Can general surgeons perform colonoscopy safely?

Risk factors for early colonoscopic perforation include non-gastroenterologist endoscopists: a multivariable analysis

BACKGROUND & AIMS

Bowel perforation is a rare but serious complication of colonoscopy. Its prevalence is increasing with the rapidly growing volume of procedures performed. Although colonoscopies have been performed for decades, the risk factors for perforation are not completely understood. We investigated risk factors for perforation during colonoscopy by assessing variables that included sedation type and endoscopist specialty and level of training.

METHODS

We performed a retrospective multivariate analysis of risk factors for early perforation (occurring at any point during the colonoscopy but recognized during or immediately after the procedure) in adult patients by using the Clinical Outcomes Research Initiative National Endoscopic Database. Risk factors were determined from published articles. Additional variables assessed included endoscopist specialty and years of experience, trainee involvement, and sedation with propofol.

RESULTS

We identified 192 perforation events during 1,144,900 colonoscopies from 85 centers entered into the database from January 2000-March 2011. On multivariate analysis, increasing age, American Society of Anesthesia class, female sex, hospital setting, any therapy, and polyps >10 mm were significantly associated with increased risk of early perforation. Colonoscopies performed by surgeons and endoscopists of unknown specialty had higher rates of perforation than those performed by gastroenterologists (odds ratio, 2.00; 95% confidence interval, 1.30-3.08). Propofol sedation did not significantly affect risk for perforation.

CONCLUSIONS

In addition to previously established risk factors, non-gastroenterologist specialty was found to affect risk for perforations detected during or immediately after colonoscopy. This finding could result from differences in volume and style of endoscopy training. Further investigation into these observed associations is warranted.

Performance measures of surgeon-performed colonoscopy in a Veterans Affairs medical center

BACKGROUND

Quality indicators are increasingly emphasized in the performance of colonoscopy. This study aimed to determine the standard of care rendered by surgeon-endoscopists in a Veterans Affairs (VA) medical center by evaluating the indications for colonoscopy and outcome performance measures according to established quality indicators for colonoscopy.

METHODS

A prospective standardized computer endoscopic reporting database (ProVation MD) was retrospectively reviewed. All colonoscopies performed by attending surgeons at the San Diego VA medical center between 1 January 2004 and 31 July 2007 were included in the study. Patients with charts that had incomplete reporting were excluded. The quality indicators used included the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) criteria for colorectal cancer screening, the American Cancer Society (ACS) guidelines for postcancer resection surveillance, and the American Society of Gastrointestinal Endoscopists (ASGE) quality indicators for colonoscopy.

RESULTS

The data for 558 patients (96% men) were analyzed. The average patient age was 63 years (range, 25-93 years). Almost all the colonoscopies (99%) were performed in accordance with established criteria. The most common indications for colonoscopy were screening (n = 143, 26%), non-acute gastrointestinal bleeding (n = 127, 23%), polyp surveillance (n = 100, 18%), postcancer resection surveillance (n = 91, 17%), abdominal pain (n = 19, 4%), and anemia (n = 14, 3%). Postcancer resection surveillance colonoscopies were performed according to recommended criteria in 98% of the cases. The cecal intubation rate was 97%, and the overall adenoma detection rate was 26%. Two patients (<1%) experienced complications requiring intervention.

CONCLUSION

The study data indicate that surgeon-performed colonoscopies meet standard quality criteria for indications and performance measures. The authors therefore conclude that surgeon-endoscopists demonstrate proficiency in the standard of care for colonoscopy examinations.

Risk of perforation from a colonoscopy in adults: a large population-based study

BACKGROUND

Previous studies that reported the incidence of perforation from a colonoscopy are limited by small sample sizes, restricted age groups, or single-center data.

OBJECTIVE

To determine the incidence and risk factors of colonic perforation from a colonoscopy in a large population cohort.

DESIGN

Retrospective, population-based, cohort study, followed by a nested case-control study.

SETTING

California Medicaid program claims database.

PATIENTS

A total of 277,434 patients (aged 18 years and older) who underwent a colonoscopy during 1995 to 2005, age, sex, and time matched to 4 unique general-population controls.

MAIN OUTCOME MEASUREMENTS

Perforation incidence in the 7 days after colonoscopy (or matched index date for controls) with odds ratio (OR); multivariate logistic regression to calculate adjusted ORs for subsequent analysis of risk factors.

RESULTS

A total of 228 perforations were diagnosed after 277,434 colonoscopies, which corresponded to a cumulative 7-day incidence of 0.082%. The OR of getting a perforation from a colonoscopy compared with matched controls (n = 1,072,723) who did not undergo a colonoscopy was 27.6 (95% CI, 19.04-39.92), P < .001. On multivariate analysis, when comparing the group that had a perforation after a colonoscopy (n = 216) with those who did not (n = 269,496), increasing age, significant comorbidity, obstruction as an indication for the colonoscopy, and performance of invasive interventions during colonoscopy were significant positive predictors. Performance of biopsy or polypectomy did not affect the perforation risk. The rate of perforation did not change significantly over time.

LIMITATIONS

Validity of coding and capturing of all perforation diagnoses may possibly be deficient.

CONCLUSION

The risk of perforation from a colonoscopy is low, but, despite increased experience with the procedure, it remains unchanged over time.

Assessment of endoscopic training of general surgery residents in a North American health region

BACKGROUND

Ensuring competency of trainees is a challenge for residency programs. The American Society for Gastrointestinal Endoscopy (ASGE) recommends that a minimum of 130 EGDs and 140 colonoscopies be performed to assess competency.

OBJECTIVE

We assessed the number of endoscopies performed by surgery and gastroenterology residents during their training. Endoscopy patterns were also assessed for staff gastroenterology specialists and general surgeons in Alberta, Canada.

DESIGN

Physician billing data were used to determine endoscopic practice patterns, and the number of endoscopies performed by gastroenterology fellows and surgery residents were obtained.

SETTING

Major teaching hospital.

MAIN OUTCOME MEASUREMENT

Procedure numbers.

RESULTS

In large cities, the number of colonoscopies performed by gastroenterologists increased ( approximately 2-fold) over the study period (there was minimal change in endoscopy numbers by surgeons). In contrast, in smaller communities, EGDs and colonoscopies by surgeons increased about 2-fold (from approximately 4065 to 7288) and about 4-fold (from approximately 1909 to approximately 7629), respectively (with only a minimal increase in colonoscopies ( approximately 3000), by gastroenterologists. During training, gastroenterology fellows performed significantly more procedures (EGDs, 29 +/- 5.6 by surgery residents vs 363.9 +/- 12.7 by gastroenterology fellows; colonoscopies, 91 +/- 14.2 by surgery residents vs 247.8 +/- 21.6 by gastroenterology fellows).

LIMITATION

All training data are from a single teaching center.

CONCLUSIONS

All gastroenterology fellows, but none of the surgery residents, achieved the minimum number of endoscopic procedures recommended by the ASGE to assess competency. These data suggest that we must reexamine our training programs and/or our methods for evaluating endoscopic competence.

Follow-up after colorectal polypectomy: a benefit-risk analysis of German surveillance recommendations

OBJECTIVE

For colorectal screening patients a mean gain of life time was previously calculated of about 30-50 days. Different recommendations for recognising at-risk groups and defining surveillance intervals after an initial finding of colorectal adenomas have been published. However, no benefit-risk analysis regarding to specific long-term effects of follow-up has been reported to date.

MATERIALS AND METHODS

A Markov model based on time-dependent transition possibilities was developed to perform a benefit-risk analysis of the risk-related surveillance recommendations based on the Erlangen Registry of Colorectal Polyps (ERCRP) in comparison with the recommendation of the German Society of Gastrointestinal Diseases and Nutrition (DGVS). The outcome was calculated for a 50-year-old patient with 30 years of follow-up after initial polypectomy. The data used in this model were taken from different sources, namely the ERCRP, the German Study Group of Colorectal Cancer, the German Statistical Yearbook, and from meta-analyses of studies reporting data on complications and sensitivity of colonoscopy.

RESULTS

Patients under surveillance have a mean lifetime gain of 98 (ERCRP) and 110 (DGVS) days compared with those who do not come for surveillance. 84% and 94% of deaths from colorectal carcinoma (CRC) could be prevented if patients were followed up according to the recommendations of the ERCRP and the DGVS, respectively. Less colonoscopies are needed to prevent one death from CRC following the recommendations of the ERCRP (221) than those of the DGVS (283). The risk of death due to colonoscopy for patients during follow-up is about 0.05% lifetime risk. Sensitivity analysis showed the stability of the results under a wide range of reasonable variations of relevant parameters. In a pessimistic one-way sensitivity analysis regarding compliance, effectiveness was reduced to one third.

CONCLUSION

Surveillance using colonoscopy is an effective tool for preventing CRC after colorectal polypectomy, especially if a good compliance is assumed. The effectiveness is higher following the recommendations of the DGVS, but more colonoscopies are needed.

The American Journal of Surgery

The March issue of the Journal carried the first digest, of articles published in late 1991 and January 1992 in The Americal Journal of Surgery and identified by that journal's Editor, Dr Hiram Polk, as of particular interest. This month we highlight papers from February and March. A digest from the same issues of The British Journal of Surgery written by our Editor, Professor John Farndon, is to be published in the July issue of our American sister journal. Correspondence on the content of papers should be addressed primarily to the source journal, although we would be interested to receive a copy.

Colonoscopic Perforations: Incidence, Management, and Outcomes

Fiberoptic colonoscopy provides superior diagnostic and therapeutic capabilities in the treatment of lower gastrointestinal disease processes. A well-recognized, but uncommon, complication during the procedure is perforation. The purpose of this study was to determine the incidence of colonoscopic perforation, define risk factors, assess the management of these complications, and evaluate outcomes. From January 1997 through December 2003, 43,609 colonoscopies were performed in our medical center. There were 14 (0.032%) perforations (1 in 3115 procedures); 7 from diagnostic and 7 from therapeutic procedures. General surgeons performed 1243 procedures (2.9%), and their rate of perforation was 0.080 per cent compared with 0.031 per cent for gastroenterologists during the same period. Half of the perforations occurred in the rectosigmoid, and the most common mechanism was mechanical (n = 6). Perforation was identified immediately during endoscopy in 50 per cent of the patients. Thirteen of 14 perforations were treated within 24 hours; 1 was delayed 48 hours. Initial surgical management was undertaken in 11/14 patients. Initial nonoperative treatment was attempted in three and was successful in only one patient. The mean length of stay following perforation was 11.2 days (range, 4–36 days). Three patients (21.4%) had 7 postoperative complications. Colonoscopic perforations are uncommon but can be recognized early and managed surgically with acceptable morbidity and postoperative length of stay.

The management of anticoagulants in the periendoscopic period for patients with atrial fibrillation: a decision analysis

PURPOSE

The management of patients who undergo endoscopy while being treated with warfarin is challenging. We used decision analysis to determine the preferred strategy to manage anticoagulants in the periendoscopic period.

METHODS

We designed a Markov model to estimate costs and quality-adjusted survival during a 10-year period in patients with nonvalvular atrial fibrillation undergoing screening colonoscopy. We compared six alternatives to the continue-warfarin strategy, which was to perform colonoscopy while the patient was taking full-dose warfarin. The hold-warfarin strategy was to stop warfarin 5 days before the colonoscopy. The repeat endoscopy strategy was to continue warfarin for a diagnostic colonoscopy, followed by a repeat procedure after cessation of warfarin if polypectomy was required. The dose-reduction strategy was to reduce the warfarin dose before colonoscopy. The low molecular weight heparin strategy was to administer subcutaneous low molecular weight heparin for 2 days before and 2 days after colonoscopy. The unfractionated heparin strategy was to administer intravenous unfractionated heparin for 2 days before and 2 days after the procedure. The vitamin K strategy was to hold warfarin for 4 days and to administer vitamin K if the international normalized ratio (INR) exceeded 2.0 the day before the procedure, or low molecular weight heparin if the INR was less than 1.5.

RESULTS

For screening colonoscopy, assuming that polyps would be removed in 35% of examinations, the hold-warfarin and dose-reduction arms were both cost-effective strategies. The hold-warfarin arm was most cost-effective if the likelihood of polypectomy exceeded 60%, or if there was a low risk of stroke despite atrial fibrillation. The continue-warfarin strategy was preferred if the probability of polypectomy was 1% or less.

CONCLUSION

Temporary warfarin cessation or halving the warfarin dose for several days before endoscopy was the preferred strategy for most patients. Periendoscopic heparin therapy was not cost-effective for patients with nonvalvular atrial fibrillation.

Perforation during colonoscopy in endoscopic ambulatory surgical centers

BACKGROUND

Perforation as a complication of colonoscopy is estimated to occur in 0.01% to 0.3% of procedures, but the frequency in ambulatory settings is unknown. This study determined the number of perforations occurring within a network of endoscopic ambulatory surgery centers.

METHODS

A total of 116,000 colonoscopies were performed within one network of 45 endoscopic ambulatory surgery centers in the United States during 1999. All identified perforations were reported to the network clinical director and reviewed by a panel of 3 gastroenterologists.

RESULTS

There were 37 (0.03%) perforations; 27 in women and 10 in men. Median patient age was 75 years (range 39-87 years); 18 patients (49%) had diverticular disease and 20 (54%) had a history of pelvic or colonic surgery. Twenty-four (65%) procedures were diagnostic, and 13 (35%) were therapeutic. The most common site of perforation was the sigmoid colon (62%); followed by the ascending colon (16%); cecum, transverse colon, and splenic flexure (11%); and rectum, anastomotic, or unknown (11%). The time to diagnosis ranged from immediate to 72 hours (29 <1 hour, 8 >1 hour). All patients were hospitalized; 35 (95%) underwent exploratory laparotomy, and 2 (5%) were treated conservatively. No patient died.

CONCLUSIONS

Reported perforations for procedures performed in endoscopic ambulatory surgery centers occurred most frequently during diagnostic colonoscopy in older woman with a history of surgery or diverticular disease. Reported perforations in endoscopic ambulatory surgery centers were uncommon.

Evaluation of endoscopic and laparoscopic training practices in surgical residency programs

BACKGROUND

The ability to adequately train surgical residents in flexible and rigid endoscopy has become a difficult challenge for program directors. The American Board of Surgery requires residents to be familiar in these procedures but the methods for training have not been well defined nor formally outlined. The goals of this study were to evaluate resident experience in flexible endoscopy and laparoscopy and to investigate the specific methods used by surgical programs for the training of residents.

METHODS

A survey was created by the authors and the Resident Education Committee of the Society of American Gastrointestinal Endoscopic Surgeons and was mailed to all program directors in general surgery in the United States based on the data base of the Association of Program Directors in Surgery (APDS).

RESULTS

Ninety-six of 283 surveys were returned (33.9%). The surgeon played a greater role in flexible endoscopic training in 1998 as compared to 1988 (p=0.002). When analyzed by type of institution, community programs showed a similar trend but this was not seen in academic programs. Formal endoscopy rotations existed in 60% of programs but flexible endoscopy (5.2%) and laparoscopy (10.4%) fellowships were uncommon. No significant differences in the number of advanced laparoscopic procedures performed were found between academic and community programs. The presence of a laparoscopic fellow did not significantly decrease the number of cases per resident.

CONCLUSION

According to our survey, surgery departments have a greater impact on flexible endoscopic training in 1998 than in 1988. This is likely due to the creation of formal endoscopy rotations and the hiring of fellowship trained endoscopic instructors. In addition, community programs have been able to provide adequate experience in both basic and advanced laparoscopic techniques as compared to academic programs. As with flexible endoscopy, however, formal laparoscopic rotations may be necessary to allow more intensive experience for each resident.

Prospective evaluation of complications in outpatient GI endoscopy: a survey among German gastroenterologists

BACKGROUND

Although most diagnostic GI endoscopic procedures in Germany are performed on an outpatient basis, there is no large-scale prospective evaluation of complication rates.

METHODS

Ninety-four gastroenterologists and internists from all regions of Germany recorded the number of EGD, colonoscopies, and polypectomies performed over a period of 1 year. All serious complications occurring in relation to the procedure, including the use of medication, were recorded in a structured protocol.

RESULTS

A total of 110,469 EGDs, 82,416 colonoscopies, and 14,249 polypectomies were evaluated. The "reach-the-cecum-rate" was 97% (median). The overall complication rates for EGD, colonoscopy, and polypectomy were low compared with published data (0.009%, 0.02%, and 0.36%, respectively). The perforation rates were 0.0009%, 0.005%, and 0.06%, respectively, the rates of significant hemorrhage 0.002%, 0.001%, and 0.26%, respectively, and the mortality rates 0.0009%, 0.001%, and 0.007%, respectively. The rates of cardiorespiratory complications associated with EGD and colonoscopy were 0.005% and 0.01%, respectively. The overall complication rate for all procedures (diagnostic and therapeutic) was lower for gastroenterologists (1 per 5155 procedures) than internists (1 per 1539 procedures). Most of the adverse events associated with diagnostic endoscopy were attributable to use of medication. The severity score ranged from 2 to 5 for most of the adverse events occurring as a result of diagnostic procedures and 2 to 50 for polypectomy. The severity sum score per 10,000 procedures was 26 for EGD, 67 for colonoscopy, and 1185 for polypectomy.

CONCLUSIONS

Outpatient endoscopy performed in practice settings by German gastroenterologists and internists is safe. The low complication rates may partly be explained by the high degree of experience resulting from the larger numbers of procedures performed relative to the numbers performed by gastroenterologists in hospitals and in other countries.

Complications of endoscopy

BACKGROUND

Although most gastrointestinal endoscopic procedures are performed by gastroenterologists, surgeons often assist in the management of patients with complications. This review provides an introduction to the incidence, prevention, and treatment of complications that may occur after upper endoscopy, colonoscopy, percutaneous endoscopic gastrostomy, and endoscopic retrograde cholangiopancreatography.

METHODS

Systematic review of the literature.

RESULTS

Preprocedural complications include medication effects and adverse effects of bowel preparation. Major procedural complications consist primarily of perforation and hemorrhage. Percutaneous endoscopic gastrostomy tube placement may be complicated by fistula and obstruction. There is also a risk of infectious disease transmission, both to and from the patient.

CONCLUSIONS

Endoscopy, like all invasive procedures, carries significant potential risks for the patient. In practiced hands, and with awareness of the problems that may arise, many complications may be avoided and others successfully managed.

A prospective analysis of 13,580 colonoscopies. Reevaluation of credentialing guidelines

BACKGROUND

The aims of this study were to assess the safety and efficacy of surgeons performing colonoscopy, and to use the results to reevaluate currently available credentialing guidelines.

METHODS

A prospective outcomes study was designed to include all members of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES). End points were related to the efficacy and safety of colonoscopy. Credentialing guidelines were reviewed.

RESULTS

Between April 1998 and September 1999 13,580 colonoscopies were prospectively entered into a database. The most common indications were rectal bleeding, colonic polyps, and change in bowel habits. The colonoscopy was normal or revealed only diverticulosis or nonspecific inflammation in 8,473 (62.4%), lower gastrointestinal bleeding in 4 (0.03%), polyps in 4,645 (34.2%), and tumors in 458 (3.4%) patients. The most common biopsy methods for polyps or tumors were the snare (n = 1,728; 34%), the hot (n = 1,600; 31%), and the cold (n = 1,340; 22%) procedures. The colonoscopy was complete in 12,495 cases (92%), requiring a mean procedure time of 22.7 min (range, 1-170 min). Intraprocedural complications included arrhythmia (n = 14; 0.1%), bradycardia (n = 115; 0.8%), hypotension (n = 171; 1.2%), and hypoxia (n = 806; 5.6%). Postprocedural complications were seen in 27 patients (0.2%). Bleeding (n = 10; 0.07%) was managed by observation alone (n = 9; 0.06%) and repeat colonoscopy with transfusion (n = 1; 0.01%). Perforation (n = 10; 0.07%) was treated successfully by observation with conservative management (n = 5; 0.05%) and surgery (n = 5; 0.05%); severe abdominal pain (n = 4; 0.03%) was managed by observation and conservative therapy; and bronchospasm (n = 2; 0.015%) was managed by observation and supportive care. One single mortality (0.007%) was that of a 70-year-old man with a massive lower gastrointestinal hemorrhage who had a cardiac arrest in the recovery room following colonoscopy. The complication rate was not significantly associated statistically with either the level of experience or the number of prior or annual colonoscopies. However, prior colonoscopic experience did have an impact on the completion rate (p < 0.001) and was inversely proportional to the time to completion (p < 0.001). Similarly, the number of annual colonoscopies affected the completion rate and was inversely correlated with the time to completion (p < 0.001).

CONCLUSIONS

This large prospective outcomes study showed that colonoscopy performed by surgeons can be rapidly and successfully done with acceptably low morbidity and mortality. There was no association between experience and complications. However, a minimum of 50 prior colonoscopies and 100 annual colonoscopies were associated with a significant improvement in the rate of completion. There was also a significant correlation between both prior and ongoing annual experience and the time required for the examination. No minimum number of cases can be mandated for credentialing to perform "safe" colonoscopies.

Medical malpractice involving colon and rectal disease: a 20-year review of United States civil court litigation

To determine objectively the causes of malpractice litigation involving colon and rectal disease, a retrospective review was undertaken of all cases tried in the U.S. federal and state civil court system over a 21-year period from 1971 through 1991. Ninety-eight malpractice cases were identified from a computerized legal data base, involving 103 allegations of negligence. Allegations fell into five major categories: 1) failure to timely diagnose disease, principally colorectal cancer and appendicitis (n = 44/103; 43 percent); 2) iatrogenic colon injury (n = 25/103; 24 percent); 3) iatrogenic medical complications during diagnosis or treatment (n = 16/103; 15 percent); 4) sphincter injury with fecal incontinence, resulting from anorectal surgery or midline episiotomy (n = 10/103; 10 percent); and 5) lack of informed consent, especially regarding extent of procedures or risk of endoscopy (n = 8/103; 8 percent). These data may aid in design of risk prevention strategies related to the diagnosis and treatment of colorectal disease.