Incidence and management of colonoscopic perforations: 8 years’ experience

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.

Incidence of colonoscopy-related perforation and risk factors for poor outcomes: 3-year results from a prospective, multicenter registry (with videos)

BACKGROUND AND AIMS

Perforation is a life-threatening adverse event of colonoscopy that often requires hospitalization and surgery. We aimed to prospectively assess the incidence of colonoscopy-related perforation in a multicenter registry and to analyze the clinical factors associated with poor clinical outcomes.

METHODS

This prospective observational study was conducted at six tertiary referral hospitals between 2017 and 2020, and included patients with colonic perforation after colonoscopy. Poor clinical outcomes were defined as mortality, surgery, and prolonged hospitalization (> 13 days). Logistic regression was used to identify factors associated with poor clinical outcomes.

RESULTS

Among 84,673 patients undergoing colonoscopy, 56 had colon perforation (0.66/1000, 95% confidence interval [CI] 0.51-0.86). Perforation occurred in 12 of 63,602 diagnostic colonoscopies (0.19/1000, 95% CI 0.11-0.33) and 44 of 21,071 therapeutic colonoscopies (2.09/1000, 95% CI 1.55-2.81). Of these, 15 (26.8%) patients underwent surgery, and 25 (44.6%) patients had a prolonged hospital stay. One patient (1.8%) died after perforation from a diagnostic colonoscopy. In the multivariate analysis, diagnostic colonoscopy (adjusted odds ratio [aOR] 196.43, p = 0.025) and abdominal rebound tenderness (aOR 17.82, p = 0.012) were independent risk factors for surgical treatment. The location of the sigmoid colon (aOR 18.57, p = 0.048), delayed recognition (aOR 187.71, p = 0.008), and abdominal tenderness (aOR 63.20, p = 0.017) were independent risk factors for prolonged hospitalization.

CONCLUSIONS

This prospective study demonstrated that the incidence of colonoscopy-related perforation was 0.66/1000. The incidence rate was higher in therapeutic colonoscopy, whereas the risk for undergoing surgery was higher in patients undergoing diagnostic colonoscopy. Colonoscopy indication (diagnostic vs. therapeutic), physical signs, the location of the sigmoid perforation, and delayed recognition were independent risk factors for poor clinical outcomes in colonoscopy-related perforation.

Quality improvement project on the development of a management algorithm for iatrogenic perforations and the long-term impact on physician knowledge

Background and study aims  Acute iatrogenic endoscopic perforations (AIEPs) can have high morbidity and mortality, especially colonic perforations. Knowledge of diagnosis and AIEP management can improve patient care. The aims of this study were to: develop an evidence-based AIEP management algorithm; study its short-term and long-term impact on physician knowledge; and evaluate physician knowledge using hypothetical clinical scenarios. Methods  An institutional AIEP management algorithm was created using the most current recommendations from the American Society for Gastrointestinal Endoscopy and the European Society of Gastrointestinal Endoscopy. Input from advanced endoscopists, nurses, and anesthesiologists was also obtained. We assessed change in physician knowledge using a 10-item questionnaire before (pretest), a standardized one-page AIEP educational material and algorithm immediately after (post-test) to test short-term retention, and 6 months later (6-month reassessment) to test long-term retention. With the 6-month reassessment, two clinical scenarios based on real AIEP were presented to evaluate application of knowledge. Results  Twenty-eight subjects (8 gastroenterology fellows and 20 practicing gastroenterologists) participated in the assessments. Pretest and immediate post-test accuracies were 75 % and 95 % ( P  < 0.01), respectively. Six-month reassessment accuracies were 83.6 %, significantly worse compared to post-test accuracies ( P  < 0.05), but significantly improved compared to pretest accuracies ( P  < 0.05). Accuracies for clinical scenarios #1 and #2 were 67.5 % and 60.3 %, respectively. Fellows had similar accuracies when compared to practicing gastroenterologists. Conclusions  Using standardized methodology and a multidisciplinary approach, an AIEP management algorithm was created to improve patient care and alleviate physician and staff stress. In addition, we showed that a one-page educational document on perforations can significantly improve short-term and long-term physician knowledge, although periodic reeducation is needed.

Colorectal barotrauma following compressed air spray to the perineum

Colorectal injuries caused by high-pressure air compressors are rare and reported especially among industrial workers. They may appear because of intended or accidental injury. In the present paper, we report a case of colorectal injuries due to air insufflation from a distance towards the anus with the clothes on, as a means of a practical joke. The patient presented one day after the trauma to the Emergency Department with complaints of severe abdominal pain and vomiting. On examination, he had signs of peritonitis. A computed tomography (CT) scan did not show any perforation. Emergency laparotomy was performed with the suspicion of pneumatic pressure-induced lesions. A total resection of the colon was made with enterostomy. The pathologic examination of the resected piece revealed multiple gangrenous areas without perforation associated to signs of peritonitis. Follow up was uneventful. A reversal of the enterostomy was scheduled.

Case report: Tension pneumoperitoneum after diagnostic colonoscopy in an 11 y/o boy with Crohns disease

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Benign Pneumoperitoneum can rarely follow colonoscopy.

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Even benign Pneumoperitoneum can lead to tension pneumoperitoneum.

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Tension pneumoperitoneum is a critically dangerous adverse event.

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Risk of perforation and microperforation increases in chronically inflamed intestine.

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Apparently, even microperforations can lead to tension pneumoperitoneum.

Introduction

Endoscopy is an established diagnostic and therapeutic tool in paediatric gastroenterology and a save method with rare complications.

Presentation of case

We present the case of an 11-year-old Caucasian boy with a long history of inflammatory bowel disease. Three years prior an ileostomy was created and is still in position. After diagnostic panendoscopy (colonoscopy, gastroscopy, endoscopy of small intestine via ileostomy) the patient showed progressive abdominal distension and pain. After diagnosis of tension pneumoperitoneum by radiological proof of massive intraabdominal air and altered vital signs, we initiated emergency laparotomy. Surgical intervention ruled out a free gastrointestinal perforation as well as peritonitis. There was a gaseous insufflation of the mesenteric tissue of the sigmoid and upper rectum most likely according to microperforations to the mesentery. Due to the pre-existing ileostomy, we took no further surgical action. The abdomen was lavaged and drains inserted. Upon further conservative treatment with intravenous antibiotics, the patient showed quick recovery and was discharged on postoperative day 6.

Discussion

With an incidence of 0.01%, perforation after diagnostic colonoscopy in children is very uncommon. The zone most frequently affected is the sigmoid colon due to direct penetration or indirect force due to flexure, or insufflation. Even without macroscopic perforation, the development of a tension pneumoperitoneum seems to be possible.

Conclusion

Even though Colonoscopy in children is a safe tool, the treating physician must never underestimate the risks of such an intervention. Especially chronically altered intestine as in long-time persisting chronic inflammatory bowel disease demand special care and intensive observation of the patient after intervention.

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.

Transanal high pressure barotrauma causing colorectal injuries: a case series

BACKGROUND

Rectal perforation by foreign bodies is known; however, high-pressure injury leading to rectal blowout has been confined to battlefields and is less often encountered in general medical practice. Apart from iatrogenic injuries during colonoscopy, barotrauma from compressed air is encountered very less frequently. Owing to the infrequent nature of these injuries, the mechanism is still not well understood. We present our experience with treating high-pressure transanal barotrauma to the rectum and colon in three similar cases.

CASE PRESENTATION

The mode of injury was accidental or a cruel, perverted joke played by acquaintances. The high-pressure air jet column overcomes the anal sphincter barrier, pushing enormous amounts of air through the anus into the bowel, which ruptures when the burst pressure is reached. A huge amount of free gas was noted in the peritoneal cavity on x-rays, and a big gush was noted during surgery. All these cases had rectosigmoid junction blowout with multiple colonic injuries. The patients underwent exploratory laparotomy with resection of severely injured segments and proximal ileostomy. They underwent restoration of bowel continuity after 2-3 months and were doing well in follow-up.

CONCLUSIONS

Colorectal injuries by pneumatic insufflation through the anus depends on the air pressure, air flow velocity, anal resting pressure, and the distance between the source and anus. The relative fixity of the rectum and the bends of the sigmoid make the rectosigmoid junction more prone to rupture by high-pressure air jet. Education regarding such machines and their safe use must be encouraged because most of these cases are accidental and due to ignorance.

Repair of a colonoscopic perforation of the rectum with transanal endoscopic microsurgery

Iatrogenic colonic perforations are relatively uncommon but serious complications of diagnostic and therapeutic colonoscopies. Transanal endoscopic microsurgery (TEM) is an useful approach to the rectum and may be used for repair of a rectal perforation during colonoscopy. A 56-year-old male had an iatrogenic perforation of the rectum during a routine follow-up colonoscopy repaired by TEM with an uneventful and rapid recovery.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Sigmoid stricture associated with diverticular disease should be an indication for elective surgery with lymph node clearance

BACKGROUND

The literature concerning stricture secondary to diverticulitis is poor. Stricture in this setting should be an indication for surgery because (a) of the potential risk of cancer and (b) morbidity is not increased compared to other indications for colectomy. The goal of this report is to study the post-surgical morbidity and the quality of life in patients after sigmoidectomy for sigmoid stricture associated with diverticular disease.

METHOD

This is a monocenter retrospective observational study including patients with a preoperative diagnosis of sigmoid stricture associated with diverticular disease undergoing operation between Jan 1, 2007 and Dec 31, 2013. The GastroIntestinal Quality of Life Index was used to assess patient satisfaction.

RESULTS

Sixteen patients were included of which nine were female. Median age was 69.5 (46-84) and the median body mass index was 23.55kg/m(2) (17.2-28.4). Elective sigmoidectomy was performed in all 16 patients. Overall, complications occurred in five patients (31.2%) (4 minor complications and 1 major complication according to the Dindo and Clavien Classification); none resulted in death. Pathology identified two adenocarcinomas (12.5%). The mean GastroIntestinal Quality of Life Index was 122 (67-144) and 10/11 patients were satisfied with their surgical intervention.

CONCLUSION

Sigmoid stricture prevents endoscopic exploration of the entire colon and thus it may prove difficult to rule out a malignancy. Surgery does not impair the quality of life since morbidity is similar to other indications for sigmoidectomy. For these reasons, we recommend that stricture associated with diverticular disease should be an indication for sigmoidectomy including lymph node clearance.

Conservative Management of Large Rectosigmoid Perforation under Peritoneal Reflection: Case Report and Review of the Literature

Colonoscopy is accepted as the best method in diagnosis, treatment, and follow-up of colorectal diseases. As the amount of the usage of diagnostic and therapeutic colonoscopy rises, iatrogenic complications are more likely to be seen. The most important complications are perforations and bleeding. Whereas perforation is a complication that is seen rarely, because of the high ratio of morbidity and mortality, it should be analyzed more carefully. There is not a common view on the optimal treatment of colonoscopic perforation. Most cases require urgent surgery, and in some cases the iatrogenic perforation of colon can be managed by conservative methods. In this report, we present a rectosigmoid perforation under peritoneal reflection and conservative management of this case.

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.

Severe adverse outcomes of endoscopic perforations in patients with and without IBD

BACKGROUND

Endoscopy-associated perforation (EAP) is a dreaded adverse event with significant morbidity and even mortality. Whether EAP in patients with inflammatory bowel disease (IBD) is associated with worse outcomes is not known. We aimed to assess the frequency of perforations in patients undergoing lower gastrointestinal (GI) endoscopies and compare the risk factors and perforation-associated complications (PAC) in patients with IBD with those without IBD.

METHODS

In this case-control study, we identified patients with lower GI EAP from January 2002 to June 2011. PAC was defined as EAP-associated death, colectomy with ileostomy, and bowel resection with/without diverting ostomy. Twenty-nine demographic, clinical, endoscopic, and surgical features were evaluated in univariable and multivariable analyses.

RESULTS

A total of 217,334 lower GI endoscopies were performed (IBD, N = 9518 and non-IBD, N = 207,816). Eighty-four patients with EAP were included. The rate of perforation was 18.91 per 10,000 and 2.50 per 10,000 procedures for IBD and non-IBD endoscopy, respectively. PAC occurred in 59 patients (70.2%) with death in 4 (4.8%) and bowel resection with or without ostomy in 55 (65.5%) (total colectomy with ileostomy, n = 3; resection with diversion and secondary anastomosis, n = 28; and resection with primary anastomosis, n = 24). On multivariable analysis, the use of systemic corticosteroids at the time of endoscopy was associated with 13 times greater risk for PAC (13.5 [95% confidence interval, 1.3-1839.7] P = 0.007), whereas IBD was not found to be associated with an increased risk for PAC (0.69 [95% confidence interval, 0.23-2.1] P = 0.52).

CONCLUSIONS

Patients with IBD have a higher frequency of EAP than those without IBD. Endoscopists need to be cautious while performing a lower GI endoscopy in patients taking systemic corticosteroids.

Management of bleeding and perforation after colonoscopy

Bleeding is a relatively rare complication occurring mainly after snare polypectomy. The majority of cases can be managed successfully by endoscopic means leaving very few cases which will ultimately need an operation. Colonic perforation, on the other hand is a serious complication that requires intensive and careful management. Prompt recognition of the perforation during the procedure allows, in selected cases, immediate endoscopic closure with an uneventful and full recovery followed by close monitoring and surgical management in case of clinical deterioration. The criteria for the right selection of perforation cases amenable to endoscopic treatment do still need to be confirmed by prospective studies and further experience is required before a standard algorithm on the endoscopic management of perforations is developed.

Clinical outcomes and direct costings of endoluminal clipping compared to surgery in the management of iatrogenic colonic perforation

OBJECTIVE

To compare the outcomes and costs of endoluminal clipping and surgery in the management of iatrogenic colonic perforation.

METHODS

A retrospective, single-center, clinical and economic analysis of outcomes and costings between endoluminal clipping and surgery in consecutive cases of iatrogenic colonic perforations was conducted.

RESULTS

In total, 7136 colonoscopies performed over a 6-year period were complicated by 12 (0.17%) perforations. Seven cases were treated by endoscopic clipping (with a success rate of 71.4%) and five with immediate surgery. Both groups of patients had similar clinical and individual characteristics. Patients who were treated with endoscopic clipping had a shorter period of hospitalization (median 9 vs 13 days) compared to surgery, but this was not statistically significant. Compared to patients who had immediate surgery, the median direct health-care costs for all procedures (US$ 115.10 vs US$ 1479.50, P = 0.012) and investigations (US$ 124.60 vs US$ 512.90, P = 0.048) during inpatient stay were lower for the endoscopic clipping group. There was a trend towards a lower overall inpatient median cost for patients managed with endoscopic clipping compared to surgery (US$ 1481.70 vs US$ 3281.90, P = 0.073).

CONCLUSION

Endoluminal clipping may be more cost-effective than surgery in the management of iatrogenic colonic perforations.

Tension Pneumothorax, Pneumoperitoneum, and Cervical Emphysema following a Diagnostic Colonoscopy

Colonoscopy is currently a widespread procedure used in screening for colorectal cancer. Iatrogenic colonic perforation during colonoscopy is a serious and potentially life-threatening complication that can cause significant morbidity and mortality. “Triple pneumo” (a combination of pneumothorax, pneumomediastinum, and pneumoperitoneum) following colonoscopy is a rare but a serious condition requiring immediate diagnosis and emergent intervention. In majority of these cases a colonic perforation is the initial injury that is followed by pneumothorax and pneumomediastinum through the potential anatomical connection with retroperitoneal and mediastinal spaces. In this rare case report we are presenting a case of “triple pneumo” with no evidence of colonic perforation. This patient developed a simultaneous pneumoperitoneum, pneumomediastinum, and a tension pneumothorax requiring immediate tube thoracostomy. This case may raise the awareness on the likelihood of these serious complications after colonoscopy.

Incidence, risk, management, and outcomes of iatrogenic full-thickness large bowel injury associated with 56,882 colonoscopies in 14 Lithuanian hospitals

BACKGROUND

The primary goal of this hospital-based retrospective multicenter case series study was to determine the incidence of large bowel full-thickness injury associated with colonoscopy in Lithuania. We assessed characteristics of patients who were treated as a result of this complication; management and outcomes were the secondary goals of this study.

METHODS

The medical records of patients with iatrogenic large bowel perforations resulting from colonoscopy within the period January 1, 2007, to December 31, 2011, were retrospectively reviewed. Representatives of 14 Lithuanian public and private hospitals participated in the survey.

RESULTS

A total of 56,882 colonoscopies were performed. Forty patients (23 female and 17 male patients) were reported to have iatrogenic full-thickness large bowel injury. Diagnostic and therapeutic colonoscopies resulted in perforation for 28 of 49,795 patients and 12 of 7,087 patients, respectively. A mean age of 70 years and a female preponderance for this complication was revealed. Sigmoid colon and rectosigmoid junction was perforated in 28 patients. All patients underwent surgical management, either primary repair (70.0 %) or bowel resection (30.0 %). Postoperative complications were diagnosed in 15 patients. Immediate treatment resulted in fewer intestinal resections and shorter hospital stays (p < 0.05). Smoking [odds ratio (OR) 14.4, 95 % confidence interval (CI) 1.16-179.8] and a large size perforation site (15 ± 10 vs. 8 ± 5 mm; OR 1.19, 95 % CI 1.03-1.38) were risk factors for developing a postoperative complication after curative surgery. Six patients died. All deaths were related to diagnostic colonoscopy.

CONCLUSIONS

Total incidence of large bowel full-thickness injury in Lithuanian hospitals is 0.07 %. Incidence of this complication after diagnostic and therapeutic colonoscopies is 0.056 and 0.169 %, respectively. The most common site of perforation is sigmoid colon and rectosigmoid junction, at 70 %. Risk rises when colonoscopy is performed in low-volume practice centers. Urgent surgical management resulted in overall mortality rate of 15.0 % and morbidity of 37.5 %.

Analysis of colonoscopic perforations at a local clinic and a tertiary hospital

AIM

To define the clinical characteristics, and to assess the management of colonoscopic complications at a local clinic.

METHODS

A retrospective review of the medical records was performed for the patients with iatrogenic colon perforations after endoscopy at a local clinic between April 2006 and December 2010. Data obtained from a tertiary hospital in the same region were also analyzed. The underlying conditions, clinical presentations, perforation locations, treatment types (operative or conservative) and outcome data for patients at the local clinic and the tertiary hospital were compared.

RESULTS

A total of 10  826 colonoscopies, and 2625 therapeutic procedures were performed at a local clinic and 32  148 colonoscopies, and 7787 therapeutic procedures were performed at the tertiary hospital. The clinic had no perforations during diagnostic colonoscopy and 8 (0.3%) perforations were determined to be related to therapeutic procedures. The perforation rates in each therapeutic procedure were 0.06% (1/1609) in polypectomy, 0.2% (2/885) in endoscopic mucosal resection (EMR), and 3.8% (5/131) in endoscopic submucosal dissection (ESD). Perforation rates for ESD were significantly higher than those for polypectomy or EMR (P < 0.01). All of these patients were treated conservatively. On the other hand, three (0.01%) perforation cases were observed among the 24  361 diagnostic procedures performed, and these cases were treated with surgery in a tertiary hospital. Six perforations occurred with therapeutic endoscopy (perforation rate, 0.08%; 1 per 1298 procedures). Perforation rates for specific procedure types were 0.02% (1 per 5500) for polypectomy, 0.17% (1 per 561) for EMR, 2.3% (1 per 43) for ESD in the tertiary hospital. There were no differences in the perforation rates for each therapeutic procedure between the clinic and the tertiary hospital. The incidence of iatrogenic perforation requiring surgical treatment was quite low in both the clinic and the tertiary hospital. No procedure-related mortalities occurred. Performing closure with endoscopic clipping reduced the C-reactive protein (CRP) titers. The mean maximum CRP titer was 2.9 ± 1.6 mg/dL with clipping and 9.7 ± 6.2 mg/dL without clipping, respectively (P < 0.05). An operation is indicated in the presence of a large perforation, and in the setting of generalized peritonitis or ongoing sepsis. Although we did not experience such case in the clinic, patients with large perforations should be immediately transferred to a tertiary hospital. Good relationships between local clinics and nearby tertiary hospitals should therefore be maintained.

CONCLUSION

It was therefore found to be possible to perform endoscopic treatment at a local clinic when sufficient back up was available at a nearby tertiary hospital.

Colonoscopy-associated perforation: a 7-year survey of in-hospital frequency, treatment and outcome in a German university hospital

AIM

Perforation occurs rarely after colonoscopy, but is associated with high morbidity and mortality. In this study, we assessed the perforation rate in our hospital, its clinical diagnosis and the long-term outcome.

METHOD

During the study period, 7535 examinations were performed, of which 4830 were diagnostic and 2705 therapeutic. The latter included polypectomy, endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), dilatation and argon plasma coagulation (APC).

RESULTS

Overall, 25 (0.33%) perforations occurred with two (0.026%) procedure-related deaths. Seven (0.14%) perforations occurred during a diagnostic procedure and 18 (0.67%) occurred during a therapeutic procedure. Dilation, submusous resection (SMR) and APC accounted for more perforations than polypectomy or diagnostic colonoscopy. Pre-existing gastrointestinal disease was present in 24 (96%) perforations. Three (12%) patients were treated conservatively and 22 (88%) underwent surgery. The site of perforation was closed by suture in four (18%) patients and resected with colonic anastomosis in five (23%) patients. Two patients underwent endoscopic clipping. A stoma was created after resection in 13 (59%) patients.

CONCLUSION

Death from perforation after colonoscopy is rare, occurring in 1/3500 examinations. The risk is increased in therapeutic colonoscopy and in the presence of previous gastrointestinal disease. Dilatation, SMR and APC appeared to confer a higher risk of perforation than polypectomy or diagnostic colonoscopy.

Impact of colonoscopy on quality of life

INTRODUCTION

Colonoscopy of asymptomatic, healthy individuals for colorectal cancer screening rarely causes complications and adverse events. Thus, quality of life (QOL) of the participants should not be affected by the procedure.

AIM

The aim of the study was to isolate the influence of colonoscopy, by investigation QOL before and after the procedure in a cohort of consecutive patients with different indications.

METHODS

This study is a prospective, longitudinal study, designed to compare the potential influence of colonoscopy on QOL. For a cohort of consecutive patients undergoing colonoscopy for various reasons and indications, we filled a QOL short form-36 and a short feedback questionnaire before, immediately after, and a month after the procedure. We also measured the quality of the endoscopy, the outcome in patients, and acceptability among patients.

RESULTS

There was no significant change before and immediately after colonoscopy in any of the short form-36 parameters. Physical functioning, role limitation physical, pain, general health, vitality, social functioning, role limitation mental, and mental health had very similar scores before and 2-3 h after the procedure. There was a decrease in the physical functioning a month after the procedure (P=0.01). The same was found for non-inflammatory bowel disease patients, but not for inflammatory bowel disease patients.

CONCLUSION

Colonoscopy did not affect QOL in the short or the long duration after the procedure. As such, colonoscopy may be suitable as a part of screening programs. We believe that QOL estimation should be an integral part of assessment of a screening program.

Outcome and complications of colonoscopy: a prospective multicenter study in northern Israel

Background. Colonoscopy for screening the population at an average risk of colorectal cancer (CRC) is recommended by many leading gastrointestinal associations. Objectives. The objective was to assess the quality, complications and acceptance rate of colonoscopy by patients. Methods. We prospectively gathered data from colonoscopies which were performed between October 2003 and September 2006. Patients were asked to return a follow-up form seven days after the procedure. Those who failed to do so were contacted by phone. Results. 6584 patients were included (50.4% males). The average age of subjects was 57.73 (SD 15.22). CRC screening was the main indication in 12.8%. Cecal intubation was achieved in 92% of patients and bowel preparation was good to excellent in 76.2%. The immediate outcome after colonoscopy was good in 99.4%. Perforations occurred in 3 cases—1 in every 2200 colonoscopies. Significant bleeding occurred in 3 cases (treated conservatively). 94.2% of patients agreed to undergo repeat colonoscopy in the future if indicated. Conclusions. The good quality of examinations, coupled with the low risk for complications and the good acceptance by the patients, encourages us to recommend colonoscopy as a primary screening test for CRC in Israel.

Acute abdominal compartment syndrome complicating a colonoscopic perforation: a case report

Introduction

A perforation occurring during colonoscopy is an extremely rare complication that may be difficult to diagnose. It can be responsible for acute abdominal compartment syndrome, a potentially lethal complex pathological state in which an acute increase in intra-abdominal pressure may provoke the failure of several organ systems.

Case presentation

We report a case of acute abdominal compartment syndrome after perforation of the bowel during a colonoscopy in a 60-year-old North African man with rectal cancer, resulting in respiratory distress, cyanosis and cardiac arrest. Our patient was treated by needle decompression after the failure of cardiopulmonary resuscitation. An emergency laparotomy with anterior resection, including the perforated sigmoid colon, was then performed followed by immediate anastomosis. Our patient remains alive and free of disease three years later.

Conclusion

Acute abdominal compartment syndrome is a rare disease that may occasionally occur after a colonoscopic perforation. It should be kept in mind during colonoscopy, especially considering its simple salvage treatment.

Colonoscopic perforation: useful parameters for early diagnosis and conservative treatment

OBJECTIVE

The purpose of this study is to determine useful parameters for the early diagnosis of colonoscopic perforation and to select those who would require surgical treatment.

METHODS

We retrospectively reviewed the demographics, clinical and colonoscopic data, diagnostic-surgical interval, operative findings, complications, and hospital stay of patients who developed postcolonoscopy iatrogenic colonic perforation between January 2002 and December 2008.

RESULTS

A retrospective multicentric study of patients diagnosed of colonoscopic perforation was performed. Fifty-four patients were found for final analysis (mean age, 71 years (26-91 years). Thirty-four were diagnostic and 20 were therapeutic colonoscopies. Most patients in whom the perforation was noticed during colonoscopy were treated surgically (p = 0.032) within 24 h (p = 0.004) and had a lesser degree of surgical peritonitis (p = 0.033). Those with deficient bowel preparation had more interventions (p < 0.05), ostomies (p = 0.015), and complications (p = 0.023) as well as major clinical (p < 0.001) and surgical peritonitis (p = 0.031). Patients with nonoperative management had fewer complications (p = 0.011) and lower hospital stay (p < 0.048). Surgical treatment within 24 h resulted in a lesser degree of surgical peritonitis (p < 0.001), fewer intestinal resections (p < 0.001), ostomies (p = 0.002) and complications (p < 0.047), and shorter hospital stay (p < 0.05).

CONCLUSIONS

We recommend a conservative treatment for patients with the following conditions: good general health, unnoticed perforation during endoscopy, early diagnosis, no signs of diffuse peritonitis, proper colonic preparation, and a different injury mechanism to traction. Patients treated surgically after the first 24 h are likely to have a greater degree of peritonitis and more intestinal resections, ostomies, and complications.

Colonoscopic perforation leading to a diagnosis of Ehlers Danlos syndrome type IV: a case report and review of the literature

Introduction

Colonoscopic perforation is a rare but serious complication of colonoscopy. Factors known to increase the risk of perforation include colonic strictures, extensive diverticulosis, and friable tissues. We describe the case of a man who was found to have perforation of the sigmoid colon secondary to an undiagnosed connective tissue disorder (Ehlers-Danlos syndrome type IV) while undergoing surveillance for hereditary non-polyposis colorectal cancer.

Case presentation

A 33-year-old Caucasian man presented to our hospital with an acute abdomen following a colonoscopy five days earlier as part of hereditary non-polyposis colorectal cancer screening. His medical history included bilateral clubfoot. His physical examination findings suggested left iliac fossa peritonitis. A computed tomographic scan revealed perforation of the sigmoid colon and incidentally a right common iliac artery aneurysm as well. Hartmann's procedure was performed during laparotomy. The patient recovered well post-operatively and was discharged. Reversal of the Hartmann's procedure was performed six months later. This procedure was challenging because of dense adhesions and friable bowel. The histology of bowel specimens from this surgery revealed thinning and fibrosis of the muscularis externa. The patient was subsequently noted to have transparency of truncal skin with easily visible vessels. An underlying collagen vascular disorder was suspected, and genetic testing revealed a mutation in the collagen type III, α1 (COL3A1) gene, which is consistent with a diagnosis of Ehlers-Danlos syndrome type IV.

Conclusions

Ehlers-Danlos syndrome type IV, the vascular type, is a rare disorder caused by mutations in the COL3A1 gene on chromosome 2q31. It is characterized by translucent skin, clubfoot, and the potentially fatal complications of spontaneous large vessel rupture, although spontaneous uterine and colonic perforations have also been reported in the literature. The present case presentation describes the identification of Ehlers-Danlos syndrome type IV in a patient with a non-spontaneous colonic perforation secondary to an invasive investigation for another hereditary disorder pre-disposing him to colorectal cancer. Invasive procedures such as arteriograms and endoscopies are relatively contra-indicated in Ehlers-Danlos syndrome type IV. Alternatives with a lower risk of perforation, such as computed tomographic colonography, need to be considered for patients requiring ongoing colorectal cancer surveillance. Furthermore, management of vascular aneurysms in patients with Ehlers-Danlos syndrome type IV requires consideration of the risks of endovascular stenting, as opposed to open surgical intervention, because of tissue friability. Genetic and reproductive counseling should be offered to affected individuals and their families.

Emergency percutaneous needle decompression for tension pneumoperitoneum

Background

Tension pneumoperitoneum as a complication of iatrogenic bowel perforation during endoscopy is a dramatic condition in which intraperitoneal air under pressure causes hemodynamic and ventilatory compromise. Like tension pneumothorax, urgent intervention is required. Immediate surgical decompression though is not always possible due to the limitations of the preclinical management and sometimes to capacity constraints of medical staff and equipment in the clinic.

Methods

This is a retrospective analysis of cases of pneumoperitoneum and tension pneumoperitoneum due to iatrogenic bowel perforation. All patients admitted to our surgical department between January 2005 and October 2010 were included. Tension pneumoperitoneum was diagnosed in those patients presenting signs of hemodynamic and ventilatory compromise in addition to abdominal distension.

Results

Between January 2005 and October 2010 eleven patients with iatrogenic bowel perforation were admitted to our surgical department. The mean time between perforation and admission was 36 ± 14 hrs (range 30 min - 130 hrs), between ER admission and begin of the operation 3 hrs and 15 min ± 47 min (range 60 min - 9 hrs). Three out of eleven patients had clinical signs of tension pneumoperitoneum. In those patients emergency percutaneous needle decompression was performed with a 16G venous catheter. This improved significantly the patients' condition (stabilization of vital signs, reducing jugular vein congestion), bridging the time to the start of the operation.

Conclusions

Hemodynamical and respiratory compromise in addition to abdominal distension shortly after endoscopy are strongly suggestive of tension pneumoperitoneum due to iatrogenic bowel perforation. This is a rare but life threatening condition and it can be managed in a preclinical and clinical setting with emergency percutaneous needle decompression like tension pneumothorax. Emergency percutaneous decompression is no definitive treatment, only a method to bridge the time gap to definitive surgical repair.

Colorectal cancer screening comparing no screening, immunochemical and guaiac fecal occult blood tests: a cost-effectiveness analysis

Comparability of cost-effectiveness of colorectal cancer (CRC) screening strategies is limited if heterogeneous study data are combined. We analyzed prospective empirical data from a randomized-controlled trial to compare cost-effectiveness of screening with either one round of immunochemical fecal occult blood testing (I-FOBT; OC-Sensor®), one round of guaiac FOBT (G-FOBT; Hemoccult-II®) or no screening in Dutch aged 50 to 75 years, completed with cancer registry and literature data, from a third-party payer perspective in a Markov model with first- and second-order Monte Carlo simulation. Costs were measured in Euros (€), effects in life-years gained, and both were discounted with 3%. Uncertainty surrounding important parameters was analyzed. I-FOBT dominated the alternatives: after one round of I-FOBT screening, a hypothetical person would on average gain 0.003 life-years and save the health care system €27 compared with G-FOBT and 0.003 life years and €72 compared with no screening. Overall, in 4,460,265 Dutch aged 50-75 years, after one round I-FOBT screening, 13,400 life-years and €320 million would have been saved compared with no screening. I-FOBT also dominated in sensitivity analyses, varying uncertainty surrounding important effect and cost parameters. CRC screening with I-FOBT dominated G-FOBT and no screening with or without accounting for uncertainty.

Quality and safety of screening colonoscopies performed by primary care physicians with standby specialist support

BACKGROUND

Expanding the population's access to colonoscopy screening can reduce colorectal cancer disparities. Innovative strategies are needed to address the prevailing 50% colonoscopy screening gap, partly attributable to inadequate specialist workforce. This study examined the quality of colonoscopies by primary care physicians (PCPs) with standby specialist support at a licensed ambulatory surgery center.

METHODS

Retrospective data on 10,958 consecutive colonoscopies performed by 51 PCPs on 9815 patients from October 2002 to November 2007 were used to calculate the rates of cecal intubation, detection of polyps, adenomas, advanced neoplasia and cancer, adverse events, and time taken for endoscope insertion and withdrawal. The center's protocol requires a 2-person technique (using a trained technician), polyp search and removal during both scope insertion and withdrawal, and onsite expert always available for rescue assistance (either navigational or therapeutic).

FINDINGS

Mean patient age was 58.3 (+/-10.9) years, 48.0% were male, and 48.1% African-American. The cecal intubation rate was 98.1%, polyp detection rate 63.1%, hyperplastic polyp 27.5%, adenoma 29.9%, advanced neoplasia 5.7%, cancer 0.63%, major adverse events 0.06% (including 2 perforations; no death). Mean insertion and withdrawal times were 14.4 (+/-9.3) and 10.9 (+/-6.8) minutes, respectively; 13.2 (+/-8.6) and 8.0 (+/-4.5) minutes without polyps found, and 15.1 (+/-9.6) and 12.5 (+/-7.3) minutes when > or =1 polyp was found.

CONCLUSIONS

In the largest published study of PCP-performed colonoscopies with standby specialist support, we observed performance quality indicators and lesion detection rates that are comparable to documented rates for experienced gastroenterologists. Systems that use PCPs with specialist backup support enable high-quality colonoscopy performance by PCPs.

Colonoscopic perforation: incidence, risk factors, management and outcome

This review discusses the incidence, risk factors, management and outcome of colonoscopic perforation (CP). The incidence of CP ranges from 0.016% to 0.2% following diagnostic colonoscopies and could be up to 5% following some colonoscopic interventions. The perforations are frequently related to therapeutic colonoscopies and are associated with patients of advanced age or with multiple comorbidities. Management of CP is mainly based on patients' clinical grounds and their underlying colorectal diseases. Current therapeutic approaches include conservative management (bowel rest plus the administration of broad-spectrum antibiotics), endoscopic management, and operative management (open or laparoscopic approach). The applications of each treatment are discussed. Overall outcomes of patients with CP are also addressed.

Is endoscopic closure with clips effective for both diagnostic and therapeutic colonoscopy-associated bowel perforation?

BACKGROUND

Colonic perforation is an uncommon but serious colonoscopy-associated complication. This study assessed the effectiveness of conservative management with endoscopic clipping for colonoscopy-associated perforations.

METHODS

Clinical manifestations and management outcomes were assessed for 38 patients with colonoscopy-associated colonic perforations that occurred between January 2001 and April 2008 at the Asan Medical Center, Seoul, Korea. These perforations were classified as endoscopically evident, endoscopically suspected, and radiologically proven.

RESULTS

Of the 38 perforations, 19 were endoscopically evident, 9 were endoscopically suspected, and 10 were radiologically proven but without endoscopic evidence. Of the 19 patients with endoscopically evident perforations, 13 (68.4%) underwent endoscopic closure with clips, and all improved without surgery. All nine patients with endoscopically suspected perforations underwent endoscopic closure, and eight (88.9%) improved without surgery. Of the 10 radiologically proven perforations, 7 were detected within 1 day after colonoscopy. All the patients improved without surgery. However, two of the three patients with delayed perforations required emergency laparotomy. Consequently, of the 38 patients with perforations, 29 (76.3%) improved without surgery. Of the 28 patients with endoscopically evident or suspected perforations, conservative management was successful for 21 (95.5%) of the 22 patients with effective clipping, but for none (0%) of the 6 patients without clipping.

CONCLUSIONS

Conservative management by immediate endoscopic closure with clips can be effective for the treatment of colonic perforations detected during colonoscopy. Conservative management also may be tried cautiously for stable patients who have radiologically proven colonoscopy-associated perforations without endoscopic evidence.

What are the risk factors of colonoscopic perforation?

BACKGROUND

Knowledge of the factors influencing colonoscopic perforation (CP) is of decisive importance, especially with regard to the avoidance or minimization of the perforations. The aim of this study was to determine the incidence and risk factors of CP in one of the endoscopic training centers accredited by the World Gastroenterology Organization.

METHODS

The prospectively collected data were reviewed of all patients undergoing either colonoscopy or flexible sigmoidoscopy at the Faculty of Medicine Siriraj Hospital, Bangkok, Thailand between January 2005 and July 2008. The incidence of CP was evaluated. Eight independent patient-, endoscopist- and endoscopy-related variables were analyzed by a multivariate model to determine their association with CP.

RESULTS

Over a 3.5-year period, 10,124 endoscopic procedures of the colon (8,987 colonoscopies and 1,137 flexible sigmoidoscopies) were performed. There were 15 colonic perforations (0.15%). Colonoscopy had a slightly higher risk of CP than flexible sigmoidoscopy (OR 1.77, 95%CI 0.23-13.51; p = 1.0). Patient gender, emergency endoscopy, anesthetic method, and the specialty or experience of the endoscopist were not significantly predictive of CP rate. In multivariate analysis, patient age of over 75 years (OR = 6.24, 95%CI 2.26-17.26; p < 0.001) and therapeutic endoscopy (OR = 2.98, 95%CI 1.08-8.23; p = 0.036) were the only two independent risk factors for CP.

CONCLUSION

The incidence of CP in this study was 0.15%. Patient age of over 75 years and therapeutic colonoscopy were two important risk factors for CP.

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

BACKGROUND

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

OBJECTIVE

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

DESIGN

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

SETTING

California Medicaid program claims database.

PATIENTS

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

MAIN OUTCOME MEASUREMENTS

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

RESULTS

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

LIMITATIONS

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

CONCLUSION

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

Complications of colonoscopy in a large public county hospital in Greece. A 10-year study

BACKGROUND AND STUDY AIMS

Information about the complications of colonoscopy in Southern Europe is limited, particularly in Greece where it is non-existent. Our study sought to determine the complications of colonoscopy in a large public county hospital in Greece over a 10-year period.

PATIENTS AND METHODS

All colonoscopy procedures from 1996 to 2006 were entered into a database. Data were analysed by both univariate and multivariate methods.

RESULTS

Nine thousand six hundred forty-eight colonoscopies were entered into a database. The procedures were diagnostic in 79% and therapeutic in 21%. Overall bleeding complications occurred in 83 out of the 9648 patients (0.8%: 95% confidence interval [0.7%, 0.9%]). Perforation occurred in four female patients (0.04%: 95% confidence interval [0.01%, 0.07%]) in the sigmoid colon. Multivariate stepwise logistic regression analysis in the therapeutic colonoscopies revealed that presence of significant polyps (odds ratio 4.7, confidence interval [2.9-7.6]), the male sex (odds ratio 2, 95% confidence interval [1.2-3.3]) and the time period of the procedure (the first 5 years) (odds ratio 1.7, 95% confidence interval [1.01-3]), are significant predictors of a post-colonoscopy bleeding episode.

CONCLUSION

This historical cohort study, the first in Greece on this subject, shows that colonoscopy is a rather safe procedure and that the rate of complications in this study was low.

Screening colonoscopy for colorectal cancer in asymptomatic people: a meta-analysis

OBJECTIVE

The preferred method for screening asymptomatic people for colorectal cancer (CRC) is colonoscopy, according to the new American guidelines. The aim of our study was to perform a meta-analysis of the prospective cohorts using total colonoscopy for screening this population for CRC. We looked for the diagnostic yield of the procedure as well as for its safety in a screening setting.

METHODS

We included papers with more than 500 participants and only those reporting diagnostic yield of adenoma (and/or advanced adenoma) and CRC. Nested analysis were performed for secondary endpoints of complications and CRC stages when this information was available. All analyses were performed with StatDirect Statistical software, version 2.6.1 ( http://www.statsdirect.com ).

RESULTS

Our search yielded ten studies of screening colonoscopy conducted in asymptomatic people that met our inclusion criteria, with a total of 68,324 participants. Colonoscopy was complete and reached the cecum in 97% of the procedures. Colorectal cancer was found in 0.78% of the participants (95% confidence interval 0.13-2.97%). Stage I or II were found in 77% of the patients with CRC. Advanced adenoma was found in 5% of the cases (95% confidence interval 4-6%). Complications were rare and described in five cohorts. Perforation developed in 0.01% of the cases (95% confidence interval 0.006-0.02%) and bleeding in 0.05% (95% confidence interval 0.02-0.09%).

CONCLUSIONS

Our findings support the notion that colonoscopy is feasible and a suitable method for screening for CRC in asymptomatic people.

Colonoscopic perforation: A report from World Gastroenterology Organization endoscopy training center in Thailand

AIM

To determine the incidence of colonoscopic perforation (CP), and evaluate clinical findings, management and outcomes of patients with CP from the World Gastroenterology Organization (WGO) Endoscopy Training Center in Thailand.

METHODS

All colonoscopies and sigmoidoscopies performed between 1999 and 2007 in the Endoscopic unit, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok were reviewed. Incidence of CP, patients' characteristics, endoscopic information, intra-operative findings, management and outcomes were analyzed.

RESULTS

A total of 17357 endoscopic procedures of the colon (13699 colonoscopies and 3658 flexible sigmoidoscopies) were performed in Siriraj hospital over a 9-year period. Fifteen patients (0.09%) had CP: 14 from colonoscopy and 1 from sigmoidoscopy. The most common site of perforation was in the sigmoid colon (80%), followed by the transverse colon (13%). Perforations were caused by direct trauma from either the shaft or the tip of the endoscope (n = 12, 80%) and endoscopic polypectomy (n = 3, 20%). All patients with CP underwent surgical management: primary repair (27%) and bowel resection (73%). The mortality rate was 13% and postoperative complication rate was 53%.

CONCLUSION

CP is a rare but serious complication following colonoscopy and sigmoidoscopy, with high rates of morbidity and mortality. Incidence of CP was 0.09%. Surgery is still the mainstay of CP management.

Retroperitoneal, mediastinal, and subcutaneous emphysema, complicating colonoscopy and rectal polypectomy

Complications of flexible endoscopy-though still rare-are increasing in frequency lately as more invasive procedures are routinely performed. Perforation, hemorrhage, coagulation disorders, thrombophlebitis, and splenic rupture have all been reported to complicate colonoscopy and colorectal polypectomies. In this paper, we report on a case of retroperitoneal, mediastinal, and neck surgical emphysema, complicating colonoscopy and rectal polypectomy, presented initially as a change in the voice and facial swelling.

Endoscopic closure of colon perforation compared to surgery in a porcine model: a randomized controlled trial (with videos)

BACKGROUND

Endoscopic closure of inadvertent or intentional colon perforations might be valuable if comparable to surgical closure.

OBJECTIVE

The aim of this study was to compare endoscopic closure of a 4-cm colon perforation in a porcine model with surgical closure in a multicenter study.

SETTING

University hospitals in the United States and Europe.

DESIGN AND INTERVENTIONS

After creating a 4-cm linear colon perforation, the animals were randomized to either endoscopic or surgical closure. The total procedure time from the beginning of perforation to the completion of procedure was measured. The animals were euthanized after 2 weeks to evaluate healing, unless there was a complication.

RESULTS

Fifty-four animals were randomized to either surgical or endoscopic closure of colon perforation. Eight animals developed complications, and 7 of these were euthanized before 2 weeks. Twenty-three animals in each group survived for 2 weeks. Surgical closure of the perforation was successful in all animals in that group, and endoscopic closure was successful in 25 of the 27 animals. The median procedure time was shorter in the surgery group compared to the endoscopy group (35 vs 44 minutes, P = .016). Peritonitis, local adhesions, and leak test results were comparable in both groups. Distant adhesions were less frequent in the endoscopic closure group (26.1% vs 56.5%, P = .03). Five of the 186 T-tags (2.7%) were noted in the adjacent viscera.

LIMITATION

This porcine study does not mimic clean colon perforation in humans; it mimics dirty colon perforation in humans.

CONCLUSIONS

Endoscopic closure of a 4-cm colon perforation was comparable to surgery, and this technique can be potentially used for closure of intentional or inadvertent colon perforations.