Mortality From EUS Jesse Lachter Introduction: EUS is widely perceived to be, as reported, a very safe procedure. Early statistics, from pooled data, found a one in 37,915 risk of mortality. New instruments, linear EUS, and FNA and other invasive techniques, justify reevaluation of data on complications. Accumulating data on complications suggests major revision of the mortality statistics. Patients and Methods: Following initiation of a national survey of EUS utilization, a repository of information on complications developed. Creation and utilization of this data base led to continuous describing of complications. The higher than expected frequency of such complications, especially of mortalities, led to investigations of each case. Results: Seven local cases, and five cases from outside of Israel, of EUS-caused deaths were found. This series represents more cases than that cumulatively described as case reports in all of the relevant literature of the past 24 years, since the introduction of EUS. In the cases analyzed, FNA was not involved in any procedure. The Pentax instruments with their longer hard tip than the Olympus linear instruments, were involved in six of the seven mortalities; no cases involved Fuji scopes. Notably, only one of the 20 EUS centers in Israel uses a Fuji system. Duodenal tears, leading to retroperitoneal perforations, were the cause of 10 of the 12 deaths. The other two deaths were (one each) from esophageal perforation, and from aspiration. One case occurred from a procedure performed as part of a live demonstration of EUS. At least five cases involved patients with duodenal diverticuli. These diverticuli may have had a role in the cause of doing the EUS, in procedures which were initiated to search for suspected CBD stones. Delay in diagnosis of perforation was common. five of the seven Israeli deaths from EUS occurred during the first year and/or 150 first procedures of the endosonographer. Conclusions: EUS has significantly higher risks than previously thought. The Israeli mortality rate from EUS, averaging about one death from each 2500 procedures, was found to be over 15 times that in the published (somewhat dated) literature. To minimize the risks of death from EUS, this study suggests 1appropriately long traineeships, 2attention to duodenal diverticuli, 3a high index of suspicion of retroperitoneal tears with knowledge of their management, 4and appreciation of the EUS instrument designs.
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