Endoscopic perforation of the colon: lessons from a 10-year study

Painless colonoscopy: fact or fiction?

Although colonoscopy is a routinely performed procedure, it is not devoid of challenges, such as the potential for perforation and considerable patient discomfort, leading to patients postponing the procedure with several healthcare risks. This review delves into preprocedural and procedural solutions, and emerging technologies aimed at addressing the drawbacks of colonoscopies. Insufflation and sedation techniques, together with various other methods, have been explored to increase patient satisfaction, and thereby, the quality of endoscopy. Recent advances in this field include the prevention of loop formation, encompassing the use of variable-stiffness endoscopes, computer-guided scopes, magnetic endoscopic imaging, robotics, and capsule endoscopy. An autonomous endoscope that relies on self-propulsion to completely avoid looping is a potentially groundbreaking technology for the next generation of endoscopes. Nevertheless, critical techniques need to be refined to ensure the development of effective and efficient endoscopes.

Air Nozzle Injury: Barotrauma Resulted From an Industrial Accident

Industrial accidents involving compressed air can lead to significant colonic injuries, ranging from minor tears to complete perforations. This study investigates a case of colonic barotrauma in a 40-year-old male oil refinery worker who suffered symptoms of lower abdominal discomfort, distension, and tenderness following the application of compressed air to his anus. Diagnostic tests, including blood count, abdominal X-ray, and ultrasonography, indicated fecal impaction, dilated bowel loops, and free gas under the diaphragm. An exploratory laparotomy revealed a 4 cm x 2 cm hole in the colon at the hepatic flexure. There were also small breaks in the mucosa at the junction of the recto-sigmoid. We surgically repaired the perforation with primary closure, metrogyl lavage, and the placement of an intra-abdominal pelvic drain. Two weeks later, the patient recovered without any complications and was discharged. This case report highlights the severe risks of non-medical compressed air exposure, as well as the critical need for immediate surgical intervention and preventive safety measures in industrial settings.

Colorectal cancer screening at age 45 years in Israel: Cost-effectiveness and global implications

BACKGROUND

Colorectal cancer (CRC) incidence at ages <50 years is increasing worldwide. Screening initiation was lowered to 45 years in the United States. The cost-effectiveness of initiating CRC screening at 45 years in Israel was assessed with the aim of informing national policy and addressing internationally relevant questions.

METHODS

A validated CRC screening model was calibrated to Israeli data and examined annual fecal immunochemical testing (FIT) or colonoscopy every 10 years from 45 to 74 years (FIT45-74 or Colo45-74) versus from 50 to 74 years (FIT50-74 or Colo50-74). The addition of a fourth colonoscopy at 75 years was explored, subanalyses were performed by sex/ethnicity, and resource demands were estimated.

RESULTS

FIT50-74 and Colo50-74 reduced CRC incidence by 57% and 70% and mortality by 70% and 77%, respectively, versus no screening, with greater absolute impact in Jews/Other versus Arabs but comparable relative impact. FIT45-74 further reduced CRC incidence and mortality by an absolute 3% and 2%, respectively. With Colo45-74 versus Colo50-74, CRC cases and deaths increased slightly as three colonoscopies per lifetime shifted to 5 years earlier but mean quality-adjusted life-years gained (QALYGs) per person increased. FIT45-74 and Colo45-74 cost 23,800-53,900 new Israeli shekels (NIS)/QALYG and 110,600-162,700 NIS/QALYG, with the lowest and highest values among Jewish/Other men and Arab women, respectively. A fourth lifetime colonoscopy cost 48,700 NIS/QALYG. Lowering FIT initiation to 45 years with modest participation required 19,300 additional colonoscopies in the first 3 years.

CONCLUSIONS

Beginning CRC screening at 45 years in Israel is projected to yield modest clinical benefits at acceptable costs per QALYG. Despite different estimates by sex/ethnicity, a uniform national policy is favored. These findings can inform Israeli guidelines and serve as a case study internationally.

Impact of prophylactic wound closure in colorectal ESD on postoperative wound complications: A meta-analysis

Endoscopic submucosa dissection (ESD) has been applied extensively in the treatment of large intestine tumours due to its high total excision ratio. Nevertheless, there is a high incidence of adverse reactions in colon ESD, and the efficacy of prophylactic ESD following ESD in prevention of postoperative haemorrhage is still disputed. The purpose of this meta-analysis is to evaluate the effectiveness of prophylaxis of wound closure in large intestine ESD after operation. For eligibility, we looked through three databases: PubMed, Embase and Cochrane Library. Heterogenity was measured by means of a chi-square method of Q-statistic and an I2 test. Fixed or random effects models were used for data processing. Based on the retrieval policy, we found a total of 1286 papers, and then we collected nine papers to extract the data. Regarding postoperative haemorrhage, there was a significant reduction in the risk of wound haemorrhage in the wound closure group than in the control group (OR, 0.29; 95% CI, 0.19-0.44 p < 0.0001). No statistical significance was found in the incidence of perforation in the wound closure and the control group (OR, 0.45; 95% CI, 0.19-1.03 p = 0.06). There was a significant reduction in the incidence of postoperation fever among those in the wound closure group than in the control group (OR, 0.37; 95% CI, 0.15-0.93 p = 0.04). Preventive endoscopic closure decreased the rate of ESD in colon disease, but did not significantly decrease the rate of postoperation perforation and postoperative fever. Future research will be required to clarify the risk factors and classify high-risk individuals in order to formulate a cost-effective prevention strategy.

Training in basic gastrointestinal endoscopic procedures: a European Society of Gastrointestinal Endoscopy (ESGE) and European Society of Gastroenterology and Endoscopy Nurses and Associates (ESGENA) Position Statement

This ESGE Position Statement provides structured and evidence-based guidance on the essential requirements and processes involved in training in basic gastrointestinal (GI) endoscopic procedures. The document outlines definitions; competencies required, and means to their assessment and maintenance; the structure and requirements of training programs; patient safety and medicolegal issues. 1:  ESGE and ESGENA define basic endoscopic procedures as those procedures that are commonly indicated, generally accessible, and expected to be mastered (technically and cognitively) by the end of any core training program in gastrointestinal endoscopy. 2:  ESGE and ESGENA consider the following as basic endoscopic procedures: diagnostic upper and lower GI endoscopy, as well as a limited range of interventions such as: tissue acquisition via cold biopsy forceps, polypectomy for lesions ≤ 10 mm, hemostasis techniques, enteral feeding tube placement, foreign body retrieval, dilation of simple esophageal strictures, and India ink tattooing of lesion location. 3:  ESGE and ESGENA recommend that training in GI endoscopy should be subject to stringent formal requirements that ensure all ESGE key performance indicators (KPIs) are met. 4:  Training in basic endoscopic procedures is a complex process and includes the development and acquisition of cognitive, technical/motor, and integrative skills. Therefore, ESGE and ESGENA recommend the use of validated tools to track the development of skills and assess competence. 5:  ESGE and ESGENA recommend incorporating a multimodal approach to evaluating competence in basic GI endoscopic procedures, including procedural thresholds and the measurement and documentation of established ESGE KPIs. 7:  ESGE and ESGENA recommend the continuous monitoring of ESGE KPIs during GI endoscopy training to ensure the trainee's maintenance of competence. 9:  ESGE and ESGENA recommend that GI endoscopy training units fulfil the ESGE KPIs for endoscopy units and, furthermore, be capable of providing the dedicated personnel, infrastructure, and sufficient case volume required for successful training within a structured training program. 10:  ESGE and ESGENA recommend that trainers in basic GI endoscopic procedures should be endoscopists with formal educational training in the teaching of endoscopy, which allows them to successfully and safely teach trainees.

Robotic Colonoscopy and Beyond: Insights into Modern Lower Gastrointestinal Endoscopy

Lower gastrointestinal endoscopy is considered the gold standard for the diagnosis and removal of colonic polyps. Delays in colonoscopy following a positive fecal immunochemical test increase the likelihood of advanced adenomas and colorectal cancer (CRC) occurrence. However, patients may refuse to undergo conventional colonoscopy (CC) due to fear of possible risks and pain or discomfort. In this regard, patients undergoing CC frequently require sedation to better tolerate the procedure, increasing the risk of deep sedation or other complications related to sedation. Accordingly, the use of CC as a first-line screening strategy for CRC is hampered by patients' reluctance due to its invasiveness and anxiety about possible discomfort. To overcome the limitations of CC and improve patients' compliance, several studies have investigated the use of robotic colonoscopy (RC) both in experimental models and in vivo. Self-propelling robotic colonoscopes have proven to be promising thanks to their peculiar dexterity and adaptability to the shape of the lower gastrointestinal tract, allowing a virtually painless examination of the colon. In some instances, when alternatives to CC and RC are required, barium enema (BE), computed tomographic colonography (CTC), and colon capsule endoscopy (CCE) may be options. However, BE and CTC are limited by the need for subsequent investigations whenever suspicious lesions are found. In this narrative review, we discussed the current clinical applications of RC, CTC, and CCE, as well as the advantages and disadvantages of different endoscopic procedures, with a particular focus on RC.

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.

Adverse events of endoscopic full-thickness resection: results from the German and Dutch nationwide colorectal FTRD registry

BACKGROUND AND AIMS

Endoscopic full-thickness resection (eFTR) is emerging as a minimally invasive alternative to surgery for complex colorectal lesions. Previous studies have demonstrated favorable safety results; however, large studies representing a generalizable estimation of adverse events (AEs) are lacking. Our aim was to provide further insight in AEs after eFTR.

METHODS

Data from all registered eFTR procedures in the German and Dutch colorectal full-thickness resection device registries between July 2015 and March 2021 were collected. Safety outcomes included immediate and late AEs.

RESULTS

Of 1892 procedures, the overall AE rate was 11.3% (213/1892). No AE-related mortality occurred. Perforations occurred in 2.5% (47/1892) of all AEs, 57.4% (27/47) of immediate AEs, and 42.6% (20/47) of delayed AEs. Successful endoscopic closure was achieved in 29.8% of cases (13 immediate and 1 delayed), and antibiotic treatment was sufficient in 4.3% (2 delayed). The appendicitis rate for appendiceal lesions was 9.9% (13/131), and 46.2% (6/13) could be treated conservatively. The severe AE rate requiring surgery was 2.2% (42/1892), including delayed perforations in .9% (17/1892) and immediate perforations in .7% (13/1892). Delayed perforations occurred between days 1 and 10 (median, 2) after eFTR, and 58.8% (10/17) were located on the left side. Other severe AEs were appendicitis (.4%, 7/1892), luminal stenosis (.1%, 2/1892), delayed bleeding (.1%, 1/1892), pain after eFTR close to the dentate line (.1%, 1/1892), and grasper entrapment in the clip (.1%, 1/1892).

CONCLUSIONS

Colorectal eFTR is a safe procedure with a low risk for severe AEs in everyday practice and without AE-related mortality. These results further support the position of eFTR as an established minimally invasive technique for complex colorectal lesions.

Characteristics and endoscopic treatment of interventional and non-interventional iatrogenic colorectal perforations in centers with high endoscopic expertise: a retrospective multicenter study

BACKGROUND

Iatrogenic colorectal perforation is a rare event with a relevant mortality and the need for surgical therapy in around ¾ of cases.

METHODS

In this retrospective multicentric cohort study iatrogenic colorectal perforations from 2004 to 2021 were analyzed. Primary outcome parameters were incidence and clinical success of 1st line endoscopic treatment. Comparative analysis of interventional and non-interventional perforations was performed and predictors for clinical success of endoscopic therapy were identified.

RESULTS

From 103,570 colonoscopies 213 (0.2%) iatrogenic perforations were identified. 68.4% were interventional (80 during polypectomy/EMR, 54 during ESD and 11 for other reasons) and 31.6% non-interventional perforations (39 by the tip, 19 by the shaft, 7 by inversion, two by biopsy and one by distension). Incidence of 1st line endoscopic therapy was 61.0% and clinical success 81.5%. Other non-surgical therapies were conducted in 8.9% with clinical success in 94.7% of cases. In interventional perforations both incidence and clinical success of 1st line endoscopic therapy were significantly higher compared to non-interventional perforations [71.7% vs. 38.2% (p < 0.01) resp. 86.5% vs. 61.5% (p < 0.01)]. Mortality was 2.3% and significantly lower in the group of interventional perforations (0.7% vs. 5.9%, p = 0.037). Multivariable analysis revealed perforation size < 5 mm as only independent predictor for clinical success of 1st line endoscopic treatment [OR 14.85 (1.57-140.69), p = 0.019].

CONCLUSIONS

Endoscopic therapy is treatment of choice in the majority of iatrogenic colorectal perforations. In case of interventional perforations it is highly effective but only a minority of non-interventional perforations are good candidates for endoscopic treatment.

Endoscopic Balloon Dilation of Strictures: Techniques, Short- and Long-Term Outcomes, and Complications

EBD is safe and effective for the treatment of strictures. Here we describe the technique of endoscopic balloon dilation (EBD) of strictures including preprocedure considerations, indications, contraindications, and postprocedure complications. The short- and long-term outcomes of EBD including factors associated with improved outcomes are also discussed.

Iatrogenic colon perforation during colonoscopy, diagnosis/treatment, and follow-up processes: A single-center experience

Objectives

latrogenic colon perforation (ICP) is one of the most feared complications of colonoscopy and causes unwanted morbidity and mortality. In this study, we aimed to discuss the characteristics of the cases of ICP we encountered in our endoscopy clinic, its etiology, our treatment approaches, and results in the light of the current literature.

Material and Methods

We retrospectively evaluated the cases of ICP among 9.709 lower gastrointestinal system endoscopy procedures (colonoscopy + rectosigmoidoscopy) performed for diagnostic purposes in our endoscopy clinic during 2002-2020.

Results

A total of seven cases of ICP were detected. The diagnosis was made during the procedure in six patients and after eight hours in one patient, and their treatment was performed urgently. Whereas surgical procedures were performed in all patients, the type of the procedure varied; laparoscopic primary repair was performed in two patients and laparotomy in five patients. In the patients who underwent laparotomy, primary repair was performed in three patients, partial colon resection and end-to-end anastomosis in one patient, and loop colostomy in one patient. The patients were hospitalized for an average of 7.14 days. The patients who did not develop complications in the postoperative follow-up were discharged with full recovery.

Conclusion

Prompt diagnosis and appropriate treatment of ICP is crucial to prevent morbidity and mortality.

Longitudinal assessment of colonoscopy adverse events in the prospective Cooperative Studies Program no. 380 colorectal cancer screening and surveillance cohort

BACKGROUND AND AIMS

Data are limited regarding colonoscopy risk during long-term, programmatic colorectal cancer screening and follow-up. We aimed to describe adverse events during follow-up in a colonoscopy screening program after the baseline examination and examine factors associated with increased risk.

METHODS

Cooperative Studies Program no. 380 includes 3121 asymptomatic veterans aged 50 to 75 years who underwent screening colonoscopy between 1994 and 1997. Periprocedure adverse events requiring significant intervention were defined as major events (other events were minor) and were tracked during follow-up for at least 10 years. Multivariable odds ratios (ORs) were calculated for factors associated with risk of follow-up adverse events.

RESULTS

Of 3727 follow-up examinations in 1983 participants, adverse events occurred in 105 examinations (2.8%) in 93 individuals, including 22 major and 87 minor events (examinations may have had >1 event). Incidence of major events (per 1000 examinations) remained relatively stable over time, with 6.1 events at examination 2, 4.8 at examination 3, and 7.2 at examination 4. Examinations with major events included 1 perforation, 3 GI bleeds requiring intervention, and 17 cardiopulmonary events. History of prior colonoscopic adverse events was associated with increased risk of events (major or minor) during follow-up (OR, 2.7; 95% confidence interval, 1.6-4.6).

CONCLUSIONS

Long-term programmatic screening and surveillance was safe, as major events were rare during follow-up. However, serious cardiopulmonary events were the most common major events. These results highlight the need for detailed assessments of comorbid conditions during routine clinical practice, which could help inform individual decisions regarding the utility of ongoing colonoscopy follow-up.

Digestive perforations related to endoscopy procedures: a local management charter based on local evidence and experts' opinion

Background and study aims  Perforations are a known adverse event of endoscopy procedures; a proposal for appropriate management should be available in each center as recommended by the European Society of Gastrointestinal Endoscopy. The objective of this study was to establish a charter for the management of endoscopic perforations, based on local evidence. Patients and methods  Patients were included if they experienced partial or complete perforation during an endoscopic procedure between 2008 and 2018 (retrospectively until 2016, then prospectively). Perforations (size, location, closure) and management (imagery, antibiotics, surgery) were analyzed. Using these results, a panel of experts was asked to propose a consensual management charter. Results  A total of 105 patients were included. Perforations occurred mainly during therapeutic procedures (91, 86.7%). Of the perforations, 78 (74.3 %) were diagnosed immediately and managed during the procedure; 69 of 78 (88.5 %) were successfully closed. Closures were more effective during therapeutic procedures (60 of 66, 90.9 %) than during diagnostic procedures (9 of 12, 75.0 %, P  = 0.06). Endoscopic closure was effective for 37 of 38 perforations (97.4 %) < 0.5 cm, and for 26 of 34 perforations (76.5 %) ≥ 0.5 cm ( P  < 0.05). For perforations < 0.5 cm, systematic computed tomography (CT) scan, antibiotics, or surgical evaluation did not improve the outcome. Four of 105 deaths (3.8 %) occurred after perforation, one of which was attributable to the perforation itself. Conclusions  Detection and closure of perforations during endoscopic procedure had a better outcome compared to delayed perforations; perforations < 0.5 cm had a very good prognosis and CT scan, surgeon evaluation, or antibiotics are probably not necessary when the endoscopic closure is confidently performed. This work led to proposal of a local management charter.

Colonic Wall Injuries After Endoscopic Resection: Still a Major Complication? A Retrospective Analysis of 3782 Endoscopic Resections

BACKGROUND

Colonic wall injuries are the most feared adverse events of endoscopic resections among endoscopists. The implementation of endoscopic closure has offered a reliable way to treat such injuries and, thus, has decreased their overall morbidity and mortality.

OBJECTIVES

The aim of our study is to assess the characteristics and outcomes of colonic wall injuries after endoscopic resection, focusing on the endoscopic treatment of these injuries.

DESIGN

This was a retrospective cohort study.

SETTINGS

Patients treated in the Central Endoscopy Unit of the Medical Centre Mannheim were included.

PATIENTS

We retrospectively analyzed all patients who underwent endoscopic mucosal resection and snare polypectomy in our center between 2004 and 2019 and isolated the resection-related colonic wall injuries. These were divided into 3 groups: group A, endoscopically treated early colonic wall injuries; group B, nonendoscopically treated early colonic wall injuries; and group C, late perforations.

MAIN OUTCOME MEASURES

Periprocedural factors and treatment outcomes were analyzed and compared among the 3 groups.

RESULTS

Of 3782 endoscopic resections, we identified 177 cases of colonic wall injuries, of which 148 were identified and treated endoscopically (group A), 9 were identified during the procedure but could not be treated endoscopically (group B), and 20 were late perforations (group C). Endoscopic treatment with use of clips had a technical success rate of 94.3%, while the clinical success rate of technically complete endoscopic closure was 92.6%. Twenty-two percent of all colonic wall injuries required surgical treatment; the type and outcomes of surgery were similar in all groups. Overall hospital stay was significantly lower in group A.

LIMITATIONS

The main limitation of the study is its retrospective design.

CONCLUSIONS

Endoscopic closure with the use of clips is a safe and feasible treatment for intraprocedurally identified colonic wall injuries and is associated with significantly decreased necessity of surgery, morbidity, and hospital stay. See Video Abstract at http://links.lww.com/DCR/B755.

LESIONES DE PARED COLNICA POSTERIOR A RESECCIN ENDOSCPICA ES AN UNA COMPLICACIN IMPORTANTE ANLISIS RETROSPECTIVO DE RESECCIONES ENDOSCPICAS

ANTECEDENTES:Las lesiones de la pared del colon son los eventos adversos más temidos por los endoscopistas durante las resecciones endoscópicas. La implementación del cierre endoscópico ha ofrecido una forma confiable de tratar tales lesiones y, por lo tanto, disminuyendo su morbilidad y mortalidad general.OBJETIVOS:El objetivo de nuestro estudio es evaluar las características y resultados de las lesiones de la pared colónica posterior a la resección endoscópica, centrándose en su tratamiento endoscópico.DISEÑO:Es un estudio de cohorte retrospectivo.ENTORNO CLÍNICO:Se incluyeron pacientes tratados en la Unidad Central de Endoscopia del Centro Médico de Mannheim.PACIENTES:Se analizaron retrospectivamente todos los pacientes sometidos a resección endoscópica de la mucosa y polipectomía en asa en nuestro centro entre 2004 y 2019, seleccionando las lesiones de la pared colónica relacionadas a la resección. Estas se dividieron en tres grupos: Grupo A: lesiones tempranas de la pared colónica tratadas endoscópicamente; Grupo B: lesiones tempranas de la pared colónica no tratadas endoscópicamente; y Grupo C: perforaciones tardías.PRINCIPALES MEDIDAS DE VALORACION:Se analizaron y compararon los factores relacionados al procedimiento y los resultados del tratamiento entre los tres grupos.RESULTADOS:De 3782 resecciones endoscópicas identificamos 177 casos de lesiones de la pared colónica, de los cuales 148 fueron identificados y tratados endoscópicamente (Grupo A), 9 fueron identificados durante el procedimiento pero no pudieron ser tratados endoscópicamente (Grupo B) y 20 fueron perforaciones tardías. (Grupo C). El tratamiento endoscópico con el uso de clips tuvo una tasa de éxito técnico del 94,3%, mientras que la tasa de éxito clínico del cierre endoscópico técnicamente completo fue del 92,6%. El veintidós por ciento de todas las lesiones de la pared colónica requirieron tratamiento quirúrgico; el tipo y los resultados de la cirugía fueron los mismos en todos los grupos. La estancia hospitalaria global fue significativamente menor en el grupo A.LIMITACIONES:La principal limitación del estudio es su diseño retrospectivo.CONCLUSIONES:El cierre endoscópico con el uso de clips es un tratamiento seguro y factible para las lesiones de la pared colónica identificadas durante el procedimiento y se asocia con una disminución significativa de la necesidad de cirugía, morbilidad y de estancia hospitalaria. Consulte Video Resumen en http://links.lww.com/DCR/B755.

Pediatric Endoscopy Quality Improvement Network Quality Standards and Indicators for Pediatric Endoscopy Facilities: A Joint NASPGHAN/ESPGHAN Guideline

INTRODUCTION

There is increasing international recognition of the impact of variability in endoscopy facilities on procedural quality and outcomes. There is also growing precedent for assessing the quality of endoscopy facilities at regional and national levels by using standardized rating scales to identify opportunities for improvement.

METHODS

With support from the North American and European Societies of Pediatric Gastroenterology Hepatology and Nutrition (NASPGHAN and ESPGHAN), an international working group of the Pediatric Endoscopy Quality Improvement Network (PEnQuIN) used the methodological strategy of the Appraisal of Guidelines for REsearch and Evaluation (AGREE) II instrument to develop standards and indicators relevant for assessing the quality of facilities where endoscopic care is provided to children. Consensus was reached via an iterative online Delphi process and subsequent in-person meeting. The quality of evidence and strength of recommendations were rated according to the GRADE (Grading of Recommendation Assessment, Development and Evaluation) approach.

RESULTS

The PEnQuIN working group achieved consensus on 27 standards for facilities supporting pediatric endoscopy, as well 10 indicators that can be used to identify high-quality endoscopic care in children. These standards were subcategorized into three subdomains: Quality of Clinical Operations (15 standards, 5 indicators); Patient and Caregiver Experience (9 standards, 5 indicators); and Workforce (3 standards).

DISCUSSION

The rigorous PEnQuIN process successfully yielded standards and indicators that can be used to universally guide and measure high-quality facilities for procedures around the world where endoscopy is performed in children. It also underscores the current paucity of evidence for pediatric endoscopic care processes, and the need for research into this clinical area.

Current endoscopic closure techniques for the management of gastrointestinal perforations

Acute gastrointestinal perforations occur either from spontaneous or iatrogenic causes. However, particular attention should be made in acute iatrogenic perforations as timely diagnosis and endoscopic closure prevent morbidity and mortality. With the increasing use of diagnostic endoscopy and advances in therapeutic endoscopy worldwide, the endoscopist must be able to recognize and manage perforations. Depending on the size and location of the defect, a variety of endoscopic clips, stents, and suturing devices are available. This review aims to prepare and guide the endoscopist to use the right tools and techniques for optimal patient outcomes.

Colorectal Cancer Screening: Have We Addressed Concerns and Needs of the Target Population?

Despite the recognized benefits of colorectal cancer (CRC) screening, uptake is still suboptimal in many countries. In addressing this issue, one important element that has not received sufficient attention is population preference. Our review provides a comprehensive summary of the up-to-date evidence relative to this topic. Four OVID databases were searched: Ovid MEDLINE® ALL, Biological Abstracts, CAB Abstracts, and Global Health. Among the 742 articles generated, 154 full texts were selected for a more thorough evaluation based on predefined inclusion criteria. Finally, 83 studies were included in our review. The general population preferred either colonoscopy as the most accurate test, or fecal occult blood test (FOBT) as the least invasive for CRC screening. The emerging blood test (SEPT9) and capsule colonoscopy (nanopill), with the potential to overcome the pitfalls of the available techniques, were also favored. Gender, age, race, screening experience, education and beliefs, the perceived risk of CRC, insurance, and health status influence one’s test preference. To improve uptake, CRC screening programs should consider offering test alternatives and tailoring the content and delivery of screening information to the public’s preferences. Other logistical measures in terms of the types of bowel preparation, gender of endoscopist, stool collection device, and reward for participants can also be useful.

Clinical practice standards for colonoscopy

Colonoscopy is considered as the most effective tool for preventing, screening, and diagnosing colorectal lesions. Effectiveness of colonoscopy was identified as a major priority, and it strictly depends on quality measures. Therefore, international guidelines were formulated on quality indicators for colonoscopy, aiming to reduce the rate of interval cancers related to missed lesions during colonoscopy. Quality indicators are divided into 3 time periods: preprocedure, intraprocedure, and postprocedure.  The main pre-procedural indicators are the assessment of the appropriateness of indication of colonoscopy and the prescription of adequate bowel preparation during a consultation prior to colonoscopy. Per-procedural criteria include all technical aspects of the procedure, which are "endoscopist-dependent" factors, particularly cecal intubation, detection of adenomas and withdrawal time. The main post-procedure indicators are the rate of complications, patient experience and optimal surveillance intervals following removal of colorectal polyps. The implementation of key performance measures in endoscopy practice is increasingly important as it can help improving our care of patients and optimize outcomes. In this review, the "Club d'endoscopie digestive" (CED) presented a summary of the main colonoscopy quality indicators, and suggested recommendations that took into account the particularities of our local conditions.

Current understanding of the impact of COVID-19 on gastrointestinal disease: Challenges and openings

The novel coronavirus disease-2019 (COVID-19) is caused by a positive-sense single-stranded RNA virus which belongs to the Coronaviridae family. In March 2019 the World Health Organization declared that COVID-19 was a pandemic. COVID-19 patients typically have a fever, dry cough, dyspnea, fatigue, and anosmia. Some patients also report gastrointestinal (GI) symptoms, including diarrhea, nausea, vomiting, and abdominal pain, as well as liver enzyme abnormalities. Surprisingly, many studies have found severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) viral RNA in rectal swabs and stool specimens of asymptomatic COVID-19 patients. In addition, viral receptor angiotensin-converting enzyme 2 and transmembrane protease serine-type 2, were also found to be highly expressed in gastrointestinal epithelial cells of the intestinal mucosa. Furthermore, SARS-CoV-2 can dynamically infect and replicate in both GI and liver cells. Taken together these results indicate that the GI tract is a potential target of SARS-CoV-2. Therefore, the present review summarizes the vital information available to date on COVID-19 and its impact on GI aspects.

A Novel Bipolar Polypectomy Snare Can Be an Alternative Choice for Endoscopic Resection

Objective: Endoscopic resection (ER) is more difficult and has a higher rate of complications, such as perforation and bleeding. The aim of this study was to evaluate the safety and feasibility of a bipolar polypectomy snare for ER.

Methods: Initial ER procedures in live pigs were carried out. Then, a human feasibility study was performed in patients with colorectal polyps. Finally, the finite element method was used to evaluate the safety and effectiveness of the new bipolar snare.

Results: In the live animal model, there were no significant differences in wound size and cutting time between monopolar and bipolar groups. The histological results (histological scores) of the two groups in porcine experiments were almost the same except that the incision flatness of bipolar group was better than that of the monopolar group. Incidence of bleeding and perforation was similar between the two groups in pigs' and patients' study. At last, the finite element model showed that the vertical thermal damage depth produced by bipolar snare system was approximately 71–76% of that produced by monopolar snare system at the same power.

Conclusions: The novel bipolar snare is feasible in patients with colorectal polyps and can be an alternative choice for ERs.

Incidence and risk factors of colonoscopic post-polypectomy bleeding and perforation in patients with end-stage renal disease

BACKGROUND AND AIMS

Colonoscopic polypectomy in end-stage renal disease (ESRD) patients are at risks of post-polypectomy bleeding and perforation, but evidences are limited. This study aimed to determine the incident polypectomy complications among ESRD patients.

METHODS

In the nationwide ESRD cohort, a propensity score matched case-control study design was conducted to assess risk associated with post-polypectomy bleeding and perforation using the Taiwanese National Health Insurance Research Database from 1997 to 2013 for adults aged 40 years and older; 7011 ESRD and 19 118 non-ESRD patients met the study criteria. A total of 5302 patients in each group were matched for further analyses. The primary endpoint was post-polypectomy bleeding or bowel perforation in 30 days. The secondary endpoint was mortality and length of hospital stay for the bleeding complications requiring hospitalization.

RESULTS

Overall incidences of post-polypectomy bleeding or perforation in patients with ESRD was higher than the non-ESRD group (5.83% vs 1.78%, P < 0.0001) in the matched cohort. High risk of adverse outcomes was associated with ESRD (adjusted odds ratio [aOR], 2.38, 95% confidence interval [CI], 1.85-3.05), female patient (aOR, 1.7, 95% CI, 1.37-2.11), history of acute myocardial infarction (aOR, 1.91, 95% CI, 1.1-3.32), liver disease (aOR, 1.79, 95% CI, 1.37-2.34), diabetes (aOR, 1.45, 95% CI, 1.16-1.82), cancer (aOR, 1.4, 95% CI, 1.09-1.81), inpatient setting (aOR, 13.19, 95% CI, 9.73-17.88), and prior use of clopidogrel (aOR, 1.61, 95% CI, 1.03-2.52) and warfarin (aOR, 2.03, 95% CI, 1.21-3.41).

CONCLUSIONS

End-stage renal disease was associated with approximately twofold higher risk of colonoscopic post-polypectomy bleeding or perforation and should be cautiously performed in this special population cohort.

Diagnosis and management of iatrogenic endoscopic perforations: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement - Update 2020

1:  ESGE recommends that each center implements a written policy regarding the management of iatrogenic perforations, including the definition of procedures that carry a higher risk of this complication. This policy should be shared with the radiologists and surgeons at each center. 2 : ESGE recommends that in the case of an endoscopically identified perforation, the endoscopist reports its size and location, with an image, and statement of the endoscopic treatment that has been applied. 3:  ESGE recommends that symptoms or signs suggestive of iatrogenic perforation after an endoscopic procedure should be rapidly and carefully evaluated and documented with a computed tomography (CT) scan. 4 : ESGE recommends that endoscopic closure should be considered depending on the type of the iatrogenic perforation, its size, and the endoscopist expertise available at the center. Switch to carbon dioxide (CO2) endoscopic insufflation, diversion of digestive luminal content, and decompression of tension pneumoperitoneum or pneumothorax should also be performed. 5 : ESGE recommends that after endoscopic closure of an iatrogenic perforation, further management should be based on the estimated success of the endoscopic closure and on the general clinical condition of the patient. In the case of no or failed endoscopic closure of an iatrogenic perforation, and in patients whose clinical condition is deteriorating, hospitalization and surgical consultation are recommended.

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.

Effects of preceding endoscopic treatment on laparoscopic surgery for early rectal cancer

AIM

Endoscopic treatment for rectal cancer, such as endoscopic mucosal resection and endoscopic submucosal dissection, causes inflammation, oedema and fibrosis in the surrounding tissue. However, little is known about the effect of these endoscopic therapies on salvage laparoscopic rectal surgery. The objective of this retrospective cohort study was to analyse the effect of preceding endoscopic treatment on the outcomes of laparoscopic surgery for rectal cancer.

METHOD

We analysed 53 patients who underwent laparoscopic surgery for rectal cancer with clinical Tis or T1 at our department between May 2011 and June 2019. Data from 30 patients who underwent laparoscopic surgery after preceding endoscopic treatment (Group E + S) were compared with those of 23 patients who underwent laparoscopic surgery alone (Group S).

RESULTS

There was no significant difference between the groups with respect to preoperative details. The mean operative time tended to be longer in Group E + S, and the volume of intra-operative blood loss was greater in Group E + S than in Group S (median 63 ml vs 10 ml, P = 0.049). There were no significant differences between the groups in other surgical parameters or oncological outcomes.

CONCLUSION

Laparoscopic surgery after endoscopic treatment for rectal cancer may be difficult due to an increased risk of intra-operative bleeding. Long-term prognosis after surgery was not affected by preceding endoscopic treatment in rectal cancer.

Risks, time trends, and mortality of colonoscopy-induced perforation in hospitalized patients

BACKGROUND AND AIM

Colonic perforation is a rare complication of colonoscopy and ranges from 0% to 1% in all patients undergoing colonoscopy. The aim of this study was to assess the time trends, risk factors, and mortality associated with colonoscopy-induced perforation (CIP) in hospitalized patients as the data are limited.

METHODS

Data are obtained from the Nationwide Inpatient Sample database to identify hospitalized patients between 2005 and 2014 that had CIP. Various factors like age and gender were assessed for association with CIP, followed by univariate and multivariate regression analyses.

RESULTS

A total of 2 651 109 patients underwent inpatient colonoscopy between 2005 and 2014, and 4567 (0.2%) of the patients had CIP. Overall, incidence of CIP has increased from 2005 to 2014 (0.1% to 0.3%) (P < 0.001). On multivariate analysis, the adjusted odds ratio (OR) for CIP was highest in Caucasian race (OR: 1.49 [1.09, 2.06]), followed by after polypectomy, history of inflammatory bowel disease, end-stage renal disease, and age > 65 years (OR [95% CI] of 1.35 [1.23, 1.47], 1.34 [1.17, 1.53], 1.28 [1.02, 1.62], and 1.21 [1.11, 1.33], respectively) (all P < 0.05). CIP group had 33% less obesity (OR [95% CI]: 0.77 [0.65-0.9], P = 0.002) and 13-fold higher mortality (0.5% vs 8.1%) (P < 0.001) as compared to patients without CIP. The CIP-associated mortality ranged from 2% to 8% and remained stable throughout the study period.

CONCLUSIONS

Our study suggests that the risk of CIP was highest in elderly patients, Caucasians, those with inflammatory bowel disease, end-stage renal disease, and after polypectomy. Recognizing the factors associated with CIP may lead to informed discussion about risks and benefits of inpatient colonoscopy.

Guidewire-assisted over-the-scope clip delivery method into the distal intestine: a case series

BACKGROUND

The Over-the-scope clip (OTSC) has been recently introduced for multiple purposes, including refractory bleeding, perforation, fistula, and anastomotic dehiscence of the gastrointestinal tract. However, no easy access techniques for delivering OTSCs to distant sites have been described. Therefore, we have developed a simple and safe guidewire-assisted OTSC delivery (GOD) method for use on the distal intestine. This study aimed to investigate the technical feasibility and safety of the method.

MATERIAL AND METHODS

Between June 2018 and April 2019, all eight patients who underwent the GOD method were retrospectively examined. The primary outcome was the successful rate of OTSC delivery to the lesion without complications. The secondary outcomes were GOD procedure time, total procedure time, technical and clinical OTSC success rates, and GOD- and OTSC-associated complications.

RESULTS

The rate of successful OTSC delivery was 100%. The median procedure time of GOD was 21 min (range 8-29). The median total procedure time was 38.5 min (range 26-41). The technical and clinical success rates of OTSC were 100% and 75% (6/8), respectively. No GOD- or OTSC-associated complications occurred.

CONCLUSIONS

The GOD method is a feasible and safe technique for delivering OTSC toward the small and proximal large intestine.

The Impact of Hospital Teaching Status on Colonoscopy Perforation Risk: A National Inpatient Sample Study

Background

Colonoscopy has been widely used as a diagnostic tool for many conditions, including inflammatory bowel disease and colorectal cancer. Colonoscopy complications include perforation, hemorrhage, abdominal pain, as well as anesthesia risk. Although rare, perforation is the most dangerous complication that occurs in the immediate post-colonoscopy period with an estimated risk of less than 0.1%. Studies on colonoscopy perforation risk between teaching hospitals and non-teaching hospitals are scarce.

Methods

The National Inpatient Sample database was queried for patients who underwent inpatient colonoscopy between January 2010 and December 2014 in teaching versus non-teaching facilities in order to study their perforation rates. Our study population included 257,006 patients. Univariate regression was performed, and the positive results were analyzed using a multivariate regression module.

Results

Teaching hospitals had a higher risk of perforation (odds ratio 1.23, confidence interval 1.07 - 1.42, P = 0.004). Perforation rates were higher in females, patients with inflammatory bowel disease and dilatation of strictures. Polypectomy did not yield any statistical difference between the study groups. Other factors such as African-American ethnicity appeared to have a lower risk.

Conclusion

Perforation rates are higher in teaching hospitals. More studies are needed to examine the difference and how to mitigate the risks.

Multicenter retrospective evaluation of ileocecocolic perforations associated with diagnostic lower gastrointestinal endoscopy in dogs and cats

Background

Ileoscopy is increasingly performed in dogs and cats with gastrointestinal signs, but iatrogenic ileocecocolic (ICC) perforations have not been described.

Hypothesis/Objectives

To characterize endoscopic ICC perforations in dogs and cats.

Animals

Thirteen dogs and 2 cats.

Methods

This is a retrospective case series. Signalment, presentation, endoscopic equipment, colonic preparation, endoscopist's experience level, ileal intubation technique, method of diagnosis, perforation location, histopathology, management, and outcome data were collected and reviewed.

Results

Six ileal, 5 cecal, and 4 colonic perforations were identified between 2012 and 2019. Dogs weighed 2.4‐26 kg (median, 10.3 kg) and cats 4.6‐5.1 kg (median, 4.9 kg). Endoscopy was performed in dogs presented for vomiting (n = 4), as well as large (n = 5), mixed (n = 4), and small (n = 1) bowel diarrhea. Cats had large bowel diarrhea. Endoscopists included 1 supervised intern, 9 supervised internal medicine residents (2 first year, 6 second year, 1 third year), and 5 internal medicine diplomates. Diagnosis was delayed in 5 dogs, occurring 1‐5 days after endoscopy (median, 3 days); dogs were presented again with inappetence (n = 4), lethargy (n = 4), abdominal pain (n = 3), retching (n = 2), and syncope (n = 1). All animals underwent surgical correction. Histopathology did not identify lesions at the perforation site in any animal. Two dogs required a second surgery; 1 died 12 hours after surgery. Survival to discharge was 93%, with 78% surviving ≥8 months.

Conclusions and Clinical Importance

Iatrogenic endoscopic ICC perforation is not indicative of underlying disease and is associated with a good prognosis. Delayed diagnosis can occur. Therefore, perforation should be considered in the differential diagnosis for animals with clinical deterioration after endoscopy.

[Medical Dispute Related to Gastrointestinal Endoscopy Complications: Prevention and Management]

Because gastrointestinal (GI) endoscopy examinations are being performed increasingly frequently, the rate of detection of cancer and of precancerous lesions has increased. Moreover, development of more advanced endoscopic technologies has expanded the indications for, and thus frequency of, therapeutic endoscopic procedures. However, the incidence of complications associated with diagnostic or therapeutic GI endoscopy has also increased. The complications associated with GI endoscopy can be ameliorated by endoscopic or conservative treatment, but caution is needed as some of the more serious complications, such as perforation, can lead to death. In this chapter, we review the possible complications of GI endoscopy and discuss methods for their prevention and treatment.

Clinical and Economic Impact of Tailoring Screening to Predicted Colorectal Cancer Risk: A Decision Analytic Modeling Study

BACKGROUND

Global increases in colorectal cancer risk have spurred debate about optimal use of screening resources. We explored the potential clinical and economic impact of colorectal cancer screening tailored to predicted colorectal cancer risk.

METHODS

We compared screening tailored to predicted risk versus uniform screening in a validated decision analytic model, considering the average risk population's actual colorectal cancer risk distribution, and a risk-prediction tool's discriminatory ability and cost. Low, moderate, and high risk tiers were identified as colorectal cancer risk after age 50 years of ≤3%, >3 to <12%, and ≥12%, respectively, based on threshold analyses with willingness-to-pay <$50,000/quality-adjusted life-year (QALY) gained. Tailored colonoscopy (once at age 60 years for low risk, every 10 years for moderate risk, and every 5 years for high risk) was compared with colonoscopy every 10 years for all. Tailored fecal immunochemical testing (FIT)/colonoscopy (annual FIT for low and moderate risk, colonoscopy every 5 years for high risk) was compared with annual FIT for all.

RESULTS

Assuming no colorectal cancer risk misclassification or risk-prediction tool costs, tailored screening was preferred over uniform screening. Tailored colonoscopy was minimally less effective than uniform colonoscopy, but saved $90,200-$889,000/QALY; tailored FIT/colonoscopy yielded more QALYs/person than annual FIT at $10,600-$60,000/QALY gained. Relatively modest colorectal cancer risk misclassification rates or risk-prediction tool costs resulted in uniform screening as the preferred approach.

CONCLUSIONS

Current risk-prediction tools may not yet be accurate enough to optimize colorectal cancer screening.

IMPACT

Uniform screening is likely to be preferred over tailored screening if a risk-prediction tool is associated with even modest misclassification rates or costs.

A Review on Curability of Cancers: More Efforts for Novel Therapeutic Options Are Needed

Cancer remains a major cause of death globally. Given its relapsing and fatal features, curing cancer seems to be something hardly possible for the majority of patients. In view of the development in cancer therapies, this article summarizes currently available cancer therapeutics and cure potential by cancer type and stage at diagnosis, based on literature and database reviews. Currently common cancer therapeutics include surgery, chemotherapy, radiotherapy, targeted therapy, and immunotherapy. However, treatment with curative intent by these methods are mainly eligible for patients with localized disease or treatment-sensitive cancers and therefore their contributions to cancer curability are relatively limited. The prognosis for cancer patients varies among different cancer types with a five-year relative survival rate (RSR) of more than 80% in thyroid cancer, melanoma, breast cancer, and Hodgkin's lymphoma. The most dismal prognosis is observed in patients with small-cell lung cancer, pancreatic cancer, hepatocellular carcinoma, oesophagal cancer, acute myeloid leukemia, non-small cell lung cancer, and gastric cancer with a five-year RSR ranging between 7% and 28%. The current review is intended to provide a general view about how much we have achieved in curing cancer as regards to different therapies and cancer types. Finally, we propose a small molecule dual-targeting broad-spectrum anticancer strategy called OncoCiDia, in combination with emerging highly sensitive liquid biopsy, with theoretical curative potential for the management of solid malignancies, especially at the micro-cancer stage.

Delayed hemorrhage after cold and hot snare resection of colorectal polyps: a multicenter randomized trial (interim analysis)

Background and study aims  Delayed bleeding is believed to occur less frequently after cold snare polypectomy (CSP), but this has not been validated in clinical trials. This study aimed to compare rates of delayed bleeding after CSP and hot snare polypectomy (HSP). Patients and methods  We conducted a multicenter, randomized controlled trial. Participants scheduled to undergo endoscopic resection of colorectal polyps ≤ 10 mm were enrolled and randomly assigned to CSP or HSP. Prophylactic clipping was performed at the endoscopists' discretion. The primary outcome was delayed bleeding rate. Secondary outcomes included immediate bleeding rate and clipping rate. Sample size calculation showed that 451 patients were required in each arm. Results  At the end of the study period decided in advance, 308 participants were recruited and an interim analysis was performed. A total of 273 patients (mean age 62.2 ± 8.8 years; 188 males) were analyzed, with 139 patients allocated to CSP and 134 to HSP. In total, 367 polyps were resected with CSP and 360 polyps with HSP. There were no significant differences in patient demographics or polyp characteristics. In per-patient-based analysis, delayed bleeding rates were 0.7 % after CSP and 0.7 % after HSP. Per-polyp analysis showed similar results (CSP: 0.3 % vs. HSP: 0.6 %). The immediate bleeding rate was significantly higher with CSP vs. HSP (54 % vs.14 %, P  < 0.0001), while clipping rates were 18 % and 19 %, respectively. Conclusion  This interim analysis did not demonstrate that delayed bleeding after CSP is less frequent than after HSP. The delayed bleeding rate after HSP was lower than expected. Meeting presentations: Digestive Disease Week 2017.

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.

Endoscopic Management of Iatrogenic Colon Perforation

Colon perforations are difficult to resolve because they occur unexpectedly and infrequently. If the clinician is unprepared or lacks training in dealing with perforations, the clinical prognosis will be affected, which can lead to legal issues. We describe here the proper approach to the management of perforations, including deciding on endoscopic or surgical treatment, selection of endoscopic devices, endoscopic closure procedures, and general management of perforations that occur during diagnostic or therapeutic colonoscopy.

Complications of Colonoscopy and its Management: A Single Gastroenterologist Experience

BACKGROUND

Colonoscopy is a widely used procedure and although is generally safe, it could have both gastrointestinal and non-gastrointestinal complications. The aim of this report is to assess the major complications of colonoscopies performed by one expert gastroenterologist and their management in Tehran Iran.

METHODS

We have recoded the rates of adverse events and their management in all the colonoscopies performed by a single expert gastroenterologist during 23 years (1994-2017). Demographic factors including age, race, and sex, and colonoscopy findings and patients’ comorbidities were recorded.

RESULTS

During 23 years, 9012 colonoscopies and about 1700 polypectomies were performed. The number of serious complications was six (0.07%). Colonic perforation occurred in five patients (0.06%); three of whom had undergone polypectomies. All cases of colonic perforation were managed by surgery and all were discharged with no complications. One patient suffered from cardiac arrest just after colonoscopy in the recovery room and died 20 days after colonoscopy (0.01%).

CONCLUSION

Although the rate of adverse events after colonoscopy was low, it is still an important concern in developing screening recommendations in low and middle-income countries.

Complication rates of trainee- versus attending-performed upper gastrointestinal endoscopy

BACKGROUND

Although esophagogastroduodenoscopy (EGD) is usually the first procedure trainees learn, it is not known whether the involvement of a trainee affects the procedure's complication rate, a key quality and safety indicator. The purpose of this study was to determine whether the complication rate of fellow-performed upper endoscopy differs from that of attending gastroenterologists, and whether that difference varies with the level of training.

METHODS

Emergency room visits within 14 days of an outpatient EGD deemed to be probably or definitely related to the EGD were categorized as complications. Complication rates were calculated for attending- and trainee-performed gastrointestinal endoscopies, the latter stratified by level of training.

RESULTS

Forty-five attendings and 43 fellows performed 21,899 EGDs during the study period. There were 43 complications (1.96 per 1000 EGDs). Procedures performed by any fellow were more likely to have a complication than those performed by an attending (odds ratio [OR] 2.3, 95% confidence interval [CI] 1.17-4.6). This difference was driven by a higher rate of complications among fellows who had completed general gastroenterology training and were in advanced training (OR 3.8, 95%CI 1.76-8.04); all of these complications involved trainees in interventional endoscopy. Fellows in any year of general gastroenterology training were not more likely to cause complications than attendings.

CONCLUSIONS

The rate of complications from EGDs performed by fellows in their general gastroenterology training does not differ from that of attending endoscopists. The complication rate of advanced trainees exceeded that of attendings, but this is likely to be attributable to the higher-risk interventions undertaken by fellows in interventional endoscopy.

Pediatric Endoscopy and High-risk Patients: A Clinical Report From the NASPGHAN Endoscopy Committee

Pediatric gastrointestinal endoscopy has been established as safe and effective for diagnosis and management of many pediatric gastrointestinal diseases. Nevertheless, certain patient and procedure factors should be recognized that increase the risk of intra- and/or postprocedural adverse events (AEs). AEs associated with endoscopic procedures can broadly be categorized as involving sedation-related physiological changes, bleeding, perforation, and infection. Factors which may increase patient risk for such AEs include but are not limited to, cardiopulmonary diseases, anatomical airway or craniofacial abnormalities, compromised intestinal luminal wall integrity, coagulopathies, and compromised immune systems. Examples of high-risk patients include patients with congenital heart disease, craniofacial abnormalities, connective tissues diseases, inflammatory bowel disease, and children undergoing treatment for cancer. This clinical report is intended to help guide clinicians stratify patient risks and employ clinical practices that may minimize AEs during and after endoscopy. These include use of CO2 insufflation, endoscopic techniques for maneuvers such as biopsies, and endoscope loop-reduction to mitigate the risk of such complications such as bleeding and intestinal perforation. Endoscopic infection risk and guidance regarding periprocedural antibiotics are also discussed.

Endoscopic closure of iatrogenic colon perforation using dual-channel endoscope with an endoloop and clips: methods and feasibility data (with videos)

BACKGROUND

Colon perforation is the most serious complication associated with colonoscopic procedures. We performed a novel purse-string suture technique to close the iatrogenic colonic perforation using dual-channel endoscope with an endoloop and clips.

METHODS

Iatrogenic colon perforations developed during diagnostic colonoscopy referred to a tertiary hospital over 10 years were considered for this endoscopic closure. An endoloop was inserted through the left channel of the endoscope and placed around the defect. The first clip was placed at the proximal site of the defect through the other channel of the endoscope, and the endoloop was anchored on the mucosa around the defect. Then, subsequent clips were placed next to previous clips and the endoloop was fixed. After the defect was encircled by the endoloop and clips, the rim of the opening was approximated by fastening the endoloop with a purse-string technique.

RESULTS

A total of 8 patients were admitted to our hospital because of iatrogenic colon perforations during diagnostic colonoscopy. Of these, 2 underwent laparoscopic surgery and 6 underwent endoscopic closure by this novel purse-string suture technique. The estimated diameters of the perforations were 20 mm. All cases were successfully treated in the endoscopy unit without sedation or general anesthesia, and recovered without any complication or subsequent operation. Abdominal pain had nearly resolved within 3 days after the procedure in all patients, and only mild peritonitis was observed.

CONCLUSIONS

Iatrogenic colon perforation can be treated with a purse-string suture technique using dual-channel endoscope with an endoloop and clips. This technique can be useful for relatively large colon perforations associated with diagnostic colonoscopy.

Contrasting Effectiveness and Cost-Effectiveness of Colorectal Cancer Screening Under Commercial Insurance vs. Medicare

OBJECTIVES

Most cost-effectiveness analyses of colorectal cancer (CRC) screening assume Medicare payment rates and a lifetime horizon. Our aims were to examine the implications of differential payment levels and time horizons for commercial insurers vs. Medicare on the cost-effectiveness of CRC screening.

METHODS

We used our validated Markov cohort simulation of CRC screening in the average risk US population to examine CRC screening at ages 50-64 under commercial insurance, and at ages 65-80 under Medicare, using a health-care sector perspective. Model outcomes included discounted quality-adjusted life-years (QALYs) and costs per person, and incremental cost/QALY gained.

RESULTS

Lifetime costs/person were 20-44% higher when assuming commercial payment rates rather than Medicare rates for people under 65. Most of the substantial clinical benefit of screening at ages 50-64 was realized at ages ≥65. For commercial payers with a time horizon of ages 50-64, fecal occult blood testing (FOBT) and fecal immunochemical testing (FIT) were cost-effective (<$61,000/QALY gained), but colonoscopy was costly (>$185,000/QALY gained). Medicare experienced substantial clinical benefits and cost-savings from screening done at ages <65, even if screening was not continued. Among those previously screened, continuing FOBT and FIT under Medicare was cost-saving and continuing colonoscopy was highly cost-effective (<$30,000/QALY gained), and initiating any screening in those previously unscreened was highly effective and cost-saving.

CONCLUSIONS

Modeling suggests that CRC screening is highly cost-effective over a lifetime even when considering higher payment rates by commercial payers vs. Medicare. Screening may appear relatively costly for commercial payers if only a time horizon of ages 50-64 is considered, but it is predicted to yield substantial clinical and economic benefits that accrue primarily at ages ≥65 under Medicare.

Impact of fellow training level on adverse events and operative time for common pediatric GI endoscopic procedures

BACKGROUND AND AIMS

Previous studies on pediatric endoscopic training have not examined in detail if adverse events (AEs) are affected by the fellow's training level. We aimed to determine whether trainee presence and educational level increase AEs or operative time (OT) for pediatric intestinal endoscopy.

METHODS

This was a prospective observational study of AEs for all endoscopic procedures and retrospective analysis of OT (time of endoscope insertion until removal) for a sample of specified procedures at a tertiary children's hospital. AEs were categorized by severity grades: 1, home management; 2, outpatient evaluation; 3, hospitalization and/or repeat endoscopy; 4, surgery and/or intensive care unit admission; and 5, death.

RESULTS

A total of 15,886 procedures (6257 with trainee) including 1627 therapeutic procedures (733 with trainee) were analyzed for AEs. Four hundred thirteen total AEs (2.60%) and 213 AEs grade 2 to 4 (1.34%) were identified. Fellow presence at any training level did not increase AE rates for any procedures. Median OT for 3762 EGDs decreased from 17 to 11 minutes from the first quarter to the fourth quarter of first-year fellowship and then remained stable. EGDs without fellows were shorter (9 minutes, P < .0001) compared with any training level. Median times of 1291 colonoscopies with EGD decreased from 55 to 51 to 47 minutes for fellows in the first half, second half of first-year fellowship, and second and third year, respectively. Attendings alone were faster (37 minutes, P < .0001).

CONCLUSIONS

Current pediatric endoscopic training for is safe regardless of fellow training level. Trainee efficiency improves during and after fellowship.

Comparison of cold and hot snaring polypectomy for small colorectal polyps: study protocol for a randomized controlled trial

Background

Colorectal cancer remains a considerable challenge in healthcare nowadays. Most patients’ disease develops via the adenoma–carcinoma sequence; colonoscopy with polypectomy effectively reduces both mortality and incidence by removing precancerous adenomas. Previous studies showed that polypectomy without electrocautery (cold snaring polypectomy) is a safe and time-saving procedure to manage polyps < 10 mm. However, randomized controlled trials have failed to prove the superiority of cold snaring polypectomy for reducing the risk of delayed bleeding in comparison with hot snaring polypectomy, generally because of their low statistical power that was limited by sample sizes. In this study, we aim to compare the risk of delayed bleeding following cold and hot snaring polypectomy based on a large sample size.

Methods

This is a prospective multicentre randomized controlled trial to compare cold and hot snaring polypectomy for the treatment of small colorectal polyps. A total of 4258 patients with small polyps (4–10 mm) will be randomized 1:1 to each group. Colonoscopy and polypectomy will be performed by 17 experienced endoscopists at six study sites. The randomization will be performed via an online website. Pathological examination using image-enhanced endoscopy with either narrow-band imaging or chromoendoscopy will be conducted to confirm optically and histologically that complete resections have been achieved, respectively. The primary outcome measurement is the risk of delayed bleeding. The secondary outcome measurements include the number of hemoclip applications, complete eradication confirmed optically and histologically, tissue retrieval rate, procedure time, emergency unit visits, and any adverse events such as immediate bleeding or perforation.

Discussion

We hypothesize that cold snaring polypectomy can reduce the risk of delayed bleeding by avoiding thermal injury. In addition, this study will also compare cold and hot snaring polypectomy in terms of the complete eradication rate and procedure time. Based on data collected, we will demonstrate that cold snaring polypectomy is a safe, effective, and economic procedure for small colorectal polyps. The results will also provide additional data on which to develop recommendations for treating small colorectal polyps.

Trial registration

ClinicalTrials.gov, NCT03373136. Registered on 29 November 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2743-z) contains supplementary material, which is available to authorized users.

Does "July effect" exist in colonoscopies performed at teaching hospitals?

Background

To compare the outcomes of the colonoscopies between the early (July-September) and the later (April-June) academic year at the urban-teaching hospitals.

Methods

Our study cluster was derived from the National Inpatient Sample (NIS) database for the years 2010-2014. International Classification of Diseases, 9^th Revision, Clinical Modification (ICD-9 CM) procedure codes were used to identify the adult patients who underwent inpatient colonoscopy at urban-teaching hospitals. Post-colonoscopy outcomes and the complications were recognized using ICD-9 CM codes among any of the secondary diagnoses. Categorical and continuous variables were assessed using Pearson's Chi-square and Student's t-test respectively. Odds of complications during the early vs. later academic year was also evaluated by the two-way hierarchical logistic regression analysis.

Results

A total of 124,155 (weighted n=617,907) colonoscopy procedures were performed at the urban teaching hospitals in the US from 2010 to 2014. Out of these, 61,272 (weighted n=304,946) and 62,883 (weighted n=312,961) procedures were performed during early (July to September) and later (April to June) academic months, respectively. There was no significant difference in the all-cause mortality (1.4% vs. 1.4%, P=0.208), and the complications such as colonic perforations (3.1% vs. 3.2%, P=0.229) and postoperative infections (0.6% vs. 0.6%, P=0.733) between the two groups. Similarly, the splenic rupture (0.0% vs. 0.0%, P=0.180) was equally infrequent in both the groups. Bleeding/hematoma following colonoscopy (0.9% vs. 0.8%, P=0.004) was marginally higher during the later academic months. There were no statistically distinctions in terms of length of stay (LOS) (days) (7.3±9.1 vs. 7.3±9.1, P=0.918), total hospitalization charges ($60,549.41 vs. $59,918.56, P=0.311) and discharge of patients to other facilities between the early and the later academic months. Colonoscopy performed during the early academic months was not found to be a significant independent predictor for post-colonoscopy complications such as colon perforation (OR =0.99, 95% CI: 0.93-1.06, P=0.760), postoperative bleeding/hematoma (OR =0.92, 95% CI: 0.81-1.04, P=0.196) and postoperative infection (OR =0.99, 95% CI: 0.84-1.15, P=0.850).

Conclusions

There was no "July effect" on the outcomes of colonoscopies between the early vs. the later academic months.

Difference in real-time magnetic image analysis of colonic looping patterns between males and females undergoing diagnostic colonoscopy

Background and study aim Magnetic imaging technology is of proven benefit to trainees in colonoscopy, but few studies have examined its benefits in experienced hands. There is evidence that colonoscopy is more difficult in women. We set out to investigate (i) associations between the looping configurations in the proximal and distal colon and (ii) differences in the looping prevalence between the sexes. We have examined their significance in terms of segmental intubation times and position changes required for the completion of colonoscopy.

Patients and methods We analyzed 103 consecutive synchronized luminal and magnetic image videos of diagnostic colonoscopies with normal anatomy undertaken by a single experienced operator.

Results Deep transverse loops and sigmoid N-loops were more common in females. A deep transverse loop was more likely to be present if a sigmoid alpha-loop or N-loop had formed previously. Patients with sigmoid N-loops were turned more frequently from left lateral to supine before the sigmoid-descending junction was reached, but there was no statistical correlation between completion time and looping pattern.

Conclusions This study has reexamined the prevalence of the common looping patterns encountered during colonoscopy and has identified differences between the sexes. This finding may offer an explanation as to why colonoscopy has been shown to be more difficult in females. Although a deep transverse loop following a resolved sigmoid alpha-loop was the most commonly encountered pattern, no statistical correlation between completion time and looping pattern could be shown. It is the first study to examine segmental completion times using a magnetic imager in expert hands.

Is Colonoscopy Indicated in Young Patients with Hematochezia

Background/Aims

While colonoscopy is indicated in patients >50 years old presenting with hematochezia, its role in those ≤50 remains debatable. This study aims to evaluate the role of colonoscopy in patients presenting with hematochezia who are ≤50 years old.

Methods

A retrospective review of all patients aged ≤50 years who underwent colonoscopy for hematochezia in 2012 was conducted. Patient demographics, endoscopic details, and histological results were analyzed. Patients were stratified by age to compare differences in outcome.

Results

A total of 361 patients with a median age of 44 (range, 18-50) years were reviewed. Hemorrhoid (n = 183, 69.6%) was the most common etiology. Seventy-two neoplastic polyps were identified in 48 (13.3%) patients. There was a significantly larger proportion of patients aged 41-50 years who had neoplastic polyps compared to those aged ≤40 (18.8 vs. 3.8%, p ≤ 0.001); 43.8% (n = 28) of the neoplastic polyps found in those aged 41-50 were proximal to the splenic flexure. The only 2 (0.5%) patients with malignancy were aged 41-50 years.

Conclusion

Performing colonoscopy in patients presenting with hematochezia should be strongly considered for those aged 41-50 years in view of the significant likelihood of underlying neoplastic polyps compared to those aged ≤40 years.

Management Outcomes of Colonoscopic Perforations Are Affected by the General Condition of the Patients

Purpose

The management of a colonoscopic perforation (CP) varies from conservative to surgical. The objective of this study was to evaluate the outcomes between surgical and conservative treatment of patients with a CP.

Methods

From 2003 to 2016, the medical records of patients with CP were retrospectively reviewed. Patients were divided into 2 groups depending on whether they initially received conservative or surgical treatment.

Results

During the study period, a total of 48 patients with a CP were treated. Among them, 5 patients had underlying colorectal cancer and underwent emergency radical cancer surgery; these patients were excluded. The mean age of the remaining 43 patients was 64.5 years old, and the most common perforation site was the sigmoid colon (15 patients). The initial conservative care group included 16 patients, and the surgery group included 27 patients. In the conservative group, 5 patients required conversion to surgery (failure rate: 5 of 16 [31.3%]). Of the surgery group, laparoscopic surgery was performed on 19 patients and open surgery on 8 patients, including 2 conversion cases. Major postoperative complications developed in 11 patients (34.4%), and postoperative mortality developed in 4 patients (12.5%). The only predictor for poor prognosis after surgery was a high American Society of Anesthesiologists physical status classification.

Conclusion

In this study, conservative treatment for patients with a CP had a relatively high failure rate. Furthermore, surgical treatment showed significant rates of complications and mortality, which depended on the general status of the patients.