Laparoscopic direct suture of perforation after diagnostic colonoscopy

Methods of Surgical Repair for Iatrogenic Sigmoid Colon Perforation Following Colonoscopy: A Case Report and Literature Review

Iatrogenic colonic perforation is a relatively infrequent yet perilous complication arising from both diagnostic and therapeutic colonoscopies, potentially leading to severe septic complications and increased morbidity or mortality. Given the gravity of potential complications, surgical intervention stands as the principal treatment strategy, with various modalities selected based on clinical discretion. In this context, we present the case of a patient who underwent primary laparoscopic repair following the identification of a sigmoid colon perforation during a routine colonoscopy. Intraoperatively, a Jackson-Pratt drain was placed to facilitate postoperative monitoring and drainage. The patient's hospitalization extended to a total of seven days due to sustained drainage and leukocytosis, highlighting the complexities of managing postoperative complications in such cases. This report underscores the current landscape of published data guiding the surgical management of iatrogenic colonic perforation following colonoscopy and highlights both the existing strengths and gaps within the current body of literature. As colonic perforation remains a critical concern in endoscopic procedures, a comprehensive understanding of optimal surgical interventions is crucial for minimizing patient morbidity and ensuring successful outcomes.

Clinical outcomes of laparoscopic versus open surgery for repairing colonoscopic perforation: a multicenter study

PURPOSE

We conducted this study to compare the perioperative outcomes of laparoscopic surgery (LS) vs. open surgery (OS) for repairing colonoscopic perforation, and to evaluate the possible predictors of complications.

METHOD

We reviewed the medical records of patients who underwent surgical repair of colonoscopic perforation by LS or OS between January 2005 and June 2019 at six Hallym University-affiliated hospitals. Multivariable analysis was performed to identify the predictors of postoperative complications.

RESULTS

Of the total 99 patients, 40 underwent OS and 59 underwent LS. The postoperative hospital stay and the time to resuming a soft diet were shorter in the LS group than in the OS group (P = 0.017 and 0.026, respectively). The complication rate and Clavien-Dindo classification were not significantly different between the two groups. Multivariable analysis revealed that an American Society of Anesthesiologists score (ASA) ≥ 3 and switching from non-operative management to surgical treatment were independently associated with complications (P = 0.025 and 0.010, respectively).

CONCLUSION

LS may be a safe alternative to OS for repairing colonoscopic perforation with a shorter postoperative hospital stay and time to resuming a soft diet. Patients with an ASA score ≥ 3 and those with changes to their planned treatment should be monitored carefully to minimize their risk of complications.

The impact of sedation on quality metrics of colonoscopy: a single-center experience of 48,838 procedures

PURPOSE

Investigation of the role of sedation during colonoscopy is meaningful as the advantages of colonoscopy performing with sedation are still controversial.

METHODS

Medical records of patients who underwent colonoscopy in our institution were retrospectively analyzed. The sedation rate, adenoma detection rate (ADR), polyp detection rate (PDR), cecal intubation rate (CIR), iatrogenic colonic perforation rate (ICP) were calculated.

RESULTS

A total of 48,838 colonoscopies (24,498 in males) dated from July 2007 to February 2017 were analyzed. The median age was 50 years (range 16-85 years). An overall sedation rate was 80.38%. The PDR was 26.77%, and was not statistically different between colonoscopy with or without sedation (26.67% vs 27.22, p = 0.474). ADR was 12.9% regardless of applying sedation or not (13.0% vs 12.44%, p = 0.337). The CIR was 87.42% in all examinations with an adjusted CIR of 90.34%, and was higher when performed with sedation than without sedation (88.92% vs 80.64%, p < 0.0001). Five cases (0.01%) of ICP were reported, all of which occurred in patients under sedation.

CONCLUSIONS

The use of sedation is associated with increased CIR, but ADR and PDR remain unchanged with or without sedation. However, perforation rate, albeit very low, is significantly higher in sedated patients.

Management of colonoscopic perforation: a systematic review and treatment algorithm

BACKGROUND

The aim of this review is to evaluate and summarize the current strategies used in the management of colonoscopic perforations as well as propose a modern treatment algorithm.

METHODS

Articles published between January 2004 and January 2019 were screened. A total of 167 reports were identified in combined literature search, of which 61 articles were selected after exclusion of duplicate and unrelated articles. Only studies that reported on the management of endoscopic perforation in an adult population were retrieved for review. Case reports and case series of 8 patients or less were not considered. Ultimately, 19 articles were considered eligible for review.

RESULTS

A total of 744 cases of colonoscopic perforations were reported in 19 major articles. The cause of perforation was mentioned in 16 articles. Colonoscopic perforations were reported as a consequence of diagnostic colonoscopies in 222 cases and therapeutic colonoscopies in 248 cases. The site of perforation was mentioned in 486 cases. Sigmoid colon was the predominant site followed by the cecum. The management of colonoscopic perforations was reported in a total of 741 patients. Surgical intervention was employed in 75% of the patients, of these 15% were laparoscopic and 85% required laparotomy. The predominant surgical intervention was primary repair.

CONCLUSION

Management strategies of colon perforations depend upon the etiology, size, severity, location, available expertise, and general health status. Usually, peritonitis, sepsis, or hemodynamic compromise requires immediate surgical management. Endoscopic techniques are under continuous evolution. Newer developments have offered high success rate with least amount of post-procedure complications. However, there is a need for further studies to compare the newer endoscopic techniques in terms of success rate, cost, complications, and the affected part of colon.

The analysis of outcomes of surgical management for colonoscopic perforations: A 16-years experiences at a single institution

BACKGROUND/OBJECTIVE

Colonoscopy-induced colonic perforation often requires surgical management. The aim of this study was to analyze the outcomes after surgery for colonoscopic perforations (CPs).

METHODS

This was a retrospective chart review study of 48 patients who underwent surgery for CPs between January 2002 and May 2017. The patients were divided into two groups: Group I (n = 25) had diagnostic CPs, and Group II (n = 23) had therapeutic CPs.

RESULTS

The most common perforation sites in Group I were the sigmoid colon (n = 19; 76.0%), whereas in Group II were the transverse colon (n = 10, 43.5%) and sigmoid colon (n = 10, 43.5%; p = 0.013). The surgeries performed were primary closure (n = 16, [64.0%] Group I; n = 11 [47.8%] Group II) and bowel resection (n = 9 [36.0%] Group I; n = 11 [47.8%] Group II). The rate of temporary stomas was higher in Group II (n = 9, 26.1%) than Group I (n = 2, 8.0%; p = 0.030). The re-perforation rate after surgery was 8.0% (n = 2) in Group I and 8.7% (n = 2) in Group II (p = 0.568). These re-perforation patients all those who had a simple closure without a wedge resection. The conversion rate after laparoscopic surgery was 20.0% (n = 2 of 10) in Group I and 33.3% (n = 1 of 3) in Group II.

CONCLUSIONS

Surgical management is one of the important therapies in the treatment of CP. Simple primary closure without a wedge resection should be used cautiously. Therapeutic CPs was associated with more temporary stoma formation. The type of surgery should be carefully selected, depending on the type of CP.

Laparoscopic repair using an endoscopic linear stapler for management of iatrogenic colonic perforation during screening colonoscopy

Introduction

Colonoscopy is a safe and effective procedure, but it is also an inevitably invasive one. Laparoscopic repair of colonoscopic perforations has been reported to be a safe and effective treatment.

Aim

We present our surgical technique and outcomes of laparoscopic repairs using an endoscopic linear stapler for iatrogenic colonic perforation during screening colonoscopy.

Material and methods

Laparoscopic repair using an endoscopic linear stapler for iatrogenic colonic perforation during screening colonoscopy was performed by two experienced laparoscopic surgeons on 14 consecutive patients between April 2010 and December 2017 at our hospital. Using prospectively collected data, an observational study was performed on a per protocol basis.

Results

The mean age of the 14 patients who underwent laparoscopic repair was 56.6 ±9.1 years. The most common perforation site was the sigmoid colon in 10 (71.4%) patients, followed by the rectosigmoid junction in 3 (21.4%) patients and the splenic flexure in 1 (7.1%) patient. The median perforation size was 10 (range: 5–30) mm. The mean operation time was 73.9 ±28.2 min. Postoperative complications occurred in 1 (7.1%) patient. There was no postoperative mortality or reoperation within 30 days after surgery. The median time to tolerance of a regular diet was 5 (range: 3–6) days. The median postoperative hospital stay was 8.5 (range: 5–15) days.

Conclusions

Laparoscopic repair using an endoscopic linear stapler is a safe, easy, and effective surgical technique to treat colonic perforation related to screening colonoscopy.

2017 WSES guidelines for the management of iatrogenic colonoscopy perforation

Iatrogenic colonoscopy perforation (ICP) is a severe complication that can occur during both diagnostic and therapeutic procedures. Although 45–60% of ICPs are diagnosed by the endoscopist while performing the colonoscopy, many ICPs are not immediately recognized but are instead suspected on the basis of clinical signs and symptoms that occur after the endoscopic procedure. There are three main therapeutic options for ICPs: endoscopic repair, conservative therapy, and surgery. The therapeutic approach must vary based on the setting of the diagnosis (intra- or post-colonoscopy), the type of ICP, the characteristics and general status of the patient, the operator’s level of experience, and surgical device availability.

Although ICPs have been the focus of numerous publications, no guidelines have been created to standardize the management of ICPs. The aim of this article is to present the World Society of Emergency Surgery (WSES) guidelines for the management of ICP, which are intended to be used as a tool to promote global standards of care in case of ICP. These guidelines are not meant to substitute providers’ clinical judgment for individual patients, and they may need to be modified based on the medical team’s level of experience and the availability of local resources.

Emergency cases following elective colonoscopy: Iatrogenic colonic perforation

Objective

Our aim in this study was to present the cases of our patients who contracted colonic perforation during elective colonoscopy and became emergency cases; we also discuss treatment modalities along with literature reports on the subject.

Material and Methods

Cases of patients who contracted iatrogenic colonic perforation following endoscopy of the colorectal system between January 2009 and December 2015 at Kartal Koşuyolu Yüksek İhtisas Training and Research Hospital's Endoscopy Unit were reviewed retrospectively.

Results

Within the duration of the study, 5.586 patients underwent colonoscopies at our hospital; 7 (0.12%) of these patients contracted iatrogenic colonic perforation. Three (42.8%) of these patients were male, four (57.2%) were female, and their mean age was 69 years (46 to 84). Six (85.7%) patients were diagnosed intraoperationally, while one (14.3%) patient was diagnosed 12 hours after the procedure. The perforation area was the sigmoid colon in six patients and the ascending colon in one patient; all patients underwent surgery. Four patients were discharged with no complications. One of the remaining three patients had enterocutaneous fistula, one had acute renal failure, and one died of sepsis.

Conclusion

The progress of perforation due to colonoscopy varies according to the underlying diseases, the mechanism of perforation formation, the treatment modality used, and the experience of the physicians treating the patient. Special attention should be paid to senior and comorbid patients receiving therapeutic procedures during colonoscopy.

Endoscopic repair of rectal perforation due to colonoscopy with a clamp method

Colon perforation during colonoscopy is a rare complication that usually requires surgical intervention. Traditionally, primary repair by laparoscopy, laparotomy, resection, and anastomosis is performed for such perforations. More recently developed minimally invasive endoscopic instruments have also been used in the repair of these perforations; this is becoming increasingly common. An endoscopic over-the-scope clip clamp was used in a 59-year-old male patient who suffered a rectum perforation in connection with a diagnostic colonoscopy. He was referred to our clinic. A colonoscopy was performed in our clinic to assess the rectal perforation caused by a diagnostic colonoscopy 2 h after the initial colonoscopy, with the concurrent therapeutic purpose of repairing the perforation using an endoscopic clamping method. Oral feeding was started 24 h after the procedure. After three days, the patient was discharged. An endoscopic clamping method in appropriate cases can be a safe and appropriate alternative therapy in the management of colonoscopic perforations.

Laparoscopic vs. open surgery for the treatment of iatrogenic colonoscopic perforations: a systematic review and meta-analysis

AIMS

Iatrogenic colonoscopy perforations (ICP) are a rare but severe complication of diagnostic and therapeutic colonoscopies. The present systematic review and meta-analysis aims to investigate the operative and post-operative outcomes of laparoscopy vs. open surgery performed for the management of ICP.

METHODS

A literature search was carried out on Medline, EMBASE, and Scopus databases from January 1990 to June 2016. Clinical studies comparing the outcomes of laparoscopic and open surgical procedures for the treatment for ICP were retrieved and analyzed.

RESULTS

A total of 6 retrospective studies were selected, including 161 patients with ICP who underwent surgery. Laparoscopy was used in 55% of the patients, with a conversion rate of 10%. The meta-analysis shows that the laparoscopic approach was associated with significantly fewer post-operative complications compared to open surgery (18.2% vs. 53.5% respectively; Relative risk, RR: 0.32 [95%CI: 0.19-0.54; p < 0.0001; I² = 0%]) and shorter hospital stay (mean difference -5.35 days [95%CI: -6.94 to -3.76; p < 0.00001; I² = 0%]). No differences between the two surgical approaches were observed for postoperative mortality, need of re-intervention, and operative time.

CONCLUSION

The present study highlights the outcomes of the surgical management of an endoscopic complication that is not yet considered in clinical guidelines. Based on the current available literature, the laparoscopic approach appears to provide better outcomes in terms of postoperative complications and length of hospital stay than open surgery in the case of ICP surgical repair. However, the creation of large prospective registries of patients with ICP would be a step forward in addressing the lack of evidence concerning the surgical treatment of this endoscopic complication.

The management of intra-abdominal infections from a global perspective: 2017 WSES guidelines for management of intra-abdominal infections

Intra-abdominal infections (IAIs) are common surgical emergencies and have been reported as major contributors to non-trauma deaths in the emergency departments worldwide. The cornerstones of effective treatment of IAIs are early recognition, adequate source control, and appropriate antimicrobial therapy. Prompt resuscitation of patients with ongoing sepsis is of utmost important. In hospitals worldwide, non-acceptance of, or lack of access to, accessible evidence-based practices and guidelines result in overall poorer outcome of patients suffering IAIs. The aim of this paper is to promote global standards of care in IAIs and update the 2013 WSES guidelines for management of intra-abdominal infections.

The role of surgery in the treatment of endoscopic complications

As the number, diversity, and complexity of endoscopic complications has increased, so too has the number, diversity, and complexity of operative interventions required to treat them. The most common complications of endoscopy in general are bleeding and perforation, but each endoscopic modality has specific nuances of these and other complications. Accordingly, this review considers the surgical complications of endoscopy by location within the gastrointestinal tract, as opposed to by complication types, since there are many complication types that are specific for only one or few locations, such as buried-bumper syndrome after percutaneous endoscopic gastrostomy and pancreatitis after endoscopic retrograde cholangiopancreatography, and since the management of a given complication, such as perforation, may be vastly different in one area than in another area, such as perforations of the esophagus versus the retroperitoneal duodenum versus the intraperitoneal duodenum. It is hoped that this review will provide guidance for gastroenterologists considering a particular procedure, either to assess the risks for surgical complications in preparation for patient counseling, or assist in assessing a patient who seems to be having a severe complication, or to learn what operation might be required to treat a given complication and how that operation might be performed. As with many operations, those for the treatment of endoscopic complications are typically performed only when less invasive, nonoperative strategies fail.

The Endoscopic Treatment of Iatrogenic Gastrointestinal Perforation

BACKGROUND

Iatrogenic gastrointestinal perforation is a life-threatening complication that arises very rarely in routine endoscopic procedures, with an incidence of 0.03-0.8%. It is more likely in highly complex and invasive therapeutic interventions. In certain situations, endoscopic closure of the perforation and treatment with antibiotics can obviate the need for emergency surgical repair.

METHODS

This review is based on pertinent articles retrieved by a selective literature search in PubMed and on a relevant position paper.

RESULTS

Existing clinical studies of treatment for iatrogenic gastrointestinal perforation are mainly retrospective and uncontrolled. No randomized and controlled trials have been performed to date. If the perforation is discovered soon after it arises, endoscopic treatment can be considered. Gastrointestinal perforations that are less than 30 mm in size can be closed with a clip. In the esophagus, expanding metal stents can be used as well. Clip application is successful in 80-100% of cases of gastrointestinal perforation, and the perforation remains permanently closed in 60-100% of cases. Reports on the endoscopic treatment of esophageal perforation show mixed results, with closure rates of roughly 90% and clinical success rates of roughly 80%. If endoscopic treatment is not possible, timely laparoscopic or open surgical repair is needed.

CONCLUSION

The endoscopic treatment of iatrogenic perforations is safe and reliable. Success depends on early detection, adequate endoscopic closure with properly mastered technique, and the early initiation of concomitant antibiotic treatment, which must be continued for a full course. Most patients who are treated in this way do not need emergency surgery.

Decision-making in the management of colonoscopic perforation: a multicentre retrospective study

BACKGROUND

The incidence of colonoscopic perforation has increased following the widespread use of colonoscopy for the diagnosis and treatment of colorectal disease. The purpose of our study was to compare the clinical outcomes between surgical and non-surgical treatment of colonoscopic perforation.

METHODS

We retrospectively reviewed the medical records of patients with colonoscopic perforation, which was treated between January 2005 and December 2014. Patients were divided into two groups depending on whether they received non-surgical (conservative management or endoscopic clipping) or surgical (primary closure, bowel resection and anastomosis, and/or faecal diversion) initial treatment for the perforation. Conversion was defined as the change from a non-surgical to surgical procedure after treatment failure.

RESULTS

One hundred and nine patients were analysed. Surgical treatment was more common following diagnostic than therapeutic colonoscopic procedures (74.5 vs. 53.7 %, P = 0.023). Of 55 patients in the non-surgical group, 11 patients required conversion to surgery. The surgical group comprised 54 patients. The complication rate (P = 0.001), and the length of hospital stay (P < 0.001) were significantly greater in the patients requiring conversion than in the surgical group. Multivariate analysis showed that old age, American Society for Anesthesiologists score ≥ 3, and conversion were independent predictors of poor outcomes (P = 0.048, 0.032, and 0.001, respectively). Only perforation size was associated with conversion in multivariate analysis (P = 0.022).

CONCLUSION

It is important to select an appropriate treatment in patients with colonoscopic perforation. To avoid non-surgical treatment failure, surgery should be considered in patients with a large perforation. By decreasing the rate of conversion, we might reduce the complication and mortality rates associated with colonoscopic perforation.

Management of iatrogenic colorectal perforation: From surgery to endoscopy

Iatrogenic colon perforation is one the most pernicious complications for patients undergoing endoscopic screening or therapy. It is a serious but rare complication of colonoscopy. However, with the expansion of the indications for endoscopic therapies for gastrointestinal diseases, the frequency of colorectal perforation has increased. The management of iatrogenic colorectal perforation is still a challenge for many endoscopists. The methods for treating this complication vary, including conservative treatment, surgical treatment, laparoscopy and endoscopy. In this review, we highlight the etiology, recognition and treatment of colorectal iatrogenic perforation. Specifically, we shed light on the endoscopic management of this rare complication.