Laparoscopic repair of colonoscopic perforations of the colon

A Case of Pneumoperitoneum after Colonoscopy without Frank Perforation

Benign pneumoperitoneum can happen after colonoscopy, which shows itself as free air in the abdomen without symptoms or pneumoperitoneum without peritonitis. In this case, we reported a rare case of an elderly man who had acute abdominal stiffness after colonoscopy and observation of free air under the diaphragm that no perforation was observed in the intestine during laparoscopy and only one tiny intestinal tumor was randomly reported. There is no consensus on the treatment of pneumoperitoneum after colonoscopy. Patients with peritonitis benefit from laparoscopy but patients with micro perforation and asymptomatic patients benefit from intravenous antibiotic treatment and bowel rest.

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.

Spontaneous Perforation of Colon in Previously Healthy Infants and Children: Its Clinical Implication

PURPOSE

Spontaneous colon perforations are usually encountered as necrotizing enterocolitis in the neonatal period, but occur rarely in infants and children without pathological conditions. This study was conducted to describe its clinical implication beyond the neonatal period.

METHODS

Cases of spontaneous colon perforation confirmed after the operation were reviewed retrospectively and the clinicopathological characteristics were analyzed. Clinical data were compared according to the presence of pneumoperitoneum as initial findings.

RESULTS

Eleven patients were included in the study period and showed a history of hospitalization before transfer due to management for fever, respiratory or gastrointestinal problems. Six patients showed a sudden onset of abdominal distention and only seven patients showed a pneumoperitoneum as initial radiologic findings, however there were no significant clinicopathological differences. Perforation was found evenly in all segments of the colon, most commonly at the sigmoid colon in four cases. There were no specific pathologic or serologic causes of perforation.

CONCLUSION

When previously healthy infants and children manifest a sustained fever with a sudden onset of abdominal distention during management for fever associated with respiratory or gastrointestinal problems, there is a great likelihood of colon perforation with no pathological condition. Prompt surgical management as timely decision-making is necessary in order to achieve a good progress.

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 direct suture of perforation after diagnostic colonoscopy

BACKGROUND

Increasing colonoscopy use increases the incidence of iatrogenic colon perforation. Operative management of iatrogenic colonoscopic perforation is diverse. This study retrospectively reviewed our experiences in treating diagnostic colonoscopy-associated bowel perforation by laparoscopic direct suturing.

METHODS

A total of 89,014 patients underwent diagnostic colonoscopy at our institution during the past 6 years. We identified 17 iatrogenic perforations (0.019 %) that were all managed by laparoscopic direct suturing.

RESULTS

Perforation patients included 11 men and 6 women (mean age 60 ± 18 years). Sixteen patients (94 %) had severe comorbidities or previous abdominal surgery. Perforations were noticed by the endoscopist during the procedure in 13 cases (76 %) while the remaining 4 cases (24 %) were diagnosed within 24 h after colonoscopy. The estimated mean longitudinal perforation length was 4.4 ± 2.1 cm. Mean operation time was 2.3 ± 0.6 h, without significant blood loss or other severe complication. The mean time to bowel function return was 3.4 ± 1.2 days, the mean time to initial oral intake was 3.9 ± 2.0 days and the mean hospitalization duration was 6.8 ± 4.2 days.

CONCLUSIONS

Diagnostic colonoscopic perforation occurred in less than 2/10,000 patients when colonoscopy was performed by experienced operators in our endoscopy center. Most of the perforation patients had severe comorbidities, to which the surgeon should pay close attention during colonoscopy. Laparoscopic primary suture of colon perforations caused by diagnostic colonoscopy is a safe and feasible repair method. Further efforts will definitively assess the feasibility of routinely using laparoscopic direct suture to repair colon perforations.

Laparoscopic management for non-traumatic colon perforation in children

PURPOSE

Although recent reports have seen an increase in acceptance of laparoscopic surgery as treatment for traumatic colon injury, its role in the management of non-traumatic colon perforation in children has not been reported. In this study, we review our experience in laparoscopic non-resectional management for children who presented with non-traumatic colonic perforation.

METHODS

Between October 2003 and May 2011, 15 children who had been diagnosed with colonic perforation and underwent laparoscopic surgery were included in the study. Their medical records were reviewed for analysis.

RESULTS

The clinical manifestation of non-traumatic colon perforation in children was non-specific. The most likely aetiology was infective colitis. Solitary perforation at the caecum was the most common finding. The exact perforation site could not be identified in 3 patients. Nine patients had primary closure while 3 patients underwent wedge resection. The single trocar laparoscopic surgery was successful in 12 patients. The mean postoperative hospital stay was 7.3 days.

CONCLUSION

For children presenting with suspected non-traumatic colon perforation, laparoscopic management is the desirable approach. The peritoneal lavage, wedge excision and primary repair can be performed with single trocar techniques and is associated with minimal morbidity. Future prospective studies are needed to compare this minimally invasive approach with conventional open surgery.

Laparoscopic perforostomy for treating a delayed colonoscopic perforation: Novel approach

INTRODUCTION:

With the implementation of bowel cancer screening programmes, more and more colonic polyps are detected, requiring hot biopsies or resections with an attendant risk of perforation. Laparoscopy is increasingly performed for assessing colonoscopic perforations, usually repaired by stitching or stapling, which is associated with a risk of a leak from the suture line.

CASE REPORT:

We describe a novel approach of laparoscopic exteriorisation of a delayed colonoscopic perforation which resolved without any further intervention.

DISCUSSION:

Laparoscopic perforostomy is an alternative minimally invasive laparoscopic approach which respects all the rules by allowing a single-stage procedure including thorough toilet with defunctioning and diversion.

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 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.

Laparoscopic repair of colonoscopic perforations: indications and guidelines

Iatrogenic colonic perforation is one of the most serious potential complications of colonoscopy. Standard management is surgical repair. No prospective data exist to clearly define the indications for laparoscopic repair. We report the largest case series to date of laparoscopic repair of colonoscopic perforations. A retrospective review was performed of all patients undergoing either exploratory laparoscopy with conversion to open repair, or laparoscopic repair of colonoscopic perforation. Exploratory laparoscopy for the attempted repair of colonoscopic perforations was performed in 11 patients at our institution. The mean colonic perforation size was 2.7 cm. Three cases were converted immediately to open laparotomy. A fourth patient that underwent primary laparoscopic repair of a 4-cm tear developed a leak at the repair site, necessitating reoperation. A fifth patient in whom exploratory laparoscopy was unrevealing underwent separate laparotomy for continued sepsis. Six patients underwent successful laparoscopic repair. Most perforations secondary to colonoscopy warrant rapid exploratory laparoscopy. Extensive inflammation or fecal soilage may require colonic diversion. Inability to laparoscopically localize the area of perforation or doubt regarding the security of the repair should prompt conversion to laparotomy. Laparoscopic repair of colonic perforations in experienced hands is a viable alternative to the open approach.

Controlled trial of immediate endoluminal closure of colon perforations in a porcine model by use of a novel clip device (with videos)

BACKGROUND

Although endoluminal closure of a small perforation of the colon is technically feasible, the outcome of such a closure is unclear.

OBJECTIVE

Our purpose was to evaluate the feasibility and the outcome of endoluminal closure of a small perforation of the colon with a novel clip device, the InScope MultiClip Applier (IMCA), and to assess the number of clips required for successful closure.

DESIGN

Prospective controlled study.

SETTING

University hospital.

ANIMALS

17 pigs.

INTERVENTIONS

A 2-cm full-thickness colon perforation was randomized to 3 groups: control, no closure (n = 4), 2-clip closure (n = 7), and 4-clip closure (n = 6).

MAIN OUTCOME MEASUREMENTS

(1) Technical feasibility of closure, (2) closure time, (3) clinical monitoring for 2 weeks, (4) necropsy (day 14), and (5) healing by a dye leak test and histologic examination.

RESULTS

Endoscopic closure of the colon perforation was technically successful in 12 of 13 animals. A wide gaping hole prevented satisfactory closure in 1 animal. The median time for closure with 2 and 4 clips was 2 and 3 minutes, respectively. Clip closure of perforation prevented clinical sepsis (P = .008) and diminished the risk for fibrinous peritonitis (P = .02 for a single test of hypothesis; however, correction for the multiple testing of data removes this significance) and adhesion formation (P = .008) compared with controls, without any leakage. The outcomes of 2- and 4-clip closure were similar.

CONCLUSIONS

Endoluminal closure of a 2-cm colon perforation with clips is successful in preventing peritonitis and adhesions and it can be accomplished quickly with this novel device. Clip closure at 1-cm intervals is sufficient for successful closure of a 2-cm colon perforation.

Endoluminal closure of large perforations of colon with clips in a porcine model (with video)

BACKGROUND

Endoluminal clip closure of small perforations of the colon is possible. It is unclear whether large perforations of the colon can be closed with clips deployed through a colonoscope.

OBJECTIVES

To evaluate the technical feasibility and outcome of endoluminal closure of large perforations of the colon with clips.

DESIGN

Pilot study.

SUBJECTS

Eight pigs.

INTERVENTIONS

Endoluminal clip closure of large perforations of the colon.

MAIN OUTCOME MEASUREMENTS

Technical feasibility of endoluminal closure was evaluated in 8 animals. A dye leak test was performed to evaluate quality of endoluminal sealing immediately after closure and 2 weeks after closure. The animals in the survival group were monitored daily for 2 weeks for sepsis and peritonitis. Necropsy was done on day 14 to check for fecal peritonitis, wound dehiscence, and histological healing of perforation.

RESULTS

Endoscopic closure of colon perforation was successful in 6 of 8 animals; in 2 animals closure was unsuccessful due to prolapse of adjacent viscera into the colon (n = 1) and severe bleeding that obscured the view (n = 1). There was a leak-proof sealing of the perforation site in 2 animals tested immediately and in all the animals tested (n = 3) 2 weeks after closure. All 4 animals in the survival group recovered well, without any sepsis or peritonitis. Necropsy did not reveal fecal peritonitis or pericolonic abscess formation. The perforation site demonstrated a thin scar and there was histological healing.

CONCLUSIONS

Endoluminal application of clips is successful in the closure of a large perforation of the colon in a porcine model.

Immediate endoscopic closure of colon perforation by using a prototype endoscopic suturing device: feasibility and outcome in a porcine model (with video)

BACKGROUND

Perforation is an uncommon but potentially devastating complication of colonoscopy. Surgical closure is the standard of care. Immediate endoluminal closure of a perforation would avoid the morbidity and mortality associated with general anesthesia, laparotomy, and surgical repair.

OBJECTIVES

To evaluate the feasibility and safety of full-thickness endoscopic closure of colonic perforations with a prototype endoscopic suturing device, the Eagle Claw, in a porcine model.

DESIGN

Endoscopic animal experimental study of closure of colon perforation by using a porcine model.

SUBJECTS

Ten pigs were included in the study.

INTERVENTIONS

The Eagle Claw was used to close small perforations (1.5 to 2 cm) of the colon created by needle-knife with the animal under general anesthesia by using the endoluminal route. All animals received intravenous antibiotics and were allowed to eat after 24 hours.

MAIN OUTCOME MEASUREMENTS

The animals were monitored daily for signs of sepsis and peritonitis. On day 7, they were euthanized. The peritoneal cavity was examined for fecal peritonitis, and the colon perforation site was checked for wound dehiscence and pericolic abscess formation.

RESULTS

Endoscopic closure of the colon perforation was successful in 7 animals, and they recovered well without any sepsis or peritonitis. Necropsy did not reveal fecal peritonitis or pericolonic abscess formation at the site of perforation, and the perforation healed well. Closure was successful in 1 animal, but necropsy revealed dehiscence of the colon perforation site. Endoscopic closure was unsuccessful in 2 animals, and these were euthanized immediately.

CONCLUSIONS

Closure of acute perforation of the colon is feasible with the Eagle Claw endoscopic suturing device in a porcine model.

Colonoscopic perforations: a retrospective review

Colonic perforation is no longer a rare complication of colonoscopy. Our previous report identified 45 such iatrogenic injuries from 1980 through 1994 (3082 colonoscopies per year). This follow-up of the ensuing 7 years examines changing trends of endoscopic usage in addition to management and prognosis of patients with colonoscopic perforations. Retrospective analysis of 78,702 colonoscopies (1994 through 2000, 11,243 colonoscopies per year) allowed assessment of medical records in all patients treated at our institution for colonic perforation. Sixty-six patients from our institution (perforation rate, 0.084%; 1 per 1192 procedures) and six patients from outside institutions were treated for colonic perforation following colonoscopy (41 women, 31 men; ages, 30-92 years; median, 73 years). Sixty-two patients underwent laparotomy, while 10 were managed nonoperatively. All 10 patients managed nonoperatively were void of peritoneal irritation by physical examination; eight patients did well (median hospital stay, 5.5 days; range, 0-12), but one death (family declined operative intervention) and one pelvic abscess requiring percutaneous drainage were noted. Peritoneal irritation by physical examination was evident in 57 of 62 patients undergoing laparotomy. Perforations occurred throughout the colon: right, 22 (31%); transverse, 5 (7%); left, 44 (61%); and unknown, 1 (1%). Thirty-eight patients (61%) underwent primary repair or resection with anastomosis. Fecal diversion was used in 100% of patients with extensive peritoneal contamination (n = 12) and 40% of patients with moderate contamination (12 of 30). Perioperative morbidity (39%) and mortality (8%) were significant. Factors predicting a poor outcome included delayed diagnosis, extensive peritoneal contamination, and patients using anticoagulants (P < .05). Compared with our prior study, the present review highlights a higher prevalence of injury based on more frequent use of colonoscopy. Perforation rates remain around 0.08%. While nonoperative management is viable in patients void of peritonitis, expedient surgical intervention seems to facilitate patient recovery.

A pilot study of endoscopic closure of colonic perforations with endoclips in a swine model

BACKGROUND

Surgical closure of a colon perforation is accompanied by the risks of general anesthesia and prolonged recovery from surgery because of ileus and other sequelae. Very little is known about the effectiveness of endoluminal repair of colon perforations with clips, which eliminates incisions of the abdominal wall and provides a less invasive alternative to surgical closure. The aim of this study is to evaluate the feasibility and the safety of endoscopic closure of colonic perforations with endoclips in a porcine model.

METHODS

Approximately 1.5- to 2-cm colon perforations created with a needle knife in 4 50-kg, female pigs that were under general anesthesia were closed with endoclips. After 24 hours of recovery, the animals were allowed to eat. All the animals received intravenous antibiotics and were carefully monitored for signs of sepsis. After a follow-up of 1 week, the pigs were euthanized for postmortem examination. The fifth pig was euthanized immediately after closure of a 5-cm colon perforation with clips to evaluate the extent of transmural closure with endoclips.

RESULTS

The animals recovered well, without any clinical features of sepsis or peritonitis. Postmortem examination did not reveal fecal peritonitis, and there was no evidence of pericolonic abscess formation at the site of perforation. The perforation site showed signs of healing without any evidence of transmural dehiscence. Histopathology demonstrated granulation tissue bridging the site of perforation. In the fifth pig, euthanized immediately after closure of the perforation, nice mucosal apposition was seen, while the muscular and serosal coats remained dehisced.

CONCLUSIONS

Endoscopic closure of small iatrogenic colon perforations with clips results in mucosal and submucosal healing and prevents fecal soiling of peritoneal cavity.

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.

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Laparoscopic-assisted repair of extensive rectosigmoid injury after colonoscopy

Treatment of colonic injury has progressed since the recognition of the value of colostomy or bowel exteriorization during the second World War. The treatment guidelines take into consideration the time interval between perforation and treatment as well as the nature, the site, and the cause of perforation. Laparoscopic primary repair of relatively small colonic perforations without spillage of bowel content has been reported. Extensive large bowel injury with appreciable colonic spillage usually requires a laparotomy and diversion. We report a case of a 57-year-old woman who presented with extensive rectosigmoid injury and colonic spillage after colonoscopy and was treated using laparoscopic assistance.

Management of cecal perforation secondary to Ogilvie's syndrome by laparoscopic tube cecostomy

Acute pseudoobstruction of the colon (Ogilvie's syndrome) rarely leads to perforation of the colon. A case of such a perforation is described that was successfully managed laparoscopically with tube cecostomy.