Colonoscopic perforations: a review of 30,366 patients

Stool-Based Testing for Post-Polypectomy Colorectal Cancer Surveillance Safely Reduces Colonoscopies: The MOCCAS Study

BACKGROUND & AIMS

Colonoscopy-based surveillance to prevent colorectal cancer (CRC) causes substantial burden for patients and health care. Stool tests may help to reduce surveillance colonoscopies by limiting colonoscopies to individuals at increased risk of advanced neoplasia.

METHODS

This cross-sectional observational study included individuals aged 50-75 years with surveillance indication. Before bowel preparation, participants collected samples for a multitarget stool DNA test and 2 fecal immunochemical tests (FITs). Test accuracy was calculated for all surveillance indications. For the post-polypectomy indication only, which is the most common and is associated with a relatively low CRC risk, long-term impact of stool-based surveillance was evaluated with the Adenoma and Serrated Pathway to Colorectal Cancer (ASCCA) model. Stool-based strategies were simulated to tune each test's positivity threshold to obtain strategies at least as effective as colonoscopy surveillance.

RESULTS

There were 3453 individuals with results for all stool tests and colonoscopy; 2226 had previous polypectomy, 1003 had previous CRC, and 224 had a familial risk. Areas under the receiver operating characteristic curve for advanced neoplasia were 0.72 (95% CI, 0.69-0.75) for the multitarget stool DNA test, 0.61 (95% CI, 0.58-0.64) for the FIT OC-SENSOR (Eiken Chemical Co, Tokyo, Japan) and 0.59 (95% CI, 0.56-0.61) for the FIT FOB-Gold (Sentinel, Milan, Italy). Stool-based post-polypectomy surveillance strategies at least as effective as colonoscopy surveillance reduced the number of colonoscopies by 15%-41% and required 5.6-9.5 stool tests over a person's lifetime. Multitarget stool DNA-based surveillance was more costly than colonoscopy surveillance, whereas FIT-based surveillance saved costs.

CONCLUSIONS

This study found that stool-based post-polypectomy surveillance strategies can be safe and cost-effective, with potential to reduce the number of colonoscopies by up to 41%.

CLINICALTRIALS

gov, Number: NCT02715141.

Endoscopic management of colonic perforations

PURPOSE OF REVIEW

We will review the current management of colonic perforations, with particular emphasis on iatrogenic perforations caused by colonoscopy, the leading etiology. We will focus on recently developed endoscopic techniques and technologies that obviate morbid emergency surgery (the standard management approach in years past).

RECENT FINDINGS

Colonic perforations are rare but potentially fatal complications of both diagnostic and therapeutic colonoscopy resulting in death in approximately 5% of cases with the mortality increasing with delay in diagnosis and treatment. As novel endoscopic techniques and tools have flourished in recent years, our approach to management of these perforations has evolved. With the availability of newer tools such as over the scope clips, enhanced through the scope clips and novel endoscopic suturing devices, colonic perforations can be managed effectively in many or most patients without the morbidity of surgical interventions.

SUMMARY

With expanding use of colonoscopy, inadvertent outcomes such as perforations are bound to increase as well. Early diagnosis permits minimally invasive, nonsurgical, endoscopic management in most cases if the expertise and tools are available. Centers with high colonoscopy volumes including therapeutic procedures would be well served to invest in the requisite technologies and expertise.

Raman spectroscopy on dried blood plasma allows diagnosis and monitoring of colorectal cancer

Colorectal cancer (CRC) remains challenging to diagnose, necessitating the identification of a noninvasive biomarker that can differentiate it from other conditions such as inflammatory bowel diseases (IBD) and diverticular disease (DD). Raman spectroscopy (RS) stands out as a promising technique for monitoring blood biochemical profiles, with the potential to identify distinct signatures identifying CRC subjects. We performed RS analysis on dried plasma from 120 subjects: 32 CRC patients, 37 IBD patients, 20 DD patients, and 31 healthy controls. We also conducted longitudinal studies of CRC patient's postsurgery to monitor the spectral changes over time. We identified six spectral features that showed significant differences between CRC and non-CRC patients, corresponding to tryptophan, tyrosine, phenylalanine, lipids, carotenoids, and disulfide bridges. These features enabled the classification of CRC patients with an accuracy of 87.5%. Moreover, longitudinal analysis revealed that the spectral differences normalized over 6 months after surgery, indicating their association with the presence of the disease. Our study demonstrates the potential of RS to identify specific biomolecular signatures related to CRC. These results suggest that RS could be a novel screening and monitoring tool, providing valuable insights for the development of noninvasive and accurate diagnostic methods for CRC.

Factors associated with irritable bowel syndrome and Helicobacter pylori infection: public knowledge and awareness of signs and symptoms

OBJECTIVE

To investigate factors related to the risk of developing irritable bowel syndrome (IBS) or Helicobacter pylori infection.

METHODS

This cross-sectional, questionnaire-based study analysed the responses from participants that completed an online questionnaire, which asked about their knowledge of the causes and risk factors associated with IBS and H. pylori infection.

RESULTS

The study analysed responses from 230 participants: 181 females (of 227 participants; 79.7%) and 190 aged 18-40 years (of 228; 83.3%). Of the 230 participants, 40 (17.4%) had been diagnosed by a physician with IBS and 57 (24.8%) had been diagnosed with H. pylori infection. Of 226 participants, 93 (41.2%) had self-medicated with antibiotics in the past 6 months for various reasons. The overall mean ± SD knowledge score about IBS and H. pylori infection for the study cohort (n = 230) was 35.8 ± 19.2%. Wald χ2-test analysis demonstrated that chronic diseases, antibiotic use and having an endoscopy were significantly associated with developing IBS. Male sex and chronic diseases were significantly associated with H. pylori infection. Logistic regression analysis showed no relationship between IBS and H. Pylori infection.

CONCLUSION

Chronic diseases was the only risk factor common for IBS and H. pylori infection.

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.

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.

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.

A case of transanal barotrauma by high-pressure compressed air leading to transverse colon perforation with extensive colon serosal tear

INTRODUCTION AND IMPORTANCE

Compressed air is used to apply paint, wash vehicles or machines, and remove water droplets after washing the precision instrument. Barotrauma due to high-pressure compressed air is extremely rare.

CASE PRESENTATION

We report a case of transverse colon perforation caused by a compressed air gun in a 20-year-old male. He used a compressed air machine to dust after work, and a coworker inserted compressed air transanally as a joke. Although he returned home once, he consulted a former hospital with worsening abdominal pain. Radiography and computed tomography (CT) revealed a massive amount of free air. The patient was admitted to our hospital. The patient underwent emergency surgery. Transverse colon perforation with extensive serosal tears and massive air bubbles inside the omental bursa were observed. Double-barrel colostomy using transverse colon perforation point for decompression and diverting the stoma at the ileum end was performed with serosal tear repair and abdominal cleaning drainage. Four months after the surgery, the patient underwent colostomy and diverting stoma closure.

CLINICAL DISCUSSION

The management of colon injury due to compressed air has two aspects: tension pneumoperitoneum and colon injury. The initial management of tension pneumoperitoneum is converted to open pneumoperitoneum and early emergency operation for colon injury is recommended as soon as full-thickness perforation is diagnosed.

CONCLUSION

Transanal high-pressure compressed air can cause lethal situations, and we encountered a similar case that required surgical intervention.

Factors Associated With Fecal Calprotectin Sample Collection Compliance: An IBD Center Quality Improvement Project

Background

Fecal calprotectin (Fcal) is a noninvasive, inexpensive biomarker of disease activity. However, patient compliance with this test is variable and incompletely described. We assessed compliance rates with Fcal tests and identified factors associated with noncompliance.

Methods

A retrospective chart review of patients with inflammatory bowel disease (IBD) who had a Fcal test ordered through our center between August 2021 and December 2021 was conducted. Demographic, clinical, disease, and test-related information were recorded. Patients with incomplete Fcal orders were sent a survey to better understand their reasons for noncompliance. Simple statistical analysis and and multivariable logistic regression modeling were performed.

Results

Of 303 patients, 165 (54.4%) had an order for Fcal. Of the Fcal tests ordered, 55 (33.3%) were not completed. Remission of IBD, no prior Fcal completion, and tests ordered at a distant site were all associated with test noncompletion. A multivariable logistic regression revealed that history of a prior completed Fcal test is associated with subsequent test completion (odds ratio = 2.1, 95% confidence interval 1.9-35.5, P = .004). Patients who did not complete the test described the pandemic and third-party testing center issues as the most common reasons for noncompliance.

Conclusions

In this single center experience with Fcal testing in patients with IBD, we identified that a history of incomplete Fcal testing and distant location of lab testing were significantly associated with noncompletion of the test. We provide practical guidance for future utilization and compliance, including the impact of home-based testing.

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.

[Factors Associated with the Clinical Outcomes of Iatrogenic Colonic Perforation]

Background/Aims

This study evaluated the incidence of iatrogenic colonic perforation (ICP) in a high-volume center and analyzed the clinical outcomes and associated factors.

Methods

As a retrospective study of the electronic medical records, the whole data of patients who underwent colonoscopy from June 2004 to May 2020 were reviewed.

Results

During 16 years, 69,458 procedures were performed, of which 60,288 were diagnostic and 9,170 were therapeutic. ICP occurred in 0.027% (16/60,288) for diagnostic colonoscopies and in 0.076% (7/9,170) for therapeutic purposes (p=0.015; hazard ratio 2.878; 95% CI, 1.184-6.997). Fifty-two percent (12 cases) were managed with endoscopic clip closure, and 43.5% (10 cases) required surgery. The reasons for the procedure and the procedure timing appeared to affect the treatment decision. Perforations during therapeutic colonoscopy were treated with surgery more often than those for diagnostic purposes (66.7% [4/6] vs. 37.5% [6/16], p=0.221). Regarding the timing of the procedure, ICP that occurred in the afternoon session was more likely treated surgically (56.3% [9/16] vs. 0/5, p=0.027). Mortality occurred in two patients (2/23, 8.7%). Both were aged (mean age 84.0±1.4 vs. 65.7±10.5, p<0.001) and lately recognized (mean elapsed time [hours], 43.8±52.5 vs. 1.5±3.0, p<0.001) than the surviving patients.

Conclusions

ICP occurs in less than 0.1% of cases. The events that occurred during the morning session were more likely managed endoscopically. Age over 80 years and a longer time before perforation recognition were associated with mortality.

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.

Clinical characteristics and outcome of iatrogenic colonic perforation related to diagnostic vs. therapeutic colonoscopy

Aim

Iatrogenic colonic perforation (ICP) is a rare serious complication of colonoscopy, where standard treatment is controversial. This study aimed to characterize diagnostic ICP (DICP) compared to therapeutic ICP (TICP) and determine the possible indication of endoscopic repair.

Methods

We studied patients with ICP over 7 years starting in 2011. Their demographics and data regarding perforation, treatment, and outcome were investigated by retrospective review of medical records, and the diagnostic and therapeutic groups were compared.

Results

Among 29,882 patients who underwent colonoscopy, ICP was identified in 28 (0.09%: diagnostic, 15/24,758, 0.06%; therapeutic, 13/5124, 0.25%). A total of 56 patients (33 DICP and 23 TICP) including 28 referred cases were analyzed. Mean age was 62.3 ± 11.4 years, and 24 were men. Perforations occurred mostly in the rectosigmoid region and half were detected during or immediately after colonoscopy. Endoscopic treatment was successful in 22 cases and 34 required surgery. Mortality occurred in 4 (7.1%).

Compared to TICP, DICP was more prevalent in females and rectosigmoid region and more frequently detected immediately (all p < 0.05); DICP tended to occur in older patients, be larger and have better chance of endoscopic repair.

Regardless of type of ICP, female predominance, smaller perforation, more frequent immediate detection, and shorter hospital stay (all p = 0.01) were found in the endoscopic repair group.

Conclusion

DICP was more frequent in the rectosigmoid area in older women and could be detected immediately. Immediate detection and small perforation size could be important factors for endoscopic repair. Careful attention and gentle manipulation should be required.

Detecting Task Difficulty of Learners in Colonoscopy: Evidence from Eye-Tracking

Eye-tracking can help decode the intricate control mechanism in human performance. In healthcare, physicians-in-training require extensive practice to improve their healthcare skills. When a trainee encounters any difficulty in the practice, they will need feedback from experts to improve their performance. Personal feedback is time-consuming and subjected to bias. In this study, we tracked the eye movements of trainees during their colonoscopic performance in simulation. We examined changes in eye movement behavior during the moments of navigation loss (MNL), a signature sign for task difficulty during colonoscopy, and tested whether deep learning algorithms can detect the MNL by feeding data from eye-tracking. Human eye gaze and pupil characteristics were learned and verified by the deep convolutional generative adversarial networks (DCGANs); the generated data were fed to the Long Short-Term Memory (LSTM) networks with three different data feeding strategies to classify MNLs from the entire colonoscopic procedure. Outputs from deep learning were compared to the expert's judgment on the MNLs based on colonoscopic videos. The best classification outcome was achieved when we fed human eye data with 1000 synthesized eye data, where accuracy (91.80%), sensitivity (90.91%), and specificity (94.12%) were optimized. This study built an important foundation for our work of developing an education system for training healthcare skills using simulation.

Paradigm shift in management of acute iatrogenic colonic perforations: 24-year retrospective comprehensive study

Background and study aims  Through advanced endoscopic clipping techniques, endoscopic treatment of both diagnostic and therapeutic acute iatrogenic colonic perforations has been shown effective. The main purpose of this study was to compare the management of acute iatrogenic perforations (AIPs) of the colon before and after the introduction of advanced clipping techniques. Methods  We conducted a retrospective study from July 1996 to February 2020. The period was divided into two sub periods, Period 1: from July 1996 to December 2012 and Period 2: from January 2013 to March 2020. All AIPs occurring during a colonoscopy and detected during or immediately (< 4 hours) after the procedure, were included in the study. Results  The total number of colonoscopies performed at our hospital was 33055 and 36831 during Periods 1 and 2 respectively. Fifteen perforations were observed in Period 1 and 11 in Period 2. The rate of surgery was 93.3 % % (14/15) in Period 1 and 27.2 % (3 /11) in Period 2 ( P  < 0.01). The mean hospital stay in Period 1 was 6.9 days and 4 in Period 2 ( P  < 0.01). Conclusions  Data from this historical cohort have clearly shown a decrease in the surgery rate and the length of hospitalization of AIPs in Period 2 compared to Period 1.

MicroRNA-320a Monitors Intestinal Disease Activity in Patients With Inflammatory Bowel Disease

In patients with inflammatory bowel disease (IBD), a treat-to-target treatment strategy requires tight monitoring of disease activity. Noninvasive biomarkers may help to monitor the intestinal disease activity. We demonstrated recently that peripheral microRNA (miR)-320a expression in mice follows the course of experimental colitis. The aim of this study was to evaluate the potential of miR-320a to monitor the disease activity in patients with IBD, to predict the course of disease, and to distinguish IBD from infectious colitis.

Medico-legal implications for the colon perforation during colonoscopy

Colon perforation is the most serious complication of colonoscopy, and tends to be considered as malpractice. The aim of this study was to identify the characteristics and causes of medical accidents by analyzing lawsuit cases on colon perforation during colonoscopy. We collected judgment results that were ruled from 2005 to 2015 using the keyword 'colonoscopy' in the 'Korea's Written Judgment Public Reading System' of the Supreme Court, and extracted the cases of colon perforation. Characteristics of medical accidents and the decisions of courts were analyzed from written judgments. Twenty-two lawsuits were analyzed. Most cases were ruled in favor of the plaintiff (n = 20). The allegations against defendants, as filed by the plaintiffs, were performance error (n = 22), improper monitoring after colonoscopy (n = 7), and a lack of informed consent (n = 8). The median compensation was 9335.47 US dollars; this is about 130 times the cost of a single colonoscopy in Korea. The greater the intestinal damage, the greater the amount of compensation (p = 0.016). The time interval from procedure to diagnosis of perforation was most frequently 24 h later (n = 9). It is important to educate patients completely about the symptoms of colon perforation and to guide them to contact medical institutions immediately when symptoms occur. In addition, doctors should explain sufficiently the possibility of perforation before colonoscopy to the patient, and not the caregiver, and get informed consent.

A Case of Tension Pneumothorax After Diverticular Rupture During Diagnostic Colonoscopy

Colonoscopy is routinely used for the diagnosis and treatment of colorectal diseases. Bowel perforation is a rare but severe complication that significantly increases the morbidity and mortality. Tension pneumothorax is an uncommon complication of colonic perforation. We present a case of the successful treatment of a patient with tension pneumothorax, following colonoscopy, by using tube thoracostomy and Hartman-type resection of the rectosigmoid junction and proximal sigmoid. Surgeons, anesthesiologists, and endoscopists should consider the possibility of pneumothorax as a rare complication of colonoscopy. Early detection and urgent treatment is the key to successful management.

Perception and Practices of Colonoscopy Procedure: A Nationwide Survey of Indian Gastroenterologists

Introduction There is a lack of data and consensus about the practices and policies regarding performing colonoscopy in India. We surveyed gastroenterologists to assess their practices and policies of performing colonoscopy.

Methodology A questionnaire was presented to gastroenterologists all over India regarding their preference of bowel preparation and method of sedation, completeness of cecal and ileal intubation rates, preferences for inflation, use of carbon dioxide and nitrous oxide, and complications faced.

Results Of the 350 surveys, 307 had completely responded (88%). Only 18% of the centers were conducting more than 100 colonoscopies a month and 46% denied following a colon cancer screening policy. Two bottles of liquid polyethylene glycol were the most preferred preparation. A total of 21% did not prefer any sedation at all. Nitrous oxide was used by only 5.6% of doctors. Ileal intubation rate was >96% in 34% of centers and cecal intubation rate >96% in 58% of centers. Air was used for inflation by 58%, while 39% used CO2. A total of 40% of the respondents believe CO2 inflation would improve cecal intubation rate, while 9.4% believed otherwise. While one third found CO2 inflation unnecessary and 14% not cost-effective, three fourths were still interested in setting up a CO2 facility. Reasons for not using nitrous oxide were practical/administrative difficulty (46.6%), side effects (20%), and cost (16%). Still more than half surveyed would consider using Entonox in future. Perforation was the most noted complication faced by respondents.

Conclusions This survey of real-world clinical practices will help to formulate practice guideline regarding colonoscopy in India.

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.

Pneumatosis Cystoides Intestinalis Identified on Screening Colonoscopy With Associated Pneumoperitoneum

Pneumatosis cystoides intestinalis (PCI) is defined by the presence of gas within the bowel wall. It is often asymptomatic and usually benign but may be associated with significant morbidity and mortality. In this patient, PCI was found incidentally on screening colonoscopy, and biopsy of the affected mucosa resulted in deflation of a cyst. Pneumoperitoneum was then identified on subsequent CT. Because pneumoperitoneum is associated with bowel perforation in most cases, it is often treated as an indication for operation. This case of benign and asymptomatic pneumoperitoneum was managed conservatively without complications. Clinicians should be able to identify PCI as a potentially benign finding on colonoscopy as well as a potentially benign cause of pneumoperitoneum. This understanding presents an opportunity to avoid the unnecessary morbidity and costs associated with surgical exploration or additional endoscopic procedures.

Magnetic resonance spectroscopy and its application in colorectal cancer diagnosis and screening: A narrative review

There are several slightly invasive methods to detect colorectal carcinoma (CRC) including colonoscopy and sigmoidoscopy; but there is no noninvasive, accurate screening test. It is recommended to initiate screening at the age of 50 for non-familial CRC. Laboratory tests are routinely suggested if internal observation and imaging are recommended for further evaluation. Spectroscopic-based imaging, such as magnetic resonance spectroscopy (MRS) is an interesting and promising tool with the potential to be an alternative to some minimally invasive procedures, such as biopsy. Accordingly, MRS might be a suitable substitution for invasive methods, such as colonoscopy. This article aimed to review the studies that have evaluated the MRS technique as a screening tool in CRC.

Development of Simulator Guidelines for Resident Assessment in Flexible Endoscopy

Virtual reality (VR) simulators may hold a role in the assessment of trainee abilities independent of their role as instructional instruments. Thus, we piloted a course in flexible endoscopy to surgical trainees who had met Accreditation Council for Graduate Medical Education endoscopy requirements to establish the relationship between metrics produced by a VR endoscopic simulator and trainee ability. After a didactic session, we provided faculty instruction to senior residents for Case 1 upper endoscopy and colonoscopy modules on the CAE Endoscopy VR. Course conclusion was defined as a trainee meeting all proficiency standards in basic endoscopic procedures on the simulator. Simulator metrics and course evaluation comprised data. Eleven and eight residents participated in the colonoscopy and upper endoscopy courses, respectively. Average time to reach proficiency standards for esophagogastroduodenoscopy was 6 and 13 minutes for colonoscopy after a median of one (range, one to two) and one (range, one to four) task repetitions, respectively. Faculty instruction averaged 7.5 minutes of instruction per repetition. A subjective course evaluation demonstrated that the course improved learners’ knowledge of the subject and comfort with endoscopic equipment. Within a VR-based curriculum, experienced residents rapidly achieved task proficiency. The resultant scores may be used as simulator guidelines for resident assessment and readiness to perform flexible endoscopy.

Can a biomarker triage test reduce colonoscopy burden in fecal immunochemical test screening?

Aim: To assess the potential of biomarker triage testing (BM-TT) in the Dutch colorectal cancer (CRC) screening program. Materials & methods: Using the Adenoma and Serrated pathway to Colorectal CAncer model, we simulated fecal immunochemical test (FIT)₄₇-screening and various FIT plus BM-TT screening scenarios in which only individuals with both a positive FIT and BM-TT are referred to colonoscopy. Results: Adding a low polyp sensitivity BM-TT to FIT-screening reduced colonoscopy burden (89-100%) while increasing CRC mortality (27-41%) compared with FIT₄₇-screening only. The FIT plus high polyp sensitivity BM-TT scenarios also decreased colonoscopy burden (71-89%) while hardly affecting CRC mortality (FIT₄₇ 0-4% increase, FIT₁₅ 2-7% decrease). Conclusion: Adding a BM-TT to FIT-screening considerably reduces colonoscopy burden, but could also decrease screening effectiveness. Combining FIT₁₅ with a high polyp sensitivity BM-TT seems most promising.

Public preferences for using quantitative faecal immunochemical test versus colonoscopy as diagnostic test for colorectal cancer: evidence from an online survey

BACKGROUND

There has been interest in using the non-invasive, home-based quantitative faecal immunochemical test (FIT) to rule out colorectal cancer (CRC) in high-risk symptomatic patients.

AIM

To elicit public preferences for FIT versus colonoscopy (CC) and its delivery in primary care.

DESIGN & SETTING

A cross-sectional online survey in England.

METHOD

A total of 1057 adults (without CRC symptoms and diagnosis) aged 40-59 years were invited from an English online survey panel. Responders were asked to imagine they had been experiencing CRC symptoms that would qualify them for a diagnostic test. Participants were presented with choices between CC and FIT in ascending order of number of CRCs missed by FIT (from 1-10%). It was measured at what number of missed CRCs responders preferred CC over FIT.

RESULTS

While 150 participants did not want either of the tests when both missed 1% CRCs, the majority (n = 741, 70.0%) preferred FIT to CC at that level of accuracy. However, this preference reduced to 427 (40.4%) when FIT missed one additional cancer. Women were more likely to tolerate missing CRC when using FIT. Having lower numeracy and perceiving a higher level of risk meant participants were less likely to tolerate a false negative test. Most of those who chose FIT preferred to return it by mail (62.2%), to be informed about normal test results by letter (42.1%), and about abnormal test results face to face (32.5%).

CONCLUSION

While the majority of participants preferred FIT over CC when both tests had the same sensitivity, tolerance for missed CRCs was low.

Clinical Characteristics of Colonoscopic Perforation and Risk Factors for Complications After Surgical Treatment

Background: There are few studies on postoperative complications after colonoscopic perforation. We aimed to study clinical characteristics and treatment after colonoscopic perforation, and to determine risk factors for postoperative complications by surgical treatment of colonoscopy perforation. Methods: Cases with perforation within 7 days after colonoscopy from January 2017 to December 2019 were collected for retrospective analysis. Data regarding demography, clinical information, colonoscopy, perforation, and operation were collected. Single-factor analysis and Spearman correlation analysis were employed to determine the risk factors of postoperative complications. Results: A total of 35,243 colonoscopy examinations were performed during the study period, of which 18 cases of colonoscopic perforation were included in the criteria. Most perforations occurred in the rectosigmoid junction (3 cases) and sigmoid colon (11 cases). All perforation patients received operational treatment, and the incidence of postoperative complications was 38.9%, but no deaths. There were 7 patients who developed postoperative complications. Spearman correlation analysis showed that preoperative medication of glucocorticoid and nonrectosigmoid perforation were positively related to postoperative complications (P < .05), while perforation diagnosed immediately and satisfying intestinal cleanliness were negatively related to it (P < .05). Conclusion: Perforation is a rare but serious complication of colonoscopy, which mostly occurs in the rectosigmoid junction and sigmoid colon. Laparoscopic primary repair is safe and feasible in resolving colonic perforation due to colonoscopy, and postoperative complications were significantly related to perforation site, preoperative medication of glucocorticoid, perforation diagnosis time, and intestinal cleanliness.

Rectal perforation following endorectal prostate MRI: an unexpected complication

Background

Prostate cancer is a common cancer among men in developed countries. Prostate magnetic resonance imaging (MRI) has been widely employed for early diagnosis of prostate cancer and recommending a treatment plan. The incidence of rectal perforation during endorectal prostate MRI is rare and has never been reported before. Herein, we present a case of rectal perforation after a prostate MRI examination that was subjected to emergency surgical intervention because of the acute presentation of generalized peritonitis. Patients with systemic comorbidities are reportedly at greater risks of encountering colonoscopic perforation. Endorectal prostate MRI is a safe diagnostic modality, but inadequate lubrication of the endorectal coil or over-insufflation of the balloon during the procedure may also lead to serious complications such as hollow organ perforation. Early surgery will be necessary should peritoneal symptoms persist.

Case presentation

In 2015, a 56-year-old man came to our ER due to acute abdominal pain after he finished his MRI exam. The exam indicated diffuse tenderness over his abdomen and at the ER, his abdominal CT (computerized tomography) was checked. The images revealed extraluminal air in the perirectal fat and the pneumoperitoneum. In response, exploratory laparotomy, simple closure of rectal perforation, and loop-S colostomy were performed and the patient was discharged 1 month after operation.

Conclusions

Prostate MRI is a secure procedure with few complications. Clinicians must keep in mind the possibility of perforation when using ultrasound probe. Hollow organ perforation can result in serious morbidity or death. As a result, patients need to be informed of the complications of prostate MRI. When performing the procedure, clinicians must be cautioned about the potential problems for patients with high-anesthetic risk.

Use of the Over the Scope Clip to Close Perforations and Fistulas

In gastrointestinal perforation or fistula, endoscopic closure techniques could be used as alternatives to surgery. Early endoscopic recognition and treatment of gastrointestinal perforation is the most important factor determining procedural success and clinical outcomes. The over-the-scope clip with full-thickness grasping capability provides greater technical and clinical success rates compared with the through-the-scope clips. Although the technical success rate of chronic fistula closure is comparable to perforation closure, it has a significantly lower clinical success owing to its less healthy tissue edge of the fistula. The over-the-scope clip system should be considered before surgery for the closure of perforation and fistula.

Verbal Descriptions Accompanying Numeric Information About the Risk: The Valence of Message and Linguistic Polarity

The aim of this study was to investigate the effect of presenting risk on decision making and evaluations with regard to the valence (positive vs. negative) and the linguistic polarity (direct vs. indirect). Participants were presented with a message in which patients were informed about risk associated with some diagnostic medical procedures. In the presented text, before obtaining statistical information about risk (e.g., 1 in 1000), four types of the verbal descriptions were used (risk is high/risk is not low/risk is low/risk is not high). The valence of information influenced the decision and respondent's evaluation. Participants receiving a verbal description with a positive valence were more positive about the patient' decision, and more positively evaluated the doctor and patient's mood than participants receiving a description with a negative valence. Neither main nor interaction effects with linguistic polarity were found. The research does not support that indirect wording mitigates the meaning of a message on risk and highlights the strength and persistence of relying on the verbal description, particularly their affective valence.

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.

Over-the-scope clip management of non-acute, full-thickness gastrointestinal defects

BACKGROUND

Endoscopic management of full-thickness gastrointestinal tract defects (FTGID) has become an attractive management strategy, as it avoids the morbidity of surgery. We have previously described the short-term outcomes of over-the-scope clip management of 22 patients with non-acute FTGID. This study updates our prior findings with a larger sample size and longer follow-up period.

METHODS

A retrospective analysis of prospectively collected data was conducted. All patients undergoing over-the-scope clip management of FTGID between 2013 and 2019 were identified. Acute perforations immediately managed and FTGID requiring endoscopic suturing were excluded. Patient demographics, endoscopic adjunct therapies, number of endoscopic interventions, and need for operative management were evaluated. Success was strictly defined as complete FTGID closure.

RESULTS

We identified 92 patients with 117 FTGID (65 fistulae and 52 leaks); 27.2% had more than one FTGID managed simultaneously. The OTSC device (Ovesco Endoscopy, Tubingen, Germany) was utilized in all cases. Additional closure attempts were required in 22.2% of defects. With a median follow-up period of 5.5 months, overall defect closure success rate was 66.1% (55.0% fistulae vs. 79.6% leaks, p = 0.007). There were four mortalities from causes unrelated to the FTGID. Only 14.9% of patients with FTGID underwent operative management. There were no complications related to endoscopic intervention and no patients required urgent surgical intervention.

CONCLUSIONS

Over-the-scope clip management of FTGID represents a safe alternative to potentially morbid operative intervention. When strictly defining success as complete closure of all FTGID, endoscopy was successful in 64.4% of patients with only a small minority of patients ultimately requiring surgery.

Hospital management of colonic perforations complicating ambulatory outpatient colonoscopy via over-the-scope clips or surgery: a case series

BACKGROUND

Colonoscopy is the standard of care for the diagnosis and treatment of many colonic disorders. Over the past few years, endoscopic closure of colonoscopy-related perforation has become more common. Endoscopic closure of perforation secondary to colonoscopy has been undertaken in patients in the hospital setting and often during the same colonoscopic procedure in which the perforation itself occurred. The aim of our study was to analyze our experience with emergency endoscopic closure of colonoscopy-related perforation with over-the-scope clip (OTSC) technique.

METHODS

We report five cases of colonic perforation that occurred during colonoscopy in an outpatient facility remotely located from our hospital and then referred as an emergency to our institution for endoscopic closure.

RESULTS

Bowel preparation was reported to be adequate in all cases. Prior to attempting endoscopic closure of colonic perforation, all patients were in stable clinical condition, early broad-spectrum antibiotic coverage was initiated, and a surgical consult was obtained. All patients had sigmoidoscopy and were found to have sigmoid colon perforations. In three cases, the perforations were closed successfully using an OTSC clip device 14 mm type t. Two patients were found to have greater than 4-cm sigmoid perforations with irregular margins, incompatible with OTSC closure, and were referred for emergency surgery. All patients had an uneventful course following either OTSC closure or surgery.

CONCLUSIONS

Based on the characteristics of the five cases and a review of the literature, we suggest a practical approach for undertaking closure of colonic perforations occurring during colonoscopy in the outpatient setting, focusing on clinical criteria to determine eligibility of patients for attempted endoscopic closure and outlining required therapeutic and monitoring steps needed to optimize outcomes.

Systematic review and case series: flexible sigmoidoscopy identifies most cases of checkpoint inhibitor-induced colitis

BACKGROUND

Immune checkpoint inhibitors are used in the treatment of multiple advanced stage cancers but can induce immune-mediated colitis necessitating treatment with immunosuppressive medications. Diagnostic colonoscopy is often performed but requires bowel preparation and may delay diagnosis and treatment. Sigmoidoscopy can be performed rapidly without oral bowel preparation or sedation.

AIMS

Characterize the colonic distribution of immune-mediated colitis to determine the most efficient endoscopic approach.

METHODS

A systematic review of checkpoint inhibitor-induced colitis case reports and series was conducted in both PubMed and Embase through 3 January 2017. A single centre retrospective chart review of patients who underwent endoscopic evaluation for diarrhoea after treatment with a checkpoint inhibitor (ipilimumab, nivolumab or pembrolizumab) between 1 January 2011 and 3 January 2017 was performed. Clinical, endoscopic and histologic data were collected.

RESULTS

A detailed systematic review resulted in 61 studies, in which 226 cases of colitis were diagnosed by lower endoscopy (125 colonoscopy, 101 sigmoidoscopy). Only four patients had isolated findings proximal to the left colon. In our centre, 31 patients had histologic features of checkpoint inhibitor-induced colitis, for which 29 patients had complete data. The left colon was involved in all cases. Sigmoidoscopy would be sufficient to diagnose >98% of reported cases of checkpoint inhibitor-mediated colitis diagnosed by lower endoscopy.

CONCLUSIONS

Moderate to severe checkpoint inhibitor-induced colitis involves the left colon in the majority of cases (>98%). Sigmoidoscopy should be the initial endoscopic procedure in the evaluation of this condition.

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.

Safety and efficacy of cold polypectomy compared to endoscopic mucosal resection and hot biopsy polypectomy

Backgrounds: Recently, several studies have demonstrated the usefulness of cold polypectomy (CP), a safe and simple method for the removal of small polyps. We investigated the safety and efficacy of CP compared to that of endoscopic mucosal resection (EMR) and hot biopsy polypectomy (HB). Methods: We retrospectively examined 1713 colorectal polyps (size 1-9 mm) in 731 patients. CP, EMR, and HB were performed on 476, 997, and 240 lesions, respectively. We compared the region, size, morphology, the presence of delayed bleeding as overt bleeding 24 h after operation, number of clips, pathology, the presence of antithrombotic therapy, procedure time from detection of a polyp to resection and hemostasis, device cost including device and clips, and polyp remnants. Results: The delayed bleeding in the CP group (0/476) was significantly lower compared to that in the HB group (3/240) and EMR group (7/997). There were no cases of perforations. The procedure time was significantly shorter in the CP group than in the EMR group (91.3sec vs 290.1sec, p < .0001). The CP group had a significantly lower device cost than the HB and EMR groups (49.2USD vs 58.0 USD vs 91.3 USD, p < .0001) was not inferior in terms of polyp remnants to the EMR and HB groups. (1.4% vs 0.6% vs 6.1%, p = .1599) Conclusions: CP is a safe treatment that achieves less delayed bleeding. Moreover, CP is not inferior to other groups in terms of polyp remnants and offers a cost benefit. CP can be considered useful for colonic polypectomy.

Pneumoretroperitoneum with subcutaneous emphysema after a post colonoscopy colonic perforation

•

Colonic perforation after colonoscopy could be intraperitoneal, extraperitoneal or a combination of both.

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Majority of the perforations are intraperitoneal.

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Risk factors include advance age, female sex, diverticulosis, previous abdominal surgery and colonic strictures.

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Extraperitoneal perforations can manifest as pneumoretroperitoneum, pneumomediastinum, pneumothorax and/or subcutaneous emphysema.

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Non operative management in isolated retroperitoneum while surgery required in majority of peritoneal perforation.

Introduction

Colonoscopy is considered as one of the most common performed procedures for both diagnostic and therapeutic purposes. Serious complication after colonoscopy could occurs like bleeding or perforation. Majority of the perforations are intraperitoneal, while extraperitoneal perforations are very rare and it may cause pneumoretroperitoneum, pneumomediastinum, pneumothorax and subcutaneous emphysema.

Presentation of the case

A case report was described of 80-year-old female who underwent a diagnostic colonoscopy for recurrent abdominal pain who presented with severe abdominal pain and tenderness with CT findings of pneumoperitoneum, pneumoretroperitoneum and subcutaneous emphysema. The patient successfully treated surgically with laparoscopic Hartman procedure.

Discussion

Colonic perforation is rare complication of colonoscopy that can manifest intraperitoneal, extraperitoneal or a combination of both. Patient risk factors include advance age, female sex, diverticulosis, previous abdominal surgery and pre-existing colonic strictures. Technical risk factors includes excessive shearing forces during endoscopic insertion, dilation, biopsy and using electrocautery. Majority of the intraperitoneal perforation warrant a surgical intervention whereas isolated extraperitoneal perforation may be managed conservatively.

Conclusion

Combined intraperitoneal and extraperitoneal colonic perforation are rare presentations following diagnostic colonoscopy and often difficult to diagnose based on the clinical manifestation only. Understanding the manifestation of extraperitoneal perforation will help to properly identify the condition and preventing morbidity and mortality in these patients.

Eye gaze of endoscopists during simulated colonoscopy

Regaining orientation during an endoscopic procedure is critical. We investigated how endoscopists maintain orientation based on video and eye gaze analysis. Novices and experts performed a simulated colonoscopy procedure. Task performance was assessed by completion time, total distance traveled, maximum depth of insertion, percentage of mucosa viewed, and air insufflation volume. Procedure videos were analyzed by transfers among three viewing areas: center of bowel lumen, edge of bowel lumen, and other structure without bowel lumen in sight. Performers' gaze features were also examined over these viewing areas. Experts required less time to complete the procedure (P < 0.001). Novices' scope traveled a greater distance (P < 0.001) and more scope was inserted compared to an expert (P < 0.001). Novices also insufflated more air than experts (P < 0.001). Experts maintained the view of bowel lumen in the middle of the screen, while novices often left it on the edge (P = 0.032). When disorientation happened, novices brought the view to the edge more frequently than the center. However, experts were able to bring it back to the center directly. Eye tracking showed that the rate of saccades in experts increased when the bowel lumen moved away from the central view, such a behavior was not observed in novices. Maintaining a centered view of the bowel lumen is a strategy used by expert endoscopists. Video and eye tracking analysis revealed a key difference in eye gaze behavior when regaining orientation between novice and experienced endoscopists.

Treatment of colonoscopic perforation: outcomes from a major single tertiary institution

BACKGROUND

The use of colonoscopy has been increasing in Australia. This case series describes management and outcomes of colonoscopic perforation managed by a single tertiary referral unit.

METHODS

An analysis of 13 years (2003-2015) of prospectively collected data on patients who had a colonoscopic perforation and were managed by the colorectal unit at a single tertiary referral centre was performed. Main outcomes were time of diagnosis, modality of management, time to theatre, length of stay, cost of admission and complications.

RESULTS

Sixty-two patients had perforations (median age of 69 years). Thirty-eight (61.2%) patients had their colonoscopy performed in another institution. The incidence rate decreased to 0.37 perforations per 1000 colonoscopies within Western Health. Overall, diagnostic colonoscopies accounted for 56% of perforations and perforations were likely to occur in the left colon (P = 0.006). Fifty-one (82%) patients underwent surgery during their admission, with 24% of these being laparoscopic procedures. An earlier diagnosis was associated with significantly less intra-abdominal contamination. Gross peritoneal contamination was more likely to be associated with the decision to form a stoma (37%, n = 19, P = 0.04). Thirty-day mortality was 1.6% (n = 1).

CONCLUSIONS

Colonoscopic perforations occur in experienced hands and may have serious implications. We demonstrated a difference in patterns of injury between therapeutic and diagnostic colonoscopies. Those who have an earlier diagnosis are less likely to have severe intra-abdominal contamination requiring a stoma formation.