Colonic perforation: can we manage it endoscopically?

Clinical outcomes of endoscopic submucosal dissection for giant rectal tumors larger than 8 cm: A European referral center experience

BACKGROUND AND AIMS

To date, western data on colorectal ESD are limited. This study aimed to assess the efficacy and safety of rectal ESD for superficial lesions ≥ 8 cm.

METHODS

A total of 138 superficial rectal neoplasms treated by ESD were allocated in two groups: 25 in the "giant" ESD group and 113 in the control group.

RESULTS

En bloc resection was achieved in 96% of cases in both groups. En bloc R0 resection rate was similar between the "giant" ESD group and the control group (84% vs 86%; p: 0.5) and curative resection was higher in the control group (81%) than in "giant" ESD group (68%) without reaching statistical significance (p: 0.2). Dissection time was significantly longer in the "giant" ESD group (251 vs 108 min; p <0.001), however, dissection speed was significantly higher (0.35 vs 0.17 cm2/min; p: 0.02).). Post-ESD stenosis was observed in 2 patients from the "giant" ESD group (8% vs 0% of control group, p: 0.03). No significant differences were found in delayed bleeding, perforation, local recurrences, and need for additional surgery.

CONCLUSIONS

ESD for superficial rectal tumors ≥ 8 cm is a feasible, safe, and effective therapeutic option.

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.

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.

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.

Complete closure versus simple closure for perforations during colorectal endoscopic submucosal dissection

Background and study aims  The efficacy of complete closure versus simple closure for perforations during endoscopic submucosal dissection (ESD) has never been evaluated. We evaluated the efficacy of complete closure and simple closure for perforations and muscular layer injuries incurred during ESD. Patients and methods  Thirty-four consecutive patients who underwent "complete closure" or "simple closure" for correction of perforations and muscular layer injuries during colorectal ESD were enrolled in this study. Complete closure was performed by the mucosa-submucosa clip closure method using only conventional endo-clips. For simple closure, endo-clips are placed just for perforation or muscular layer injury, while leaving any mucosal defects open. Results  Among the 15 patients in the complete closure group, eight developed perforations and seven developed muscular layer injuries. Among the 19 patients in the simple closure group, six developed perforations and 13 developed muscular layer injuries during the ESD procedure. There were no statistically significant differences between the two groups in inflammatory reactions, adverse events, or length of the hospital stay. Conclusion  Complete closure and simple closure for perforations and muscular layer injuries during ESD seem to have similar efficacy. While simple closure for a perforation during ESD seems sufficient, further study will be required to confirm our results.

Endoscopic Band Ligation Is Able to Close Perforations Caused by Colonoscopy: A Porcine Model Study

Objective

Diagnostic colonoscopy is important for diagnosing colorectal diseases, including inflammatory bowel disease and colorectal tumours. Perforation during diagnostic colonoscopy, a rare but serious complication, is a considerable factor before performing the procedure. Immediate endoluminal closure of a perforation could prevent the adverse consequences associated with general anaesthesia and surgery. This study is aimed at assessing the potential effectiveness and safety of endoscopic band ligation (EBL) in closing a colon perforation during endoscopy in a porcine model.

Methods

Colon perforations were created and then subsequently closed with EBL in six porcine models. After 28 days of careful follow-up, pigs were euthanized for clinical and pathologic evaluations.

Results

All colon perforations were successfully closed using EBL in pigs. The mean time of perforation closure with EBL was 244.3 seconds with one to two bands, and there were no immediate complications or clinical manifestations of peritonitis or sepsis in any animals. No pericolonic abscess or peritonitis was found during necropsy. Histopathology demonstrated reepithelialization of the mucosa at the perforation site.

Conclusions

Immediate closure of perforations caused during colonoscopy with EBL is feasible and safe in a porcine model.

2017 WSES guidelines for the management of iatrogenic colonoscopy perforation

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

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

Endoscopic perforations: what are the indications for surgery?

BACKGROUND

Despite their low occurrence, endoscopic perforations (EPs) are concerning. Some predictive factors have been identified, and EP management is debated, whether non-surgical (medical and/or endoscopic) or surgical. The objective was to elaborate a predictive score for surgical management of EP.

METHODS

All the patients addressed for upper and lower EP, except oesophageal EP, were retrospectively included (2004-2015). Demographic data, endoscopic features (indication, location, type), clinical, biological and radiological presentations of EP were reviewed. Management of EP and outcomes were recorded. A predictive score was constructed by multiple linear regression and a cut-off value for surgical management was identified. Additional subgroup analysis was performed according to the location of EP (upper and lower).

RESULTS

Among 41150 endoscopic procedures, 44 patients (22 males, median age = 65 years [22-87]) presenting with EP were included (0.09%). Lower gastrointestinal (GI) endoscopy was mostly performed (66%). EP diagnosis was immediate in 73% of the cases (n = 32). Non-surgical management was efficient in 2/3 cases treated medically alone, and 18/20 cases treated by endoscopy. Surgical management was always successful (n = 24/24). In case of peritonitis, surgery was systematically required, whereas easily required in case of delayed diagnostic of EP. The EP score was based on the presence of previous abdominal surgery, lower GI endoscopy and diagnostic endoscopy. A cut-off EP score of 22.8% for surgery was chosen; it was associated with a specificity and sensitivity of 40 and 100%, respectively. When subgroups were analysed according to EP location, the EP score was still based on the presence of previous abdominal surgery and diagnostic endoscopy. The cut-off was 6.3 and 73.3% for upper (specificity: 73%, sensitivity: 100%) and lower (89 and 45%) locations, respectively.

CONCLUSION

The predictive EP score may avoid inappropriate surgical management, as well as delayed surgery after non-surgical management failure. Forthcoming study should prospectively validate this score.

Colonoscopy: Advanced and Emerging Techniques-A Review of Colonoscopic Approaches to Colorectal Conditions

A complete colonoscopy is key in the diagnostic and therapeutic approaches to a variety of colorectal diseases. Major challenges are incomplete polyp removal and missed polyps, particularly in the setting of a difficult colonoscopy. There are a variety of both well-established and newer techniques that have been developed to optimize polyp detection, perform complete polypectomy, and endoscopically treat various complications and conditions such as strictures and perforations. The objective of this article is to familiarize the colorectal surgeon with techniques utilized by advanced endoscopists.

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

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

Complications of endoscopic polypectomy, endoscopic mucosal resection and endoscopic submucosal dissection in the colon

Endoscopic resection (ER), including endoscopic polypectomy (EP), endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are used to remove superficial neoplasms from the colon. Snare resection is used for EP and EMR, whereas endoscopic knives are used to perform dissection in the submucosal space in ESD. 80-90% colonic polyps are <10 millimetres (mm) and are effectively managed by conventional EP. Increasingly cold snare polypectomy is preferred. Large laterally spreading lesions (LSLs) and sessile polyps ≥20 mm are primarily removed by EMR. ESD may be used when superficial invasive disease is suspected and for some LSLs, particularly non-granular subtypes. Resection of colonic lesions by ER is associated with a small but definite incidence of significant complications, most commonly bleeding and perforation. This review discusses complications of ER with a particular focus on their prevention, early recognition and management. In many cases, complications from all three procedures share similar mechanisms and management principles and these are described at the start of each section, followed by a description of specific aspects for individual procedures.

Iatrogenic Perforations During Colonoscopy In a Portuguese Population: A Study Including In and Out-Of-Hospital Procedures

INTRODUCTION

The risk of iatrogenic perforations in colonoscopy is not negligible. Experience with endoscopic closure of perforations is increasing and new devices for this purpose are being released, making endoscopy a therapeutic option. National data regarding iatrogenic perforations is scarce and the burden of iatrogenic perforations in out-hospital procedures is poorly characterized in the literature.

OBJECTIVE

Evaluation of iatrogenic perforations rate during colonoscopy, their characteristics, management and prognosis.

METHODS

Retrospective study of all patients with perforations secondary to in-hospital and non-hospital colonoscopies treated in a tertiary hospital between 01-01-2006 and 01-10-2014. Demographic, endoscopic, radiological and therapeutic data were analyzed.

RESULTS

Fifty-three perforations were identified, 20 occurring in colonoscopies performed in non-hospital environment (45% with therapeutic procedures) and 33 occurring in-hospital procedures (73% in therapeutic colonoscopies; representing 0.12% of all colonoscopies carried out in-hospital). Patients: male in 56%, average age of 71 years, history of previous abdominopelvic surgery in 31% and diverticulosis in 10%. Colonoscopy: elective in 93%, under deep sedation in 21%, with less than excellent/good bowel preparation in 56%. A resident was the first performer in 10 cases. Perforations: average size of 21 mm (4-130 mm), diagnosed during the procedure in 51% of cases and occurred in rectum-sigmoid transition in 58.5%. Regarding therapeutics, all patients with perforation occurring in non-hospital colonoscopies were managed by surgery. Concerning treatment of those in our unit: 2-conservative, 12-endoscopic (10 successfully), 21-surgical (including the 2 cases with failure of the endoscopic approach). Comparing endoscopic treatment (n = 10, G1) versus surgery (n = 21; G2): perforation size - 9 mm (G1) versus 28 mm (G2); perforation location - 7/10 in rectum-sigmoid (G1) versus 8/21 in rectum-sigmoid and 10/21 transverse/ascending colon/hepatic angle (G2). Morbidity: 1 infection in G1 and 13 complications in G2 (infection, hemorrhage, fistula). Mortality: no deaths in G1 and 2 deaths at 30 days due to septic shock in G2.

CONCLUSION

Perforations in colonoscopy are rare in our clinical practice. Endoscopic closure was effective, though limited to perforations found during the procedure. The mortality was relatively low and endoscopic management did not seem to worsen it. An additional effort is necessary in order to detect perforations during colonoscopy.

Endoscopic clips for the closure of acute iatrogenic perforations: Where do we stand?

BACKGROUND AND AIM

Iatrogenic perforation of the gut during endoscopy remains an uncommon but critical complication with significant morbidity and probable mortality than usual surgical treatment. Some authors have adopted a non-surgical closure method in chosen cases and, since 1993, endoclips have been used to close perforation in the stomach. The endoscopic practice of endoclips has been commonly used in the gut for hemostasis. Currently, the use of endoscopic techniques is increasing for the closure of endoscopic submucosal dissection or endoscopic mucosal resection. Endoscopic perforations that improved with endoscopic closure in the literature prior to 2008 have been previously described. In the present article, we present a descriptive review of cases with iatrogenic perforation in the gut treated with endoclips between 2008 and 2014.

METHODS

Comprehensive literature screening and a systematic review using PubMed and Medline was done for all reports published between January 2008 and December 2014 using the endoclip technique in the closure of iatrogenic perforations.

RESULTS

A total of 47 studies published between 2008 and 2014 using endoclips for the closure of iatrogenic perforations of the gut (nine esophagus, 11 stomach, 15 duodenum, 12 colon and rectum) were found. All studies were explained briefly and summarized in a table.

CONCLUSIONS

There is strong evidence to show the efficacy of endoclips in the management of iatrogenic perforations, especially when recognized early. Limitations of endoclipping such as inefficiency against large perforations may be overcome by improving novel techniques in the future.

Perforation of a Long-standing Ileocolonic Anastomosis During Colonoscopy

Colonoscopy is a valuable diagnostic and therapeutic procedure. Colonic perforation is a serious complication of colonoscopy that must be promptly recognized to limit morbidity and mortality. We present a 69-year-old woman who, during colonoscopy, had a perforation secondary to barotrauma of a long-standing ileocolonic anastomosis proximal to the point of colonoscopic intubation. To our knowledge, this is the first case report of a perforation of a well-established anastomosis proximal to the point of endoscope intubation during colonoscopy.

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.