Aspects on the role of prophylactic procedures to influence post-ERCP complication rates

摘要

Background: When the technique to use ERCP was introduced almost fifty years ago, themorbidity in treatment of hepato-biliary diseases decreased due to the introduction of this miniinvasivemodality, reducing the need for open surgical procedures. However, ERCP proceduresare still marred with complications such as pancreatitis, cholangitis, hemorrhage andperforation and every measure must be undertaken to reduce these adverse events. Objectives: The hypotheses of this thesis were: 1) Prophylactic antibiotics in ERCP do notreduce the complication rates enough to recommend it generally. 2) Prophylactic pancreaticstents reduce the PEP risk more the larger they are. 3) A grading scale for the complexity of theERCP procedure (HOUSE) was validated in relation to success-rates, complications and durationof the procedure. 4) Preoperative SEMS in periampullary tumors show less bacterialcontamination in intraoperatively collected bile than plastic stents, thereby reducingperioperative complications. Methods: In the first study all ERCPs, included in GallRiks between May 2005 and June 2013,were studied regarding complication rates in relation to prophylactic antibiotics. Further, in thesecond paper, all ERCPs between 2006 and 2014 where an accidental pancreatic cannulationoccurred and a prophylactic pancreatic stent was used were investigated, determinating howthe diameter and length of the stent affected the adverse events. In the third study, an ERCPcomplexity classification, (HOUSE), was validated in relation to success-rates, complications andduration of the procedure. The final study, an RCT compared preoperative SEMS to plastic stentsin resectable periampullary tumors regarding intraoperative bacterial, histopathological andsurgical technical findings as well as perioperative complications. Results: In the first study complications were studied in relation to prophylactic antibiotics. Wefound a reduction of 26 % of OR in overall complications if prophylactic antibiotics were given,but in absolute figures reduction of the risk was a modest 2.6% and the NNT 38 patients to avoidone complication. In our second study an almost fourfold OR elevation (OR 3.58) in complicationrates was seen if prophylactic pancreatic stents with a diameter ≤5 Fr were used compared tostents >5 Fr, the complication rates were further lowered (1.4 %) if the stents were >5 cm. Thethird paper validated a new three-graded ERCP complexity grading scale (HOUSE) in relation tosuccess and complication rates, demonstrating a doubled PEP rate in HOUSE 2 and 3 (7.0 % and6.8 %) compared to class 1 (3.4%) and longer procedure times, the higher the HOUSE class(HOUSE 1, 40 min; 2, 65 min; and 3, 106 min). In the final study, comparing preoperative SEMSto plastic stents in resectable periampullary tumors, higher preoperative stent dysfunction rateswere found among the plastic stents (19 % vs 0 %, p=0.03). Intraoperatively, no differenceswere seen in bacterial occurrence in collected bile or in operative technical difficulties, but ahigher histopathological foreign body reaction (sinus histiocytos) in lymph nodes in the hepatoduodenalligament in the plastic stent group. Also, the overall postoperative complication rateswere increased in the group where plastic stents were used (72 % vs 52 %), as were thefrequency of anastomotic leakages (12 % vs 3.7 %), but none of these postoperativecomplications reached statistical significance. Conclusion: Prophylactic antibiotics in ERCP lower the overall complication rates but notsufficiently to recommend this as prophylaxis in every ERCP procedure. On the contrary,prophylactic pancreatic stents could be used more frequently in ERCP and larger diameters andlonger stents demonstrated lower complications rates. We also launched an ERCP complexitygrading scale (HOUSE) and validated it in relation to complication rates and procedure duration.Finally, we demonstrated that SEMS could be used in resectable periampullary tumors andfound no differences in bacterial growth in intraoperatively collected bile but a lowerpreoperative stent dysfunction rate if SEMS were used. Neither did we find any intraoperativetechnical downsides when using SEMS, or any disadvantages in postoperative complicationrates.