Perforated duodenal events post-cpre with vbp stent which procedure?

Introduction: Advances in the study of biliary and pancreatic pathologies (1,2,3,4) obtained with endoscopic retrograde cholangiopancreatography (CPRE) have seen an evolution over the years which, from an exclusive diagnostic method, has been transformed, in therapeutic method . the indications to ERCP have changed and the method, while maintaining a diagnostic role, has taken on a position of Level II, with a clear decrease in its diagnostic indications and a decisive change towards an almost exclusively therapeutic use of footprints (13.14). , however, the complications arising in the execution of the procedure with an incidence varying between 1% and 17% of cases (15,16) are opposed, which cause changes in conduct in the care of the patient, and expose him to additional diagnostic and therapeutic procedures, which prolong the stay. The occurrence, in fact, of an unexpected complication constitutes a factor of strong perturbation, representing a therapeutic act which, by inserting itself in a sudden way, conditions the course of the basic disease, endangering the patient's life. In the present work we will deal with complicative perforative events, which occur in patients undergoing ERCP with biliary stenting,
Materials and Methods: Our case history observed at the Department of Medical Surgical and Specialized Sciences II of the AOU Polyclinic University of Catania consists of 41 duodenal perforations on 1197 cases of ERCP, between January 2015 and December 2018, in patients of the average age of 50 (35-65) years, of which 19 are female and 22 are male. The percentage incidence of the lesion is equal to 3. 4%. the diagnostic procedure adopted after the performative event was in that of a direct abdomen CT and X-ray examination, and MRI colangiography. The clinical picture, in all the examined patients belonging to type I and II, was characterized by a nuanced or silent pain symptomatology in retroperitoneal perforations, and of acute pain, fever and leukocytosis, established in those intra-peritoneal, in which the abdominal distension and parietal defense, up to an acute abnormal abdomen.
Results: In the diagnosis of iatrogenic lesion type I and according to Stapfer, the adopted therapeutic treatment opted for the positioning by endoscopy of the nose-duodenal tube (SND) and of the nose-biliary tube (SNB), in order to obtain useful diversion of duodenal juice and bile and to continue in the toilet of the VBP. In the course of absolute fasting, a pharmacological supportive therapy was established with antibiotics and total parenteral nutrition, and inhibitors of gastric and pancreatic secretion. In the patients who obtained the diagnosis of iatrogenic lesion type II ,III and IV according to Stapfer, the illustrated instrumental findings and the severe clinical picture forced us to desist from any type of conservative treatment and to subject the patient to surgical intervention in ur -genza / emergency, during which, once the mobilization of the duodenum with Kocher maneuver was performed, the solution was continued simply or raffia, in consideration of the timeliness of the intervention that guarantees us the absence and / or the limited " mining”of neighboring fabrics to the small breach
Discussion: The debate on what should be the most appropriate treatment of post-CPRE perforation events and with SE: if an aggressive attitude with immediate recourse to surgery or conservative therapy, in relation to the lacerations of the side wall of the duodenum, we have diversified our therapeutic approach: and we have opted, as expected, for ab initio surgery in the absence of contamination of neighboring tissues. the timeliness of the intervention, has allowed us to guarantee ourselves from the risks of dehiscence, and to resort to a simple raffia of the solution continuously provided for after "kocherization" of the duodenum; departing from what is recommended by the guidelines, with a initially conservative approach. We considered the severity condition of the clinical picture in which the patients were paying for the treatment of perforation; it is the worsening of local conditions, documented by CT and MRI monitoring, which requires surgery. the therapeutic strategy adopted for conservative treatment was due only to the patient's favorable general and local condition. Conclusion: the timeliness of the intervention, allows to reduce the risks and the gravity of the clinical picture that acts as a compass on which treatment to opt.