APP – Das Amberger Perforationsprojekt als Grundlage für die Etablierung eines Komplikationserfassungs- und Managementsystems (KEMS) in der Endoskopie

Zusammenfassung

Hintergrund Zurzeit ist ein Paradigmenwechsel bei der Therapie der iatrogenen gastrointestinalen Perforation hin zu einer primär endoskopischen Versorgung festzustellen.

Material und Methoden Alle Perforationen im Rahmen aller konsekutiven gastrointestinalen Endoskopien von 01.01.2014 bis 31.12.2017 im Klinikum St. Marien Amberg wurden erfasst, dokumentiert und evaluiert. Hausinterne SOPs zum Prozedere wurden erstellt und kommuniziert. Grundsätzlich wurde der primäre interventionell-endoskopische Perforationsverschluss angestrebt, stets im interdisziplinären Konsens mit der Viszeralchirurgie.

Ergebnisse Es kam im Beobachtungszeitraum zu 24 Perforationen bei 18 627 konsekutiven Endoskopien (0,13 %). Fälle mit bildgebendem Nachweis freier Luft ohne erkennbare Perforation waren gleich häufig wie Perforationen (12 Post-Polypektomiesyndrome und 12 Ereignisse nach ERCP mit EPT). Die Diagnose der Perforation erfolgte zu 95,8 % (23/24) innerhalb 12 h (davon 20 bereits bei der Endoskopie). Die initiale Therapiemodalität war in jeweils 3 Fällen primär operativ bzw. primär konservativ und in 17 Fällen primär endoskopisch (4 × Clips, 10 × OTSC, 3 × SEMS). In 1 Fall wurde keine Therapie durchgeführt. Es war eine Letalität von 4,2 % (1/24) zu verzeichnen. In 3 Fällen war sekundär ein operatives Vorgehen erforderlich, sodass insgesamt in 25 % (6/24) eine chirurgische Therapie erfolgte. Die interventionell-endoskopische Therapie war technisch erfolgreich zu 94,1 % (16/17) bei einem klinischen Erfolg nach Perforationsverschluss von 87,5 % (14/16).

Diskussion Das Konzept der interventionell-endoskopischen Therapie iatrogener Perforationen ist im klinischen Alltag sicher und erfolgreich umsetzbar. Entscheidende Erfolgsfaktoren sind die kurze Zeitspanne bis zum Verschluss der Perforation und der stets anzustrebende interdisziplinäre Konsens im Vorfeld der Therapie. Auf der Basis der Ergebnisse wurde ein umfassendes Komplikationserfassungs- und Managementsystem (KEMS) für die Endoskopie ab 2016 in unserer Klinik etabliert (integriert in das Befunderstellungssystem und das Klinikinformationssystem).

Abstract

Background Recently, there has been a significant change in the management of iatrogenic gastrointestinal perforation from surgery towards primary endoscopic therapy.

Material and methods All perforations occurring in all consecutive endoscopies from 1/1/2014 to 12/31/2017 in our hospital (Klinikum St. Marien Amberg, Germany) were recorded, evaluated and followed up prospectively. In-house SOPs were designed and communicated with all physicians within our hospital. Endoscopic closure of the perforation was primarily attempted, always in consent with the abdominal surgeon.

Results In total, we observed 24 perforations in 18 627 consecutive endoscopies (0.13 %). There were also 24 cases of free extraluminal gas without perforation (12 post-polypectomy-syndromes und 12 post-ERCP with papillotomy). Diagnosis of perforation could be established within 12 hours in 95.8 % (23/24) (in 20 cases during endoscopy). Initial therapeutic approach was surgical in 3 cases, conservative in 3 cases and interventional-endoscopic closure of perforation in 17 cases (4 × Clips, 10 × OTSC, 3 × SEMS). In 1 case, no therapy was performed. Mortality was 4.2 % (1/24). In 3 cases, the patient had to be operated on secondary to endoscopic therapy. In summary, surgical therapy was necessary in 6 of 24 cases (25 %). Interventional-endoscopic therapy was successful technically in 94.1 % (16/17) and clinically in 87.5 % (14/16).

Discussion Primary interventional-endoscopic closure of iatrogenic gastrointestinal perforation is a safe and successful option in the everyday practice of a secondary referral hospital. The most important factor is prevention of delay until closure of perforation. Also, interdisciplinary consensus between endoscopist and surgeon is essential. Based on our own data, we developed and introduced a system for documentation and management of all endoscopic complications in endoscopy called “KEMS”, which could be successfully integrated in our IT-system.

Schlüsselwörter

Perforation - Endoskopie - iatrogen - Therapie - OTSC

Key words

perforation - endoscopy - iatrogenic - therapy - OTSC

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