Laparoscopic treatment of a sigmoid perforation after colonoscopy. Case report and review of literature

Colonoscopic perforation management by laparoendoscopy: an algorithm

Laparoscopic intervention may be a safe and effective alternative to open surgery for management of perforation during colonoscopic examination. A simple algorithm is presented that may be helpful for those considering a laparoscopic approach to managing this condition.

Background and Objectives:

The role of laparoscopy in the management of iatrogenic colonoscopic injuries has increased with surgeons becoming facile with minimally invasive methods. However, with a limited number of reported cases of successful laparoscopic repair, the exact role of this modality is still being defined. Drawing from previous literature and our own experiences, we have formulated a simple algorithm that has helped us treat colonoscopic perforations.

Methods:

A retrospective review was undertaken of patients treated for colonoscopic perforations since the algorithm's introduction. For each patient, initial clinical assessment, management, and postoperative recovery were carefully documented. A Medline search was performed, incorporating the following search words: colonoscopy, perforation, and laparoscopy. Twenty-three articles involving 106 patients were identified and reviewed.

Results:

Between May 2009 and August 2012, 7 consecutive patients with colonoscopic perforations were managed by 2 surgeons using the algorithm. There were no complications and no deaths, with a mean length of stay of 4.43 days (range, 2–7 days). Of the 7 patients, 6 required surgery. A single patient was managed conservatively and later underwent an elective colon resection.

Conclusions:

Traditionally, laparotomy was the preferred method for treating colonoscopic perforations. Our initial experience reinforces previous views that laparoendoscopic surgery is a safe and effective alternative to traditional surgery for managing this complication. We have formulated a simple algorithm that we have found helpful for surgeons considering a laparoscopic approach to managing this condition.

Laparoscopic repair of colonoscopic perforation: a new standard?

BACKGROUND

Scientific evidence demonstrating interest in the laparoscopic approach for surgical repair of colonoscopic perforations is still lacking. The authors retrospectively reviewed the records of 43 patients who suffered from colonic perforations after colonoscopy between 1989 and 2008 in two tertiary centers in order to compare the results of the laparoscopic and the open approaches to repair.

METHODS

The patients' demographic data, perforation location, therapy, and outcome were recorded from the medical charts. Forty-two patients were managed operatively (19 laparoscopies and 23 laparotomies). In three patients who underwent explorative laparoscopy, the procedure had to be converted to laparotomy due to surgical difficulties. The patients who underwent laparotomy management had a longer period between the colonoscopy and the surgery (P=0.056) and more stercoral contaminations.

RESULTS

The mean hospital stay was shorter for the laparoscopy group (P=0.02), which had fewer postoperative complications (P=0.01) and no mortality (NS).

CONCLUSION

This series demonstrates that early laparoscopic management of colonoscopic perforation is safe. Laparoscopic management may lead to reduced surgical and psychological stress for the patient because of its low morbidity and mortality rates and shorter hospital stay. However, the procedure should be converted to a laparotomy if necessary.

Laparoscopic monitored colonoscopic polypectomy: long-term follow-up

BACKGROUND

Colonoscopy is widely used to remove benign polyps. However, a variety of "difficult polyps" are not accessible for colonoscopic removal because of their size, broad base, or difficult location (impossible to see the polyp's base, polyps behind mucosal folds or in tortuous colonic segments). The aim of the study was to evaluate the long-term follow-up and oncologic safety of laparoscopically monitored colonoscopic polypectomy (LMCP).

METHODS

From May 1990 to January 2008, all the patients undergoing LMCP were analyzed and prospectively followed with colonoscopic studies at 6 months, 1 year, and every year thereafter.

RESULTS

A total of 209 polyps were removed in 160 patients: 82 men (51%) and 78 women (49%). The mean age was 74.7 years (range 46-99 years). During a mean follow-up of 63.37 months (range 6-196 months) and median follow-up of 65 months, there has been no recurrence.

CONCLUSIONS

Long-term follow-up demonstrated that a combined endoscopic-laparoscopic approach is safe and effective. Malignant lesions identified during LMCP can be treated laparoscopically during the same operation, avoiding the need of a second procedure, with good long-term oncologic outcome.

The role of laparoscopy in the treatment of complications after colonoscopy

Perforations of the colonic wall or splenic injury during colonoscopy are rare complications. Treatment of these complications by laparoscopy is an advisable compromise instead of an invasive surgery with a laparotomy or a noninvasive and potentially risky nonoperative therapy. All surgical procedures that can be performed by open approach can also be performed laparoscopically. We present in this report 15 patients who were treated for a perforation after colonoscopy. In addition, 2 cases of splenic injury after colonoscopy are described. Twelve perforations were sutured laparoscopically and 3 perforations were sutured via laparotomy. Except for 1 minor wound infection, there were no complications. One splenic injury was treated by spleen wrapping via an open approach due to former pancreatic surgery, and 1 injury was treated laparoscopically with a hemostypticum. Mortality was 0%. Early laparoscopic intervention is a safe and effective method in the treatment of serious complications after colonoscopy.

[Iatrogenic colon perforation: experiences with early laparoscopy]

BACKGROUND

Perforation during colonoscopy is a rare but severe complication.

PATIENTS AND METHODS

Retrospective analysis was done of 15 patients operated on for perforation from colonoscopy between January 2000 and December 2006.

RESULTS

Three perforations occurred during diagnostics and 12 during interventional colonoscopy. Two perforations occurred as transmural thermal injury to the colon wall. Peritonitis was found in four cases and correlated significantly with mean time between perforation and operation. Twelve perforations were sutured laparoscopically and three by laparotomy. Hospital stay was significantly shorter after laparoscopic treatment than by laparotomy. One patient had a postoperative wound infection, and mortality was 0%.

CONCLUSION

Early laparoscopic suturing is a safe and effective method in the treatment of perforation from colonoscopy.

Laparoscopic repair of iatrogenic colonic perforation

Perforation of the colon during colonoscopy can occur for a variety of reasons. When it is caused directly by the endoscope itself, operative intervention is virtually unavoidable. Current practice is laparotomy and repair or resection. Simple oversewing of the defect in a well-prepared colon is safe and effective if the diagnosis is made early. This can be carried out by the laparoscopic route; however, there are few cases of this being performed. We describe our technique for laparoscopic repair here, reviewing the literature on perforation and its management. With advanced laparoscopic techniques such as intracorporeal suturing becoming more widely practiced, a mind shift toward considering laparoscopy for treatment of these patients should be made. Laparoscopy does not exclude the conversion to laparotomy if required.

Laparoscopically monitored colonoscopic polypectomy: an established form of endoluminal therapy for colorectal polyps

BACKGROUND

Benign polyps, the most common disorders of the colon, are considered by many to be premalignant lesions. Colonoscopy is widely used to remove the majority of these polyps. However, a variety of "difficult polyps" are not accessible for colonoscopic removal because of their location and size, the tortuosity of the colon, or the complexity of the lesion (sessile vs pedunculated). In the past, a formal segmental resection usually was suggested for these difficult polyps.

METHODS

For 110 patients with a median age of 73 years, a total of 149 polyps were removed as follows: 88 from the right colon, 18 from the transverse colon, 10 from the left colon, and 33 from the rectosigmoid colon. Pathologic evaluation showed adenomatous polyps in 13 patients (11.81%), hyperplastic polyps in 1 patient (0.9%), adenocarcinomas in 10 patients (9.09%), carcinoma in situ in 1 patient (0.9%), and adenomas in the remaining patients (tubulovillous, 40.18%; villous, 19.31%, and tubular, 17.77%). All the specimens were evaluated for margins and depth of resection.

RESULTS

The median size of the polyps was 2.30 cm (range, 0.2-6 cm). The average hospital stay was 1.14 days, with a liquid diet started 6 h postoperatively. Mild abdominal pain/trocar-site pain was the most common complaint. The patients were followed with colonoscopy 6 months postoperatively and yearly thereafter.

CONCLUSIONS

A combined endoscopic-laparoscopic approach provides a valid alternative for treating difficult colonic polyps and eliminating the morbidity of a segmental resection. This approach seems to be safe and effective.

Laparoscopic treatment of endoscopic sigmoid colon perforation: a case report and literature review

Perforation of the colon after colonoscopy is a rare but potentially lethal complication. It usually occurs when endoscopy is performed for therapeutic purposes. In these cases the election of the best treatment is difficult and still controversial. Laparoscopy is a new approach for diagnosis and treatment of this condition. We report a case of a patient who was initially treated laparoscopically after a colonoscopic perforation. A postoperative leak was detected and the patient underwent open surgery. Possible therapeutic approaches and a literature review are discussed.

Laparoscopic repair of colon perforation after colonoscopy in children: report of 2 cases and review of the literature

Perforation of the colon is an uncommon complication of colonoscopy in children. In the past, such injuries were treated by laparotomy with primary repair or colostomy. We performed laparoscopic primary repair of the colon in 2 young boys who showed signs of bowel perforation after colonoscopic polypectomy. Both recovered uneventfully and were discharged within several days of admission. In the first patient, the colon had been well prepared, and the perforation was identified almost immediately, resulting in minimal peritoneal contamination. The second patient presented 48 hours after colonoscopy, but there was no gross fecal contamination. In each case, primary repair was felt to be a safe option. Laparoscopic primary repair of colon perforation after colonoscopic polypectomy in children appears to be safe and effective in selected cases. Advantages of the minimally invasive approach include the ability to evaluate the entire colon for injuries, more rapid postoperative recovery, and improved cosmesis.

[Experimental model of laparoscopic handsewn suture in colon of dogs]

PURPOSE

Develop an experimental model of laparoscopic hand-sewn suture in colon of dogs to be specially used for surgeons' training.

METHODS

Forty male dogs were operated on, weight between 15 and 20 kg, from the laboratory of the Veterinary School of the State University of Ceara. They were distributed within two groups with 20 animals each: GI--The colonic wall incision was done with an electrical scalpel followed by haemosthasia and GII--The colonic wall incision was performed with a scissors. Each group was shared in two other groups with 10 animals each, according to the abdominal approach used. A-Laparotomic approach and B-Laparoscopic approach. Under intra-venous general anesthesia, a transverse incision was performed envolving 50% of the sigmoid wall, 15 cm far from the pelvic peritoneal pouch, followed by an extra-mucosa, one layer and interrupted suture with 000 polydioxanona (PDSâ). The animals were evaluated concerning to the clinical recovery, macroscopic appearance, suture-tension test and histologic study. The animals were sacrificed on the 7th postoperative day. Fisher and Qui-square tests were used for statistical analysis.

RESULTS

All the animals submitted to colotomy performed by scissor (GIIA, GIIB) and nine animals operated on with an electrical scalpel (GI), five (50.0%) by laparotomic approach (GIA) and four (40.0%) laparoscopically (GIB) had a satisfactory clinical recovery, walking and accepting oral diet on the first post-operative day. The first bowel movement occurred between 48 and 72 hours. It didn't occur diarrhea or vomits. Eleven animals from group I, five (50%) from group IA and six (60.0%) from group IB didn't accept oral diet and complained of diarrhea (3 to 5 evacuations each day), 1 to 3 episodes of vomits each day and they die between the fourth and seventh postoperative day. Comparing groups GI with GII, a statistical significant difference was observed (p<0.005). There was no difference between GIA and GIB. Colonic sutures were intact in all the animals from group II and in five from group I with statistical significant difference (p<0.005). Three (30.0%) were from group IA and two (20.0%) from group IB. The colonic suture was envolved by epiploon in four animals, two (20%) from GIA and 2 (20%) from GIB. Suture dehiscence with peritonitis occurred in eleven (55%) animals from GI (p<0.005), five (50%) from GIA and six (60%) from GIB (p>0.005). All the animals died between the fourth and seventh postoperative day. The tension suture test was performed with an average pressure of 222,1 mmHg and there was no colonic suture disruption in any animal from the group II and in five (40.0%) from the group I (p<0.005). Three (30%) animals were from GIA and two (20.0%) from GIB (P>0.005). Colonic suture rupture occurred in four (20%) dogs from group I, two from GIA and two (20%) from GIB with an average pressure of 94.0 mmHg. The histological analysis of the surgical specimens removed on the 7th postoperative day demonstrated the same level of the inflammatory process in both approach used.

CONCLUSION

The handsewn laparoscopic colonic suture in dogs can be safely performed, showing the same results of the laparotomic approach. The surgical results depend specially on the adequate surgeon's training in laparoscopic surgical technique.