Gastroenterological Endoscopy. Группа авторов

the presence of a disconnected pancreatic duct.¹¹⁸ Magnetic resonance pancreatography (if possible with secretin) is recommended before any decision to remove the transmural stents. If ductal disconnection is present, stents (exclusively plastic, not SEMS) should remain in place indefinitely.

      10.7.3 Peroral Endoscopic Myotomy

      POEM, and more largely any intervention requiring access to the submucosal space (also called third space endoscopy to differentiate it from the luminal and extraluminal cavities), including esophageal or pyloric myotomies but also resection of submucosal tumors, has become a standard procedure in tertiary specialized centers. These techniques offer new possibilities of treatment, potentially more effective than surgery in selected cases. They are, however, associated with specific complications. In one of the largest series to date,¹¹⁹ (1,680 patients treated with POEM), major complications occurred in 55 (3.3%) patients, including 13 (0.8%) postoperative mucosa breach, 3 (0.2%) delayed bleeding, 8 (0.5%) hydrothorax, 25 (1.5%) pneumothorax that required thoracic tube placement, and 6 (0.4%) other complications. Four patients required ICU admission and 14 (0.8%) stayed more than 10 days in the hospital. The rate of major complications decreased over time and reached a plateau of 1% after 3.5 years. Multivariate analysis identified experience < 1 year (odds ratio [OR], 3.00; 95% confidence interval [CI], 1.12–8.06), air insufflation (OR, 2.78; 95% CI, 1.03–7.52), and mucosal edema (OR 1.92; 95% CI, 1.05–3.49) as risk factors. Other than the need for case volume and experience, it is clear that CO₂ insufflation is essential when performing such procedures.

      When performed by experienced physicians, these techniques are very safe, but one must be aware about incidental imaging findings such as pneumomediastinum, pneumothorax, and pneumoperitoneum, which are not as common with other endoscopic techniques. When pneumoperitoneum occurs during the procedure, it must be relieved when associated with hemodynamic disturbances. The presence of free air must only be considered when associated with clinical symptoms and one should understand this to avoid unnecessary interventions.¹²⁰

      10.8 Conclusion

      Therapeutic endoscopy continues to progress and therefore potential complications need to be recognized and properly prevented and treated. Prevention of complications relies on a fine knowledge of the patient’s condition and procedural indications. Scheduling must consider the available resources, evaluate if proper experience is available, and draw different strategies for managing complications. Early diagnosis of complications and multidisciplinary approach are paramount. The best approach will, in most cases, be dictated by local expertise. Concentration of cases will become necessary with the sophistication of techniques, which will require more resources and experience and patient education about the risks. Local expertise will remain a cornerstone in management.

      10.9 Key Points

      • Avoidance of unnecessary invasive examinations is the best way to prevent adverse events.

      • Preprocedural patient information and informed consent are paramount.

      • Acquiring and maintaining experience and competency in specific procedures is essential to reduce the risk of adverse events. Inexperienced and/or undertrained endoscopists should avoid performing advanced complex, therapeutic endoscopic procedures.

      • Standardization of training and adherence to guidelines are required in order to prevent and manage adverse events.

      • Assessing center- and operator-specific complication rates are important issues leading to improved quality and safety.

      References

      [1] Cotton PB, Eisen GM, Aabakken L, et al. A lexicon for endoscopic adverse events: report of an ASGE workshop. Gastrointest Endosc. 2010; 71(3):446–454

      [2] Cai MY, Zhou PH, Yao LQ, et al. Thoracic CT after peroral endoscopic myotomy for the treatment of achalasia. Gastrointest Endosc. 2014; 80(6):1046–1055

      [3] Quine MA, Bell GD, McCloy RF, et al. Prospective audit of upper gastrointestinal endoscopy in two regions of England: safety, staffing, and sedation methods. Gut. 1995; 36(3):462–467

      [4] Vargo JJ, Niklewski PJ, Williams JL, et al. Patient safety during sedation by anesthesia professionals during routine upper endoscopy and colonoscopy: an analysis of 1.38 million procedures. Gastrointest Endosc. 2017; 85(1):101–108

      [5] Veitch AM, Vanbiervliet G, Gershlick AH, et al. Endoscopy in patients on antiplatelet or anticoagulant therapy, including direct oral anticoagulants: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guidelines. Endoscopy. 2016; 48(4):c1

      [6] Kimmey MB, Burnett DA, Carr-Locke DL, et al. Technology assessment position paper: transmission of infection by gastrointestinal endoscopy. Gastrointest Endosc. 1993; 39:885–888

      [7] Petersen BT, Chennat J, Cohen J, et al; ASGE Quality Assurance In Endoscopy Committee. Society for Healthcare Epidemiology of America. Multisociety guideline on reprocessing flexible gastrointestinal endoscopes: 2011. Gastrointest Endosc. 2011; 73(6):1075–1084

      [8] Beilenhoff U, Neumann CS, Biering H, et al; ESGE. ESGENA. ESGE/ESGENA guideline for process validation and routine testing for reprocessing endoscopes in washer-disinfectors, according to the European Standard prEN ISO 15883 parts 1, 4 and 5. Endoscopy. 2007; 39(1):85–94

      [9] Rubin ZA, Murthy RK. Outbreaks associated with duodenoscopes: new challenges and controversies. Curr Opin Infect Dis. 2016; 29(4):407–414

      [10] U.S. Public Health Service. Updated U.S. Public Health Service guidelines for the management of occupational exposures to HBV, HCV and HIV and recommandations for post-exposure prophylaxis. MMWR. 2001; 50:1–42

      [11] Silvis SE, Nebel O, Rogers G, et al. Endoscopic complications. Results of the 1974 American Society for Gastrointestinal Endoscopy Survey. JAMA. 1976; 235(9):928–930

      [12] Montalvo RD, Lee M. Retrospective analysis of iatrogenic Mallory-Weiss tears occurring during upper gastrointestinal endoscopy. Hepatogastroenterology. 1996; 43(7):174–177

      [13] Van Os EC, Kamath PS, Gostout CJ, Heit JA. Gastroenterological procedures among patients with disorders of hemostasis: evaluation and management recommendations. Gastrointest Endosc. 1999; 50(4):536–543

      [14] Straumann A, Bussmann C, Zuber M, et al. Eosinophilic esophagitis: analysis of food impaction and perforation in 251 adolescent and adult patients. Clin Gastroenterol Hepatol. 2008; 6(5):598–600

      [15] Green J. BSG guidelines: complications of gastrointestinal endoscopy. 2006. Available at: www.bsg.org.uk

      [16] Siddiqui N, Katznelson R, Friedman Z. Heart rate/blood pressure response and airway morbidity following tracheal intubation with direct laryngoscopy, GlideScope and Trachlight: a randomized control trial. Eur J Anaesthesiol. 2009; 26(9):740–745

      [17] Boeckxstaens GE, Annese V, des Varannes SB, et al; European Achalasia Trial Investigators. Pneumatic dilation versus laparoscopic Heller’s myotomy for idiopathic achalasia. N Engl J Med. 2011; 364(19):1807–1816

      [18] Bechara R, Ikeda H, Inoue H. Peroral endoscopic myotomy: an evolving treatment for achalasia. Nat Rev Gastroenterol Hepatol. 2015; 12(7):410–426

      [19] Hernandez LV, Jacobson JW, Harris MS. Comparison among the perforation rates of Maloney, balloon, and savary dilation of esophageal strictures. Gastrointest Endosc. 2000; 51(4 Pt 1):460–462

      [20] Metman EH, Lagasse JP, d’Alteroche L, et al. Risk factors for immediate complications after progressive pneumatic dilation for achalasia. Am J Gastroenterol. 1999; 94(5):1179–1185

      [21] Saeed ZA, Winchester CB, Ferro PS, et al. Prospective randomized