Management of colonoscopic perforations

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.

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.

CT imaging findings of complications of optical colonoscopy

Colonoscopy is one of the most commonly performed endoscopic procedures and remains the most commonly used screening modality method for colorectal cancer (CRC) screening in the USA. Although serious complications of fiberoptic colonoscopy are uncommon due to technical advances, due to increasing number of colonoscopy procedures, post-procedural complications are not uncommonly encountered in the routine clinical practice. Also, as some of the post-colonoscopy complications are life threatening, it is important to diagnose them early so that timely treatment measures can be taken to decrease mortality and morbidity. In this review, we present a case-based illustration of the utility of CT to detect complications of colonoscopy including bowel perforation, hemorrhage, splenic injury, and postpolypectomy syndrome.

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.

Computed tomography colonography and radiation risk: How low can we go?

Computed tomography colonography (CTC) has become a key examination in detecting colonic polyps and colorectal carcinoma (CRC). It is particularly useful after incomplete optical colonoscopy (OC) for patients with sedation risks and patients anxious about the risks or potential discomfort associated with OC. CTC's main advantages compared with OC are its non-invasive nature, better patient compliance, and the ability to assess the extracolonic disease. Despite these advantages, ionizing radiation remains the most significant burden of CTC. This opinion review comprehensively addresses the radiation risk of CTC, incorporating imaging technology refinements such as automatic tube current modulation, filtered back projections, lowering the tube voltage, and iterative reconstructions as tools for optimizing low and ultra-low dose protocols of CTC. Future perspectives arise from integrating artificial intelligence in computed tomography machines for the screening of CRC.

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

BACKGROUND AND AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

Background

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

Methods

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

Results

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

Conclusion

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

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.

Recognition and Management of Colonic Perforation following Endoscopy

Although rare, perforation can be a devastating complication of colonoscopy. Incidence ranges from 0.012 to 0.65% during diagnostic procedures and is higher in therapeutic procedures. Early diagnosis and management are of paramount importance to decrease morbidity. Diagnostic imaging after colonoscopy can reveal extraintestinal air, but overall clinical status including leukocytosis, fever, pain, and peritonitis is equally important to determine management. With the expanding availability of complex endoscopic interventions, an increasing number of perforations are recognized during colonoscopy or immediately afterward based on high degree of suspicion. Colonoscopic management of these early perforations may be feasible and avoid the morbidity of surgery. Patients who require surgery may be managed with laparoscopic or open surgical techniques. Surgical management may consist of primary repair of the injury, resection with anastomosis, or resection with ostomy. Mechanical bowel preparation before endoscopy decreases fecal contamination after perforation, often obviating the need for ostomy creation.

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

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

Pneumoperitoneum

Pneumoperitoneum, usually seen as free air under the diaphragm, is a finding that can be seen on plain abdominal radiographs, signifying a leakage of air, usually from a perforation in the gastrointestinal tract. There are several other potential pathways from other body compartments for air to enter the abdominal cavity. Pneumoperitoneum does not always signify bowel rupture, as it can also result from pneumomediastinum and pneumothorax, and in patients who are being mechanically ventilated. Patient history and physical examination can assist in a preliminary diagnosis before diagnostic imaging. Plain chest/abdominal radiograph or computed tomographic scan of the abdomen can be diagnostic of pneumoperitoneum. Surgical versus nonsurgical conservative observation is determined on the basis of the cause and amount of free air.

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

Purpose

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

Methods

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

Results

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

Conclusion

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

Low Rates of Gastrointestinal and Non-Gastrointestinal Complications for Screening or Surveillance Colonoscopies in a Population-Based Study

BACKGROUND

The full spectrum of serious non-gastrointestinal post-colonoscopy complications has not been well characterized. We analyzed rates of and factors associated with adverse post-colonoscopy gastrointestinal (GI) and non-gastrointestinal events (cardiovascular, pulmonary, or infectious) attributable to screening or surveillance colonoscopy (S-colo) and non-screening or non-surveillance colonoscopy (NS-colo).

METHODS

We performed a population-based study of colonoscopy complications using databases from California hospital-owned and nonhospital-owned ambulatory facilities, emergency departments, and hospitals from January 1, 2005 through December 31, 2011. We identified patients who underwent S-colo (1.58 million), NS-colo (1.22 million), or low-risk comparator procedures (joint injection, aspiration, lithotripsy; arthroscopy, carpal tunnel; or cataract; 2.02 million) in California's Ambulatory Services Databases. We identified patients who developed adverse events within 30 days, and factors associated with these events, through patient-level linkage to California's Emergency Department and Inpatient Databases.

RESULTS

After S-colo, the numbers of lower GI bleeding, perforation, myocardial infarction, and ischemic stroke per 10,000-persons were 5.3 (95% confidence interval [CI], 4.8-5.9), 2.9 (95% CI, 2.5-3.3), 2.5 (95% CI, 2.1-2.9), and 4.7 (95% CI, 4.1-5.2) without biopsy or intervention; with biopsy or intervention, numbers per 10,000-persons were 36.4 (95% CI, 35.1-37.6), 6.3 (95% CI, 5.8-6.8), 4.2 (95% CI, 3.8-4.7), and 9.1 (95% CI, 8.5-9.7). Rates of dysrhythmia were higher. After NS-colo, event rates were substantially higher. Most serious complications led to hospitalization, and most GI complications occurred within 14 days of colonoscopy. Ranges of adjusted odds ratios for serious GI complications, myocardial infarction, ischemic stroke, and serious pulmonary events after S-colo vs comparator procedures were 2.18 (95% CI, 2.02-2.36) to 5.13 (95% CI, 4.81-5.47), 0.67 (95% CI, 0.56-0.81) to 0.99 (95% CI, 0.83-1.19), 0.66 (95% CI, 0.59-0.75) to 1.13 (95% CI, 0.99-1.29), and 0.64 (95% CI, 0.61-0.68) to 1.05 (95% CI, 0.98-1.11). Biopsy or intervention, comorbidity, black race, low income, public insurance, and NS-colo were associated with post-colonoscopy adverse events.

CONCLUSIONS

In a population-based study in California, we found that following S-colo, rates of serious GI adverse events were low but clinically relevant, and that rates of myocardial infarction, stroke, and serious pulmonary events were no higher than after low-risk comparator procedures. Rates of myocardial infarction are similar to, but rates of stroke are higher than, those reported for the general population.

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.

Colonoscopic Perforations

Colonoscopy is the gold standard for colon cancer screening. It has led to a decrease in the incidence of colorectal cancer mortality. Colon perforation is a feared complication of this procedure with high morbidity and substantial mortality. Due to the high volume of colonoscopies performed, the absolute number of colonoscopic perforations is relatively high. It leads to a substantial cost to the patient and the health system. Understanding the mechanisms and the risk factors may help in preventing perforation. Traditionally, a laparotomy with creation of a stoma was used to address this complication. However, minimally invasive techniques such as laparoscopy and endoluminal repairs are being used more commonly now. More surgeons are favoring primary anastomosis (with or without a diverting loop ileostomy) than a Hartmann procedure.

Colonoscopic perforations: Single center experience and review of the literature

OBJECTIVE

Iatrogenic colonic perforation is a well-known complication that can increase mortality and morbidity in patients undergoing colonoscopy. Closer follow-up and a well-planned treatment strategy are required when perforation arises as a complication. The aims of this study are to (1) report our experience with a large colonoscopy series; (2) evaluate the underlying mechanisms of iatrogenic colonic perforation; (3) discuss the ideal period between onset and treatment; and (4) review the current literature regarding the management of iatrogenic colonic perforations.

MATERIAL AND METHODS

Patients who underwent colonoscopy between January 2005 and May 2015 at a single center were reviewed retrospectively. Procedures during which colonic perforations occurred were documented and analyzed.

RESULTS

Between January 2005 and May 2015, 31,655 patients underwent colonoscopy and 5,214 patients underwent recto-sigmoidoscopy at our center. Thirteen of these procedures were associated with perforation. The perforation rate was found to be 0.041%. The most frequent locations of perforation were (a) the rectosigmoid junction, (b) the proximal rectum, and (c) the sigmoid colon. Management included surgical treatment in 11 patients and conservative management in 2 patients. Twelve patients (92.31%) were discharged uneventfully, and death occurred in one (7.69%) patient.

CONCLUSION

Although they are rarely encountered, colonic perforations are serious complications of colonoscopy. A high index of clinical suspicion is required for early diagnosis and appropriate treatment. Age, co-morbidities, the location and size of the perforation, and the time interval between onset and diagnosis should be evaluated, and the treatment approach should be planned accordingly.

Laparoscopic vs. open surgery for the treatment of iatrogenic colonoscopic perforations: a systematic review and meta-analysis

AIMS

Iatrogenic colonoscopy perforations (ICP) are a rare but severe complication of diagnostic and therapeutic colonoscopies. The present systematic review and meta-analysis aims to investigate the operative and post-operative outcomes of laparoscopy vs. open surgery performed for the management of ICP.

METHODS

A literature search was carried out on Medline, EMBASE, and Scopus databases from January 1990 to June 2016. Clinical studies comparing the outcomes of laparoscopic and open surgical procedures for the treatment for ICP were retrieved and analyzed.

RESULTS

A total of 6 retrospective studies were selected, including 161 patients with ICP who underwent surgery. Laparoscopy was used in 55% of the patients, with a conversion rate of 10%. The meta-analysis shows that the laparoscopic approach was associated with significantly fewer post-operative complications compared to open surgery (18.2% vs. 53.5% respectively; Relative risk, RR: 0.32 [95%CI: 0.19-0.54; p < 0.0001; I² = 0%]) and shorter hospital stay (mean difference -5.35 days [95%CI: -6.94 to -3.76; p < 0.00001; I² = 0%]). No differences between the two surgical approaches were observed for postoperative mortality, need of re-intervention, and operative time.

CONCLUSION

The present study highlights the outcomes of the surgical management of an endoscopic complication that is not yet considered in clinical guidelines. Based on the current available literature, the laparoscopic approach appears to provide better outcomes in terms of postoperative complications and length of hospital stay than open surgery in the case of ICP surgical repair. However, the creation of large prospective registries of patients with ICP would be a step forward in addressing the lack of evidence concerning the surgical treatment of this endoscopic complication.

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.

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

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

Risk of colon perforation during colonoscopy at Baylor University Medical Center

Colonoscopy is an important procedure in preventing colon cancer. The risk of colonic perforation during colonoscopy at the Baylor University Medical Center (BUMC) Gastrointestinal Laboratory was chosen as a surrogate marker for the safety of colonoscopy. A recent 2-year experience at BUMC was examined and compared with reports in the medical literature. The results are presented here along with a discussion of problems inherent with different health care systems and their ability to accurately track complications. It was concluded that colonoscopy at BUMC is as safe as that reported by comparable health care systems. The risk of perforation at BUMC was 0.57 per 1000 procedures or 1 in 1750 colonoscopies. Continued efforts to make colonoscopy safer are needed.

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.

Risk factors for early colonoscopic perforation include non-gastroenterologist endoscopists: a multivariable analysis

BACKGROUND & AIMS

Bowel perforation is a rare but serious complication of colonoscopy. Its prevalence is increasing with the rapidly growing volume of procedures performed. Although colonoscopies have been performed for decades, the risk factors for perforation are not completely understood. We investigated risk factors for perforation during colonoscopy by assessing variables that included sedation type and endoscopist specialty and level of training.

METHODS

We performed a retrospective multivariate analysis of risk factors for early perforation (occurring at any point during the colonoscopy but recognized during or immediately after the procedure) in adult patients by using the Clinical Outcomes Research Initiative National Endoscopic Database. Risk factors were determined from published articles. Additional variables assessed included endoscopist specialty and years of experience, trainee involvement, and sedation with propofol.

RESULTS

We identified 192 perforation events during 1,144,900 colonoscopies from 85 centers entered into the database from January 2000-March 2011. On multivariate analysis, increasing age, American Society of Anesthesia class, female sex, hospital setting, any therapy, and polyps >10 mm were significantly associated with increased risk of early perforation. Colonoscopies performed by surgeons and endoscopists of unknown specialty had higher rates of perforation than those performed by gastroenterologists (odds ratio, 2.00; 95% confidence interval, 1.30-3.08). Propofol sedation did not significantly affect risk for perforation.

CONCLUSIONS

In addition to previously established risk factors, non-gastroenterologist specialty was found to affect risk for perforations detected during or immediately after colonoscopy. This finding could result from differences in volume and style of endoscopy training. Further investigation into these observed associations is warranted.

Perforation following colorectal endoscopy: what happens beyond the endoscopy suite?

BACKGROUND

The risk factors for perforation from colorectal endoscopy have been well studied, but little is known about clinical outcomes beyond the immediate event.

OBJECTIVE

To evaluate short- and long-term outcomes of iatrogenic colorectal perforation following colorectal endoscopy.

DESIGN

Retrospective review over 16 years at a single tertiary care institution.

MAIN OUTCOME MEASURES

Treatment interventions, morbidity and mortality rates, hospital length of stay, stoma closure rate, and long-term complications.

RESULTS

Of 132,259 colorectal endoscopies, 26 patients (0.02%) had a perforation (54% males; mean age, 67 years). The rectosigmoid colon was the most common site of perforation (65%). Thirty-eight percent of the perforations were recognized at the time of procedure, 31% presented within 24 hours, and 31% presented beyond 24 hours. Operative repair was undertaken in 85% of the patients, and 15% were managed with inpatient hospital observation. Primary repair was performed in 68% (defunctioning stoma in 18%). Mean hospital length of stay was 10.1 days. The overall postoperative complications rate was 55%, and wound complications were noted in 45%. The 30-day mortality rate was 19%. No death was observed beyond the first month. American Society of Anesthesiologists physical status Classes 3 and 4 were associated with mortality (p = 0.004). Of 7 patients who received a stoma, only 2 patients (29%) had stoma reversal. Long-term complications included incisional hernia (10%) and small-bowel obstruction (5%).

CONCLUSIONS

Perforation following colorectal endoscopy was uncommon in this study but was associated with significant morbidity and mortality. An increased risk of death was noted with higher American Society of Anesthesiologists physical status class.

Laparoscopic direct suture of perforation after diagnostic colonoscopy

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Dose reduction methods for CT colonography

Patients, referring physicians, the media, and government agencies have all expressed concern over the risks of medical radiation, particularly as it relates to CT. This concern is particularly paramount when associated with a screening examination such as CT colonography. These theoretical risks must be weighed realistically against the substantial benefits of colon cancer screening as well as against the risks inherent in the major alternative screening option, optical colonoscopy. When put into perspective, the risk-benefit ratio is highly in favor of the performance of CT colonography. Nevertheless, in following the ALARA principle, there is an ever increasing armamentarium of options that can be employed in the pursuit of CT radiation dose reduction, all of which can be used in many synergistic combinations allowing for dose reduction while simultaneously preserving image quality and minimizing image noise. After a brief tutorial on estimating radiation dose, various strategies will be discussed including reductions in tube current and tube voltage as well as the use of automatic dose modulation and iterative reconstruction. Other practical considerations will also be reviewed including proper patient isocentering, optimization of colonic insufflation to minimize additional decubitus scans, proper choice of scan volumes to avoid overranging, and variation of slice thickness and window width to minimize perceived image noise. Finally, a strategy for how to incrementally introduce these methods as well as a way to compare dose reduction efforts across institutions throughout the country will be offered.

Iatrogenic sinistral hypertension complicating screening colonoscopy

Colonoscopy is widely accepted as the gold-standard screening technique for detecting malignancies in the distal gastrointestinal tract in patients with symptoms suggestive of colon cancer. However, this procedure is not without risk, including colonic perforation. We report a patient who was managed conservatively after colonoscopy induced perforation. Eighteen months after appearing to make a full recovery, he presented with an upper gastrointestinal bleed. Oesophago-gastro-duodenoscopy (OGD) revealed large gastric fundal varices and computed tomography (CT) revealed splenic vein thrombosis. The ensuing left-sided (sinistral) hypertension explains the development of the fundal varices in the presence of normal liver function. At surgery, a persistent abscess cavity was identified and cultures from this site grew Streptococcus anginosus. Curative splenectomy was performed and the patient made a full recovery. We advocate more prompt operative intervention in selected cases of iatrogenic colonic perforation with primary repair to prevent late complications.

Risk factors for colonoscopic perforation: A population-based study of 80118 cases

AIM: To assess the incidence and risk factors associated with colonic perforation due to colonoscopy.

METHODS: This was a retrospective cross-sectional study. Patients were retrospectively eligible for inclusion if they were 18 years and older and had an inpatient or outpatient colonoscopy procedure code in any facility within the Geisinger Health System during the period from January 1, 2002 to August 25, 2010. Data are presented as median and inter-quartile range, for continuous variables, and as frequency and percentage for categorical variables. Baseline comparisons across those with and without a perforation were made using the two-sample t-test and Pearson’s χ² test, as appropriate.

RESULTS: A total of 50 perforations were diagnosed out of 80118 colonoscopies, which corresponded to an incidence of 0.06% (95%CI: 0.05-0.08) or a rate of 6.2 per 10000 colonoscopies. All possible risk factors associated with colonic perforation with a P-value < 0.1 were checked for inclusion in a multivariable log-binomial regression model predicting 7-d colonic perforation. The final model resulted in the following risk factors which were significantly associated with risk of colonic perforation: age, gender, body mass index, albumin level, intensive care unit (ICU) patients, inpatient setting, and abdominal pain and Crohn’s disease as indications for colonoscopy.

CONCLUSION: The cumulative 7 d incidence of colonic perforation in this cohort was 0.06%. Advanced age and female gender were significantly more likely to have perforation. Increasing albumin and BMI resulted in decreased risk of colonic perforation. Having a colonoscopy indication of abdominal pain or Crohn’s disease resulted in a higher risk of colonic perforation. Colonoscopies performed in inpatients and particularly the ICU setting had substantially greater odds of perforation. Biopsy and polypectomy did not increase the risk of perforation and only three perforations occurred with screening colonoscopy.

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

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

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

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

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

Colorectal cancer screening and surveillance in the elderly patient

Colorectal cancer (CRC) is the third leading cause of cancer-related deaths in the United States. Older age is associated with a rise in colorectal cancer and adenomas, necessitating the need for CRC screening in older patients. However, decisions about CRC screening and surveillance in older adults are often difficult and challenging. The decision requires an individualized assessment that incorporates factors unique to performing colonoscopy in older adults in order to weigh the risks and benefits for each patient according to their overall health and preferences. This review addresses the factors unique to colorectal cancer and performing colonoscopy in older adults that are relevant in weighing the risks and benefits of screening and surveillance in this population.

Laparoscopic approach to colonic perforation due to colonoscopy

BACKGROUND

Iatrogenic perforation due to colonoscopy is the most serious complication of this procedure. Usually, resolution of this event requires segmental resection. The laparoscopic approach could be an option to minimize the outcome of this complication. The aim of the present study was to assess the effectiveness of the laparoscopic approach in treating colonic perforations due to colonoscopy.

METHODS

Between July 1997 and November 2008 data were collected retrospectively on all patients who underwent colonoscopy and had a perforation caused by the procedure. Patients with other complications after colonoscopy as well as other colonic perforations were excluded. According to the method employed for the approach, the series was divided in two groups: those treated by the laparoscopic approach (group I; GI) and those treated via laparotomy (group II; GII). Morbidity and recovery parameters were compared between the two groups. Statistical analysis was performed using Student's t-test and the chi square test.

RESULTS

A total of 14,713 colonoscopies were performed during the study period. Of these, 10,299 (73 %) were diagnostics and 4,414 (27%) were therapeutics. There were 20 (0.13%) iatrogenic perforations (GI = 14 versus GII = 6). The mean age of the patients was 62 +/- 12.1 years. There were no differences in patient demographics, co-morbidities, and American Society of Anesthesiologists (ASA) grades between the groups. Seventeen patients had segmental colectomy with primary anastomosis (GI: 13 versus GII: 4). One patient in each group had simple suture with diverting ileostomy, and one patient from GII underwent a Hartmann's procedure. Patients from GI had a shorter hospital stay (GI: 4.2 +/- 2.06 days versus GII 11.5 +/- 8.8 days; P = 0.007) and there were no differences in complication rate compared with GII (GI: 3 versus GII: 5; P = 0.058).

CONCLUSIONS

Laparoscopic colectomy is effective in resolving colonic perforation due to colonoscopy, and it might offer benefits over the open approach.

Endoscopist experience as a risk factor for colonoscopic complications

AIM

We aimed to determine the incidence of colonic perforation (CP) following colonoscopy and postpolypectomy bleeding (PPB) in a teaching hospital, assessing the influence of endoscopist experience as a risk factor.

METHOD

All colonoscopies performed between 1995 and 2008 were reviewed. Demographic data, endoscopic procedure information, incidence of CP and PPB, and endoscopist experience were recorded.

RESULTS

In the 14-year period, 25,214 endoscopic colonic procedures were performed, and 3991 patients underwent polypectomy. The overall CP risk was 0.51/1000 procedures; and PPB 14.7/1000. The relative risk (RR) ratio of complications was 2.8/1000 procedures. The RR rate was highest for endoscopists performing less than 591 procedures per year (4.0/1000 [95% CI, 3.7-4.3] vs 2.9/1000 [95% CI, 2.6-3.2]), P < 0.001).

CONCLUSION

The complication rate after colonoscopy was comparable to that previously reported. Colonoscopy carried out by a low-volume endoscopist was independently associated with bleeding and perforation.

The impact of national guidelines on the waiting list for colonoscopy: a quantitative clinical audit

OBJECTIVE

To assess the compliance of the surveillance colonoscopy waiting list with ACPGBI/BSG guidelines for colonoscopy follow-up and to measure the impact of adjusting referrals to be inline with the guidelines.

DESIGN AND SETTING

This is a quantitative five-stage clinical audit cycle involving a large patient cohort from the Kent and Medway Cancer Network, which includes seven hospitals across four NHS Hospital Trusts and an estimated population of 1.8 million.

PARTICIPANTS

3020 patients were waiting for a surveillance colonoscopy. Their notes were reviewed and the indications for colonoscopy were compared with the ACPGBI/BSG 2002 guidelines.

INTERVENTIONS

Those patients whose referral to the surveillance colonoscopy waiting list was not found to be compliant were adjusted to be inline with the guidelines.

MAIN OUTCOME MEASURES

The impact of adjusting the surveillance colonoscopy waiting list on the diagnostic colonoscopy service was assessed by measuring the average waiting times for a colonoscopy before and after the intervention.

RESULTS

Around 22% (n = 664) of surveillance colonoscopy referrals were inline with the guidelines, 51% (n = 1540) could be cancelled from the list and 27% (n = 816) could be given a new date. Implementing these recommendations reduced the average wait for a diagnostic colonoscopy from 76.8 to 56.0 days (P = 0.0022).

CONCLUSION

Following guidelines for surveillance colonoscopy can reduce waiting times for diagnostic colonoscopy. This allows a faster patient journey for diagnostic colonoscopy and a uniform plan for duration and frequency of surveillance colonoscopy. However, this action promoted serious debate on the social, moral and ethical issues.

[Large iatrogenic colonic perforation treated by endoscopic suturing]

Perforation of the colon during colonoscopy is still one of the most severe complications of this technique and occurs with a frequency of between 0.12 % and 0.2 % of cases after diagnostic colonoscopy and in up to 3 % of patients after therapeutic colonoscopy. The site of perforation is usually the sigmoid colon. The gold standard for treatment of this complication is surgery to be performed as rapidly as possible: a simple suture and peritoneal cleaning, with limited resection and anastomosis or colostomy only in case of confirmed fecal peritonitis. However, interventional endoscopy has made progress, in particular endoscopic suturing and Natural Orifice Transluminal Endocopic Surgery (NOTES) has been developed. There are several reports of endoscopically sutured perforated colons, most less than 10mm. We report our experience of two colonic perforations which were at least 10mm treated by endoscopic suturing with hemoclips: a perforated sigmoid diverticulum during simple colonoscopy in the first case and a large polypectomy by endoscopic mucosal resection of the ascending colon in the second.

Colonoscopic perforation: Incidence, risk factors, management and outcome

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

Colonoscopic splenic injuries: incidence and management

PURPOSE

Splenic injuries that occur during colonoscopies are rare. There is no available incidence of this serious complication, and the literature is limited to case reports. Our study looks at single institution experience of splenic injuries during colonoscopy to define the incidence and management of this serious complication.

METHODS

All patients from 1980 through June 2008 sustaining a splenic injury during colonoscopy were reviewed.

RESULTS

Four patients (of 296,248 colonoscopies) sustained a splenic injury directly from colonoscopy performed at our institution (incidence 0.001%). Three additional patients were treated at our tertiary referral center after splenic injury from colonoscopy performed elsewhere. The mean age at the time of colonoscopy was 54 years (range 40-70 years). The most common presenting symptom was abdominal pain (n = 4) with a mean decrease in hemoglobin of 6.5 g/dl (range 4.5-8.5 g/dl). Splenic injury was diagnosed by computed tomography in five patients. Six patients received a mean of 5.5 U of packed red blood cells (range 2-14 U). All patients were managed with splenectomy, six patients within 24 h of the index colonoscopy, and one patient presented more than 24 h after initial colonoscopy. There was no evidence of preexisting splenic disease in any of the patients by surgical pathology, and there were no postoperative complications or deaths. The mean duration of stay was 10 days (range 7-15 days). All patients are alive at a median follow up of 22 months (range 1-164 months).

CONCLUSION

Splenic injury occurring during colonoscopy is a rare but serious complication. Patients presented with abdominal pain and a precipitous decrease in hemoglobin and have all required emergent splenectomy.

The role of laparoscopy in the treatment of complications after colonoscopy

Perforations of the colonic wall or splenic injury during colonoscopy are rare complications. Treatment of these complications by laparoscopy is an advisable compromise instead of an invasive surgery with a laparotomy or a noninvasive and potentially risky nonoperative therapy. All surgical procedures that can be performed by open approach can also be performed laparoscopically. We present in this report 15 patients who were treated for a perforation after colonoscopy. In addition, 2 cases of splenic injury after colonoscopy are described. Twelve perforations were sutured laparoscopically and 3 perforations were sutured via laparotomy. Except for 1 minor wound infection, there were no complications. One splenic injury was treated by spleen wrapping via an open approach due to former pancreatic surgery, and 1 injury was treated laparoscopically with a hemostypticum. Mortality was 0%. Early laparoscopic intervention is a safe and effective method in the treatment of serious complications after colonoscopy.

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

BACKGROUND

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

OBJECTIVE

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

DESIGN

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

SETTING

California Medicaid program claims database.

PATIENTS

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

MAIN OUTCOME MEASUREMENTS

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

RESULTS

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

LIMITATIONS

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

CONCLUSION

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

Colonoscopy and its complications across a Canadian regional health authority

BACKGROUND

Defining the complication rate of endoscopy performed across an entire city will capture usual as opposed to referral center data.

OBJECTIVE

Our purpose was to evaluate the current practice of colonoscopy and complications associated with lower GI endoscopy in usual clinical practice.

DESIGN

All admissions within 30 days of an outpatient lower GI endoscopy at any of the 6 adult-care Winnipeg hospitals were identified. This includes endoscopy for both complex and routine patients. A chart audit of all cases with potential complications was performed.

RESULTS

A total of 24,509 outpatient lower GI endoscopies for adults were performed at the 6 hospitals over the 2 study years (April 1, 2004, to March 31, 2006). There were 303 admissions with potential complications. The colonoscopy completion rate was 65% (72% for gastroenterologists vs 59% for general surgeons, P < .005). Quality of bowel preparation and nature of polyps were often not documented. The overall rate of complications was 2.9/1000 procedures; the perforation rate after polypectomy was 1.8/1000; and the postpolypectomy bleeding rate was 6.4/1000. Most (67%) complications were recognized after discharge for the index procedure. The complication rate was highest for the endoscopists performing fewer than 200 procedures per year (5.4/1000 vs 2.7/1000 for the rest, P = .02, relative risk 2 [95% CI, 1.1-3.7]).

LIMITATIONS

Chart audit was limited to cases requiring admission within 30 days of the index procedure.

CONCLUSIONS

The overall complication rate after lower GI endoscopy in usual clinical practice in Winnipeg is comparable to that previously reported. A higher complication rate after endoscopy by low-volume endoscopists needs to be further evaluated. The reporting of endoscopy must be standardized to enhance outcomes interpretation.

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

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

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

RESULTS: A total of 17 357 endoscopic procedures of the colon (13 699 colonoscopies and 3658 flexible sigmoidoscopies) were performed in Siriraj hospital over a 9-year period. Fifteen patients (0.09%) had CP: 14 from colonoscopy and 1 from sigmoidoscopy. The most common site of perforation was in the sigmoid colon (80%), followed by the transverse colon (13%). Perforations were caused by direct trauma from either the shaft or the tip of the endoscope (n = 12, 80%) and endoscopic polypectomy (n = 3, 20%). All patients with CP underwent surgical management: primary repair (27%) and bowel resection (73%). The mortality rate was 13% and postoperative complication rate was 53%.

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

Detection of occult colonic perforation before CT colonography after incomplete colonoscopy: perforation rate and use of a low-dose diagnostic scan before CO2 insufflation

OBJECTIVE

The purpose of this study was to obtain a low-dose CT scan before CT colonography to estimate the prevalence of occult colonic perforation among patients referred for same-day or next-day CT colonography after incomplete colonoscopy.

MATERIALS AND METHODS

Two hundred sixty-two patients (74 men, 188 women; mean age, 64 years; range, 21-92 years) consecutively referred for same-day or next-day CT colonography after incomplete colonoscopy underwent low-dose diagnostic CT before rectal tube insertion and CO(2) insufflation.

RESULTS

Perforation was found on the low-dose CT scans of two of the 262 patients (0.8%; 95% CI, 0.1-2.7%). One of these patients had no symptoms; the other had mild abdominal discomfort at the time of CT.

CONCLUSION

The rate of occult colonic perforation after incomplete colonoscopy may be significant. For patients referred for CT colonography after incomplete endoscopy, use of low-dose diagnostic CT before rectal tube insertion and insufflation is indicated.

Colonic perforation during screening CT colonography using automated CO2 insufflation in an asymptomatic adult

CT colonography has become a potential alternative technique to optical colonoscopy for the detection of colorectal polyps and cancer. While considered safer than optical colonoscopy, CT colonography is not without risk. We report a case of colonic perforation during CT colonography using automated CO(2) insufflation and present procedural changes to help minimize the adverse effects of perforation when it occurs.

Imaging evaluation of complications at optical colonoscopy

Optical colonoscopy (OC) is an essential component of colorectal cancer screening. In addition to favorable polyp detection capabilities, OC has a unique therapeutic role with the ability to remove identified polyps. However, this procedure carries a low but real risk for morbidity and mortality. OC requires physical intubation of the length of the colon and manipulation of the instrument. In addition, the performance of therapeutic polyp removal increases risk. Inherent to this procedure are several pathways for potential adverse events. Complications can be divided into several major categories including perforation, hemorrhage, postpolypectomy syndromes, and issues related to sedation. The imaging manifestations of complications related to optical colonoscopy as well as the potential underlying mechanisms will be reviewed. Emphasis will be placed on cross-sectional imaging given the improved sensitivity and specificity over conventional radiography.

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

BACKGROUND

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

OBJECTIVE

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

SETTING

University hospitals in the United States and Europe.

DESIGN AND INTERVENTIONS

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

RESULTS

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

LIMITATION

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

CONCLUSIONS

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

Pediatric endoscopic injuries: incidence, management, and outcomes

BACKGROUND

Endoscopy has assumed a significant role in the management of gastrointestinal disorders. However, endoscopic-related injuries are poorly reported.

METHODS

Review of our surgical database (1980-2006) identified all patients age 18 years or younger with an endoscopic-related injury managed at our institution.

RESULTS

A total of 3269 colonoscopies were performed; there were 3 iatrogenic perforations (incidence, 0.09%). All were managed operatively: 2 underwent fecal diversion, and 1 was repaired primarily. There was 1 postoperative complication (internal hernia) and no deaths related to colonoscopic perforation. Nine thousand three hundred eight esophagogastroduodenoscopy (EGD) procedures were performed, resulting in 6 iatrogenic injuries (0.06%): bleeding (2), perforation (2), and mucosal tears (2) (0.02% each). All EGD-related injuries occurred in the esophagus except for 1 duodenal perforation which was managed operatively by primary repair. Both patients with bleeding complications underwent repeat endoscopy and cautery with satisfactory results. The other 3 patients were managed conservatively without complication. Three hundred eighty-nine endoscopic retrograde cholangiopancreatogram procedures were performed with 2 iatrogenic injuries (0.5%): 1 bleed and 1 perforation (0.25% each). Both were managed conservatively without complication.

CONCLUSION

Endoscopic injuries are uncommon. Colonoscopic perforations require prompt surgical intervention. Esophagogastroduodenoscopy- and endoscopic retrograde cholangiopancreatogram-related injuries are amenable to conservative therapy in clinically stable patients devoid of peritonitis.