure was 75% in type I, 22.5% in type II and none died after surgical treatment for failure of NOM in type III perforations. CONCLUSIONS: This systematic review showed that in patients with Stapfer type I lesions, early surgical treatment gives better results, however the opposite seems true in Stapfer III and IV lesions.

Deep mural injury and perforation after colonic endoscopic mucosal resection: a new classification and analysis of risk factors.

OBJECTIVES: Perforation is the most serious complication associated with endoscopic mucosal resection (EMR). We propose a new classification for the appearance and integrity of the muscularis propria (MP) after EMR including various extents of deep mural injury (DMI). Risk factors for these injuries were analysed. DESIGN: Endoscopic images and histological specimens of consecutive patients undergoing EMR of colonic laterally spreading lesions ≥20 mm at a large Australian tertiary referral endoscopy unit were retrospectively analysed using our new DMI classification system. DMI was graded according to MP injury (I/II intact MP without/with fibrosis, III target sign, IV/V obvious transmural perforation without/with contamination). Histological specimens were examined for included MP and patient outcomes were recorded. All type III-V DMI signs were clipped if possible, types I and II DMI were clipped at the endoscopists' discretion. RESULTS: EMR was performed in 911 lesions (mean size 37 mm) in 802 patients (male sex 51.4%, mean age 67 years). DMI signs were identified in 83 patients (10.3%). Type III-V DMI was identified in 24 patients (3.0%); clipping was successfully performed in all patients. A clinically significant perforation occurred in two patients (0.2%). Only one of the 59 type I/II cases experienced a delayed perforation. 85.5% of patients with DMI were discharged on the same day, all without sequelae. On multivariable analysis, type III-V DMI was associated with transverse colon location (OR 3.55, p=0.028), en bloc resection (OR 3.84, p=0.005) and high-grade dysplasia or submucosal invasive cancer (OR 2.97, p 0.014). CONCLUSIONS: In this retrospective analysis, use of the new classification and management with clips appeared to be a safe approach. Advanced DMI types (III-V) occurred in 3.0% of patients and were associated with identifiable risk factors. Further prospective clinical studies should use this new classification. TRIAL REGISTRATION NUMBER: NCT01368289; results.

[Sigmoid colon diverticulitis : Treatment modalities 2011-2013]. / Sigmadivertikulitis : Behandlungsmodalitäten 2011 bis 2013.

INTRODUCTION: Diverticulosis is a relevant disease in Germany with a prevalence of over 60 % in patients aged ≥70 years. The S2k guidelines for the treatment of diverticulosis were recently published. Systematic epidemiological data on treatment modalities do not exist. METHODS: Analysis of in-hospital treatment modalities for diverticulosis based on data from the Federal Office of Statistics. RESULTS: Approximately 130,000 inpatient cases of diverticulosis are treated in Germany per year. Approximately 25 % undergo surgery and of these slightly under 50 % (12,000 procedures) are carried out by laparoscopy. The complication rates are 18 % in a best case scenario and up to 85 % in a worst case scenario. A stage-adjusted classification of treatment modalities based on data from the Federal Office of Statistics is currently practically impossible. CONCLUSION: To enable stage-adjusted epidemiological analysis of diverticulosis, a standardized and transparent documentation system enabling systematic analysis is necessary, which does not currently exist (e. g. ICD 10 coding); moreover, information on conservative and interventional treatment options are not included in the operations and procedures key (OPS) coding system.

[Sigmoid diverticulitis: indications and timing of surgery]. / Sigmadivertikulitis: Indikation und Zeitpunkt zur Operation.

BACKGROUND: Diverticular disease represents a common problem in the clinical routine. In addition to the question of who should be admitted to hospital for treatment and who can be treated as an outpatient, the questions of the indications and timing for surgery are decisive. Because the disease is internationally classified in different ways, the recommendations are also not uniform. OBJECTIVE: In this article the essential aspects of the indications for and timing of surgery are structured and oriented to the new S2K guidelines. RESULTS: The indications and timing of surgery can only be reasonably determined by evaluating all essential information on diverticular disease. A prerequisite is an exact, comprehensive and applicable classification of the disease before treatment. An adequate assessment cannot be made using morphological information obtained by imaging alone. DISCUSSION: The new classification of sigmoid diverticulitis corresponding to the German guidelines for diverticular disease classification (GGDDC) enables an appropriate strategy for evaluating the indications and selection of the time for surgery.

Preoperative staging of perforated diverticulitis by computed tomography scanning.

BACKGROUND: Treatment of perforated diverticulitis depends on disease severity classified according to Hinchey's preoperative classification. This study assessed the accuracy of preoperative staging of perforated diverticulitis by computerized tomography (CT) scanning. METHODS: All patients who presented with perforated diverticulitis between 1999 and 2009 in two teaching hospitals of Rotterdam, the Netherlands, and in addition had a preoperative CT scan within 24 h before emergency surgery were included. Two radiologists reviewed all CT scans and were asked to classify the severity of the disease according to the Hinchey classification. The CT classification was compared to Hinchey's classification at surgery. RESULTS: Seventy-five patients were included, 48 of whom (64 %) were classified Hinchey 3 or 4 perforated diverticulitis during surgery. The positive predictive value of preoperative CT scanning for different stages of perforated diverticulitis ranged from 45 to 89 %, and accuracy was between 71 and 92 %. The combination of a large amount of free intra-abdominal air and fluid was strongly associated with Hinchey 3 or 4 and therefore represented a reliable indicator for required surgical treatment. CONCLUSIONS: The accuracy of predicting Hinchey's classification by preoperative CT scanning is not very high. Nonetheless, free intra-abdominal air in combination with diffuse fluid is a reliable indication for surgery as it is strongly associated with perforated diverticulitis with generalized peritonitis. In 42 % of cases, Hinchey 3 perforated diverticulitis is falsely classified as Hinchey 1 or 2 by CT scanning.

A simple prognostic scoring system for typhoid ileal perforation peritonitis.

The increasing awareness of the worse than expected outcome after typhoid ileal perforation (TIP) prompted us to prospectively prognosticate patients with the help of the Jabalpur prognostic score (JPS), a simplified scoring system for peptic perforation peritonitis (PPP). Eighty-two consecutive patients with TIP were studied from May 2005 to August 2008 in the Department of Surgery, NSCB Government Medical College, Jabalpur (MP), India. Six parameters used in the JPS were recorded: age, heart rate, mean blood pressure, serum creatinine, any co-morbid illness and perforation-operation interval. JPS correlated with morbidity and mortality in TIP patients and, as the score increased, so did the morbidity and mortality. Survivors had a significantly lower mean score (3.86 ± 2.23) than non-survivors (7.94 ± 3.6; P < 0.001). Expectedly, TIP patients had worse outcome, stage by stage, than PPP patients. JPS can be easily modified for TIP (JPS-TIP) and can be easily used for its prognostication.

Preoperative CT staging in sigmoid diverticulitis--does it correlate with intraoperative and histological findings?

PURPOSE: This study was designed to evaluate whether the computed tomography (CT) reflects the extent of the inflammation in sigmoid diverticulitis (SD) in order to draw conclusions for selecting the appropriate treatment. METHODS: Two hundred four patients who underwent resection for SD from January 2003 to December 2008 were included. The preoperative CT stage was compared with intraoperative and histological findings. Patients were classified into phlegmonous (Hansen-Stock IIa), abscess-forming (HS IIb), and free perforated (HS IIc) forms of SD. Patients with a recurrent type of diverticulitis were excluded. RESULTS: In the phlegmonous type (HS IIa; n = 75), we found a correlation with the preoperative stage in 52% (intraoperative) and 56% (histological), an understaging in 12% (intraoperative) and 11% (histological), and an overstaging in 36% (intraoperative) and 33% (histological). In the abscess-forming type (HS IIb, Hinchey I/II; n = 87), we found conformity in 92% (intraoperative) and 90% (histological), understaging in 3% (intraoperative) and 0% (histological), and overstaging in 5% (intraoperative) and 10% (histological). In the presence of a free perforation (HS IIc, Hinchey III/IV; n = 42), we saw conformity in 100% (intraoperative and histological). The positive predictive value for correctly diagnosing of phlegmonous type (HS IIa), abscess-forming type (HS IIb), and free perforation (HS IIc) by CT was intraoperatively (histologically) 52% (56), 92% (90), and 100% (100), respectively. CONCLUSIONS: The CT is one of the most accurate methods for staging in SD. However, in the phlegmonous type (HS IIa), it leads to an overestimation of the findings in every third patient. It must be clarified whether this pronounced low inflammation should really be regarded as a complicated form of SD. In contrast, the abscess-forming (HS IIb) and free perforated (HS IIc) type of complicated SD is very well reflected by CT.

[Laparoscopic resection with primary anastomosis in Hinchey stages I and II without previous abscess drainage]. / Laparoskopische Resektion mit primärer Anastomose im Hinchey-Stadium I und II ohne vorherige Abszessdrainage. Eine prospektive Untersuchung.

INTRODUCTION: Intra-abdominal abscesses in diverticulitis so far have been drained percutaneously until the acute inflammation subsides and colon resection can be carried out for restoration of continence. However this method is successful in only about half of patients and lavage lasts for 2 to 3 weeks. Therefore it has to be decided whether an early operation without prior interventional drainage can attain results similar to those of the elective operation. METHODS: We performed primary laparoscopic surgery without prior interventional drainage or colon lavage in 72 patients in Hinchey stages I and II within 12 h of hospital admission. The peri- and postoperative processes were analyzed prospectively using 115 parameters. RESULTS: There was no difference in the postoperative course of patients receiving elective surgery for recurrent diverticular disease and those undergoing surgery for acute diverticulitis (Hinchey stages I and II). The rates of surgical and general complications were identical (7.7% vs 9.6% and 9% vs 3.6%, respectively). Wound infections were noted in 7.7% and 7.2%, respectively. No case of anastomotic leakage was observed. CONSEQUENCE: Based on our prospective data (grade of evidence II), we consider laparoscopic sigmoid resection with primary anastomosis (in continuity) in Hinchey stages I and II without prior interventional drainage and colon preparation to be justified.

Iatrogenic duodenal perforations caused by endoscopic biliary stenting and stent migration: an update.

Endoscopic biliary stenting is the preferred method of decompression in obstructive jaundice. Duodenal perforations caused during stenting and stent migration are rare but life-threatening complications, and require judicious management. With the increasing use of therapeutic endoscopy, an awareness of these complications is becoming important in our surgical practice. Advances in interventional radiology, endoscopy, and laparoscopy have enhanced the scope and reduced the morbidity of both conservative and surgical treatments of these perforations. This article presents an update on the current state of our knowledge on the science and the management of this complication.

The management of complicated diverticulitis and the role of computed tomography.

PURPOSE: Acute diverticulitis is a disease with a wide clinical spectrum, ranging from a phlegmon (stage Ia), to localized abscesses (stages Ib and II), to free perforation with purulent (stage III) or feculent peritonitis (stage IV). While there is little debate about the best treatment for mild episodes and/or very severe episodes, uncertainty persists about the optimal management for intermediate stages (Ib and II). The aim of our study was therefore to define the role of computed tomography (CT) and to analyze its impact on the management of acute diverticulitis. METHODS: We retrospectively analyzed 511 patients (296 males, 215 females) admitted for acute diverticulitis between January 1994 and December 2003. Excluded were patients with stoma reversal only, "diverticulitis" mimicked by cancer, or significantly deficient patient records. Patients were analyzed either as a whole or subgrouped according to age (<40 yr, >40 yr). A modified Hinchey classification was used to stage the severity of acute diverticulitis. RESULTS: In 99 patients (19.4%), an abscess was found (74 pericolic, 25 pelvic, median diameter: 4.0 cm). CT-guided drainage was performed in 16 patients, one failure requiring a two-stage operation. Whereas conservative treatment failed in 6.8% in patients without abscess or perforation, 22.2% of patients with an abscess required an urgent resection (68.2%, one-stage, 31.8%, two-stage). Recurrence rates were 13% for mild cases, as compared to 41.2% in patients with a pelvic abscess (stage II) treated conservatively with/without CT-guided drainage. Of all surgical cases, resection/primary anastomosis was achieved in 73.6% with perioperative mortality of 1.1% and leak rate was 2.1%. CONCLUSIONS: CT evidence of a diverticular abscess has a prognostic impact as it correlates with a high risk of failure from nonoperative management regardless of the patient's age. After treatment of diverticulitis with CT evidence of an abscess, physicians should strongly consider elective surgery in order to prevent recurrent diverticulitis.

Prognostic factors for mortality in left colonic peritonitis: a new scoring system.

BACKGROUND: Perforating lesions of the colon affect a heterogeneous group of patients, often elderly, and usually present as abdominal emergencies, with high morbidity and mortality. The aims of this study were to assess the prognostic value of specific factors in patients with left colonic peritonitis and to evaluate the utility of a scoring method that allows one to define groups of patients with different mortality risks. STUDY DESIGN: Between January 1994 and December 1999, 156 patients (77 men and 79 women), with a mean (SD) age of 63.2 years (15.5 years) (range 22 to 87 years), underwent emergency operation for a distal colonic perforation. Intraoperative colonic lavage was the first choice operation and it was performed in 74 patients (47.4%). There were three alternative procedures: the Hartmann operation was performed in 69 patients (44.2%), subtotal colectomy in 9, and colostomy in 4 patients. We analyzed specific variables for their possible relation to death including gender, age, American Society of Anesthesiologists (ASA) score, immunocompromised status, etiology, and degree of peritonitis, preoperative organ failure, time (hours) between hospital admission and surgical intervention, and degree of temperature elevation (38 degrees C). Univariate relations between predictors and outcomes (death) were analyzed using logistic regression. Multivariate logistic regression analysis was used to assess the prognostic value of combinations of the variables. Significant factors identified in univariate and multivariate logistic regression analyses were used to define a left colonic Peritonitis Severity Score (PSS). Factors that were significant only in univariate analysis scored 2 points if present and 1 if not. Variables significant in multivariate analysis were scored from 1 to 3 points. Patients were randomly split into two groups, one to calculate the scoring system and the other to validate it. RESULTS: Overall postoperative mortality rate was 22.4%. Septic-related mortality was observed in 24 patients (15.4%). Age, peritonitis grade, ASA score, immunocompromised status, and ischemic colitis were significant for postoperative death in univariate analysis. But only ASA score and preoperative organ failure were significantly associated with postoperative mortality in multivariate logistic regression analysis. The PSS, as defined in this study, was related to outcomes of patients. Mortality rate increased from 0%, when PSS was 6 points (minimum possible score), to 100% in patients with a PSS of 13 (maximum possible PSS = 14). CONCLUSIONS: Left colonic peritonitis continues to have a persistently high mortality in patients with septic complications. ASA score and preoperative organ failure are the only factors that are significantly associated with mortality in the multivariate analysis. The PSS classification may help uniformly define the mortality risk of patients with distal large bowel peritonitis, and may help to increase the comparability of studies carried out at different centers.

Perforaciones colónicas. Factores pronósticos / Colonic peforations. Prognostic factors

Objetivos. El objetivo principal del estudio fue valorar la influencia de diferentes factores de riesgo sobre la mortalidad de los pacientes, la influencia de dichos factores sobre la supervivencia en las perforaciones tumorales y finalmente comparar los resultados del grupo de perforaciones de etiología maligna con el de etiología benigna. Pacientes y métodos. En el presente estudio retrospectivo multicéntrico se presenta la experiencia de tres hospitales de la Comunidad Valenciana (Hospital General de Castellón, Hospital Gran Vía de Castellón y Hospital Comarcal de Vinaroz) en perforaciones de colon durante el período de tiempo comprendido entre enero de 1994 y abril de 1998. Fueron incluidos en el estudio un total de 68 pacientes, 38 varones y 30 mujeres con una edad media de 68 ñ 14 años (rango, 29-90). Se recogieron datos referentes a etiología, comorbilidad, clínica de presentación, exploraciones, hallazgos, técnica operatoria, morbimortalidad y seguimiento. Resultados. Se recogieron 13 etiologías diferentes, siendo la diverticulitis (n = 26; 38,2 por ciento) y las neoplasias (n = 21; 29,4 por ciento) las causas más frecuentes. En cuanto a los hallazgos (grado de contaminación), 17 pacientes (25 por ciento) presentaron abscesos, 15 (22,1 por ciento) peritonitis localizada, 21 (30,9 por ciento) peritonitis purulenta difusa y 15 (22,1 por ciento) peritonitis fecaloidea difusa. La estancia media hospitalaria fue de 18,3 ñ 13,8 días. Presentaron complicaciones postoperatorias 45 pacientes (66,2 por ciento), siendo las más frecuentes la infección de la herida quirúrgica (15; 22,1 por ciento), la evisceración (7; 10,3 por ciento) y el fallo multiorgánico (5; 7,4 por ciento). La mortalidad operatoria fue del 26,6 por ciento (14 pacientes). Conclusiones. La mortalidad perioperatoria es más elevada en aquellos pacientes de mayor edad, con clínica de diarrea al ingreso y a los que no se les practica resección de la zona perforada. La perforación es una complicación grave del cáncer de colon, con una mortalidad alta y mal pronóstico, presentando los pacientes con perforaciones tumorales mayor frecuencia de clínica de distensión abdominal y de complicaciones postoperatorias que aquellos con perforaciones benignas (AU)

Positive predictive value of ICD-9th codes for upper gastrointestinal bleeding and perforation in the Sistema Informativo Sanitario Regionale database.

We identified patients whose records in the Sistema Informativo Sanitario Regionale database in the Italian region of Friuli-Venezia Giulia showed a code of upper gastrointestinal bleeding (UGIB) and perforation according to codes of the International Classification of Diseases (ICD)-9th revision. The validity of site- and lesion-specific codes (531 to 534) and nonspecific codes (5780, 5781, and 5789) was ascertained through manual review of hospital clinical records. The initial group was made of 1779 potential cases of UGIB identified with one of these codes recorded. First, the positive predictive values (PPV) were calculated in a random sample. As a result of the observed high PPV of 531 and 532 codes, additional hospital charts were solely requested for all remaining potential cases with 533, 534, and 578 ICD-9 codes. The overall PPV reached a high of 97% for 531 and 532 site-specific codes, 84% for 534 site-specific codes, and 80% for 533 lesion-specific codes, and a low of 59% for nonspecific codes. These data suggest a considerable research potential for this new computerized health care database in Southern Europe.

[Large-intestine perforations caused by primary colorectal cancer]. / Debelochrevni perforatsii, predizvikani pri purvichen kolo-rektalen rak.

Twenty-seven cases of perforation, produced by primary colorectal carcinoma over the period 1993-1998, are described. The underlying causes of colorectal carcinoma complication and types of perforations observed are discussed. This is a report on personal experience with the therapeutic approach and operative management of this severest complication of colorectal carcinoma.

[Perforated colonic diverticulitis. Surgical technique]. / Le perforazioni diverticolitiche del colon. Tattica chirurgica.

Emergency surgery is required for performed colonic diverticulitis. Surgical indications are not uniform in literature. In the experience of the authors the operations have been performed in the case of peritonitis subsequent to the perforation or in the case of failure of the conservative treatment. Twenty-four patients underwent surgical intervention because of diffuse (17 cases) or localized peritonitis (7 cases). Exitus were related to cardiovascular complications in patients over seventy. Postoperative results are related to the age, the general conditions of the patient and to the intraoperative finding, of localized or generalized peritonitis. Operations may be divided into two groups: conservative procedures or primary resections. In the first one it is possible to suture the colonic wall without resection; in the second one the intraoperative finding or the extensive necrotic lesions indicates colonic resection or exteriorization. The surgical treatment adopted is correlated both to the age and cardiorespiratory conditions and to the other associated diseases.

Perforación intestinal por fiebre tifoidea (1988-1993). Hospital de Niños Alejandro Mann, de la ciudad de Guayaquil

Se realizó un estudio retrospectivo de 309 casos condiagnóstico de fiebre tifoidea, en pacientes hospitalizados desde 1988-1993 en el Hospital de niños Alejandro Mann de la ciudad de Guayaquil. Se seleccionaron 32 casos en los que la perforación intestinal se presentó como complicación de la enfermedad. Todos fueron intervenidos quirúrgicamente y se encontró que la relación de edad y sexo fue de dos a uno (masculina /femenino) con mayor afectación en edades entre los 4 y los 7 años. El cuadro clínico característico fue de abdomen agudo perforativo; entre los síntomas más importantes se observó náusea (81.20 por ciento) y el signo de la scudida ded los rectos positivo (90.6). La Salmonella tiphi tiene una localización preferencial a nivel del ileon (11 a 20 cm de distancia de la válvula ileo cecal, 50 por ciento) el tipo de perforación fue única en el 68.7 por ciento, durante la segunda semana de evolución de la fiebre tifoidea se presentó el 53.1 por ciento de las perforaciones. Para corroborar el diagnóstico de los casos de perforación intestinal por salmonella thiphi se analizaron ciertos datos de laboratorio, radiológicos e histopatológicos...