Perforation during colonoscopy in endoscopic ambulatory surgical centers

Effect of Abdominal Compression on Total Single-Balloon Enteroscopy Rate: A Randomized Controlled Trial

OBJECTIVE

To evaluate whether abdominal compression significantly increased the total enteroscopy rate in single-balloon enteroscopy (SBE).

METHODS

Consecutive patients who underwent SBE at 2 hospitals were prospectively included between June 1, 2020, and September 30, 2021. They were randomly divided into an abdominal compression group and a non-abdominal compression group with use of sealed envelopes generated by a computer. Total enteroscopy rates were compared between the groups.

RESULTS

The study included 200 patients. The total enteroscopy rates were 73% and 16% in the abdominal compression and non-abdominal compression groups, respectively (relative risk, 13.55; 95% CI, 6.79 to 27.00; P<.001). The total enteroscopy rate was higher in the 70 patients who were identified to have undergone no previous abdominal surgery or small intestinal stenosis than in the 32 patients who had undergone such procedures in the abdominal compression group (84% vs 47%; relative risk, 6.08; 95% CI, 2.36 to 15.67; P<.001). Relevant positive findings were not significantly different between the groups (58% vs 45%; P=.07). Binary logistic regression analysis found abdominal compression to be associated with a better total enteroscopy rate (odds ratio, 16.68; 95% CI, 7.92 to 35.15; P<.001), and the presence of previous abdominal surgery or small intestinal stenosis was associated with difficulty in completing the total enteroscopy procedure (odds ratio, 0.26; 95% CI, 0.12 to 0.58; P<.01).

CONCLUSION

Abdominal compression significantly increased the total enteroscopy rate in SBE. Complete total enteroscopy may be challenging in patients with a history of abdominal surgery or small intestinal stenosis.

Identification of Iatrogenic Perforation in Pediatric Gastrointestinal Endoscopy

OBJECTIVES

Iatrogenic viscus perforation in pediatric gastrointestinal endoscopy (GIE) is a very rare, yet potentially life-threatening event. There are no evidence-based recommendations relating to immediate post-procedure follow-up to identify perforations and allow for timely management. This study aims to characterize the presentation of children with post-GIE perforation to better rationalize post-procedure recommendations.

METHODS

Retrospective study based on unrestricted pooled data from centers throughout Europe, North America, and the Middle East affiliated with the Endoscopy Special Interest Groups of European Society for Paediatric Gastroenterology Hepatology and Nutrition and North American Society for Pediatric Gastroenterology Hepatology and Nutrition. Procedural and patient data relating to clinical presentation of the perforation were recorded on standardized REDCap case-report forms.

RESULTS

Fifty-nine cases of viscus perforation were recorded [median age 6 years (interquartile range 3-13)]; 29 of 59 (49%) occurred following esophagogastroduodenoscopy, 26 of 59 (44%) following ileocolonoscopy, with 2 of 59 (3%) cases each following balloon enteroscopy and endoscopic retrograde cholangiopancreatography; 28 of 59 (48%) of perforations were identified during the procedure [26/28 (93%) endoscopically, 2/28 (7%) by fluoroscopy], and a further 5 of 59 (9%) identified within 4 hours. Overall 80% of perforations were identified within 12 hours. Among perforations identified subsequent to the procedure 19 of 31 (61%) presented with pain, 16 of 31 (52%) presented with fever, and 10 of 31 (32%) presented with abdominal rigidity or dyspnea; 30 of 59 (51%) were managed surgically, 17 of 59 (29%) managed conservatively, and 9 of 59 (15%) endoscopically; 4 of 59 (7%) patients died, all following esophageal perforation.

CONCLUSIONS

Iatrogenic perforation was identified immediately in over half of cases and in 80% of cases within 12 hours. This novel data can be utilized to generate guiding principles of post-procedural follow-up and monitoring.

PLAIN LANGUAGE SUMMARY

Bowel perforation following pediatric gastrointestinal endoscopy is very rare with no evidence to base post-procedure follow-up for high-risk procedures. We found that half were identified immediately with the large majority identified within 12 hours, mostly due to pain and fever.

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.

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.

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.

Weekend and evening planned colonoscopy activity: a safe and effective way to meet demands

Background and study aims  Colonoscopy is the "gold standard" investigation for assessment of the large bowel that detects and prevents colorectal cancer, as well as non-neoplastic conditions. The Joint Advisory Group (JAG) on Gastrointestinal Endoscopy recommends monitoring key performance indicators such as cecal intubation rate (CIR) and adenoma detection rate (ADR). We aimed to investigate the quality of colonoscopies carried out during evening and Saturday lists in our unit and compare them against JAG standards of quality for colonoscopies. Patients and methods  We retrospectively collected and analyzed demographical and procedure-related data for non-screening colonoscopies performed between January 2016 and November 2018. Evenings and Saturdays were defined as the out-of-hour (OOH) period. We compared the outcomes of the procedures done in these against the working hours of the weekdays. We also wanted to explore whether the outcomes were different among certain endoscopists. Other factors that could affect the KPIs, such as endoscopist experience and bowel preparation, were also analyzed. Results  There were a total of 17634 colonoscopies carried out; 56.9 % of the patients (n = 10041) < 70 years old. Key Performance Indicators (KPIs) of weekday, evening, and Saturday colonoscopies regarding the CIR and ADR met the JAG standards as they were above 93 % and 24 %, respectively. Advanced colonoscopists had better KPIs when compared to the non-advanced colonoscopists, with CIR at 97.6 % vs. 93.2 % and ADR at 40.8 % vs. 26 %, respectively. Conclusions  JAG standards were maintained during colonoscopies done on weekdays, evenings, and Saturdays. Advanced colonoscopists had higher CIR and ADRs.

Screening for Colorectal Cancer: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force

IMPORTANCE

Colorectal cancer (CRC) remains a significant cause of morbidity and mortality in the US.

OBJECTIVE

To systematically review the effectiveness, test accuracy, and harms of screening for CRC to inform the US Preventive Services Task Force.

DATA SOURCES

MEDLINE, PubMed, and the Cochrane Central Register of Controlled Trials for relevant studies published from January 1, 2015, to December 4, 2019; surveillance through March 26, 2021.

STUDY SELECTION

English-language studies conducted in asymptomatic populations at general risk of CRC.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently appraised the articles and extracted relevant study data from fair- or good-quality studies. Random-effects meta-analyses were conducted.

MAIN OUTCOMES AND MEASURES

Colorectal cancer incidence and mortality, test accuracy in detecting cancers or adenomas, and serious adverse events.

RESULTS

The review included 33 studies (n = 10 776 276) on the effectiveness of screening, 59 (n = 3 491 045) on the test performance of screening tests, and 131 (n = 26 987 366) on the harms of screening. In randomized clinical trials (4 trials, n = 458 002), intention to screen with 1- or 2-time flexible sigmoidoscopy vs no screening was associated with a decrease in CRC-specific mortality (incidence rate ratio, 0.74 [95% CI, 0.68-0.80]). Annual or biennial guaiac fecal occult blood test (gFOBT) vs no screening (5 trials, n = 419 966) was associated with a reduction of CRC-specific mortality after 2 to 9 rounds of screening (relative risk at 19.5 years, 0.91 [95% CI, 0.84-0.98]; relative risk at 30 years, 0.78 [95% CI, 0.65-0.93]). In observational studies, receipt of screening colonoscopy (2 studies, n = 436 927) or fecal immunochemical test (FIT) (1 study, n = 5.4 million) vs no screening was associated with lower risk of CRC incidence or mortality. Nine studies (n = 6497) evaluated the test accuracy of screening computed tomography (CT) colonography, 4 of which also reported the test accuracy of colonoscopy; pooled sensitivity to detect adenomas 6 mm or larger was similar between CT colonography with bowel prep (0.86) and colonoscopy (0.89). In pooled values, commonly evaluated FITs (14 studies, n = 45 403) (sensitivity, 0.74; specificity, 0.94) and stool DNA with FIT (4 studies, n = 12 424) (sensitivity, 0.93; specificity, 0.85) performed better than high-sensitivity gFOBT (2 studies, n = 3503) (sensitivity, 0.50-0.75; specificity, 0.96-0.98) to detect cancers. Serious harms of screening colonoscopy included perforations (3.1/10 000 procedures) and major bleeding (14.6/10 000 procedures). CT colonography may have harms resulting from low-dose ionizing radiation. It is unclear if detection of extracolonic findings on CT colonography is a net benefit or harm.

CONCLUSIONS AND RELEVANCE

There are several options to screen for colorectal cancer, each with a different level of evidence demonstrating its ability to reduce cancer mortality, its ability to detect cancer or precursor lesions, and its risk of harms.

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.

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

BACKGROUND AND AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSIONS

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

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

Background

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

Methods

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

Results

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

Conclusion

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

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.

Complications of Colonoscopy and its Management: A Single Gastroenterologist Experience

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Detection of endoscopic looping during colonoscopy procedure by using embedded bending sensors

Background

Looping of the colonoscope shaft during procedure is one of the most common obstacles encountered by colonoscopists. It occurs in 91% of cases with the N-sigmoid loop being the most common, occurring in 79% of cases.

Purpose

Herein, a novel system is developed that will give a complete three-dimensional (3D) vector image of the shaft as it passes through the colon, to aid the colonoscopist in detecting loops before they form.

Patients and methods

A series of connected links spans the middle 50% of the shaft, where loops are likely to form. Two potentiometers are attached at each joint to measure angular deflection in two directions to allow for 3D positioning. This 3D positioning is converted into a 3D vector image using computer software. MATLAB software has been used to display the image on a computer monitor. For the different configuration of the colon model, the system determined the looping status.

Results

Different configurations (N loop, reverse gamma loop, and reverse splenic flexure) of the loops were well defined using 3D vector image.

Conclusion

The novel sensory system can accurately define the various configuration of the colon during the colonoscopy procedure.

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

Background

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

Methods

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

Results

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

Conclusions

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

Pediatric Colonoscopy: The Changing Patterns and Single Institutional Experience Over a Decade

The safety and effectiveness of pediatric colonoscopy for lower gastrointestinal tract diseases have been established in Korea for about 30 years. Both diagnostic and therapeutic colonoscopies have had many advances in terms of operator skill and experience and are now being performed by most pediatric gastroenterologists. Pediatric colonoscopy is different in many aspects from that of adults, such as expected diagnoses, patient management, bowel preparation, selection criteria for sedation, and instrument selection. In this review, the author presents practical information on pediatric colonoscopy, the author's experiences, and the changes in colonoscopy practices over a decade in a tertiary hospital in Korea.

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.

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.

Training in Endoscopy: Colonoscopy

Colonoscopy is effective in reducing the morbidity and mortality associated with colorectal cancer (CRC). Interval cancers or post-colonoscopy CRCs, are cancers detected within the surveillance interval, or between 6–36 months after a clearing colonoscopy. The incidence of interval cancers is 3.4%–9.2% of all detected CRCs, as reported in population-based studies. Colonoscopy is a technically difficult procedure that is challenging to learn, and needs time and effort to gain competency. Therefore, trainee competence is a critical component of CRC screening and surveillance. Herein, we review the colonoscopy training methods and quality assessment metrics for colonoscopy competency.

The Present Status of Fecal Microbiota Transplantation and Its Value in the Elderly

OPINION STATEMENT

PURPOSE OF REVIEW: This article will review current literature describing fecal microbiota transplantation (FMT) in the treatment of various diseases, and its potential role in elderly patients (age ≥ 65 years).

RECENT FINDINGS

Research on FMT has blossomed in the last decade and its pivotal role in the treatment of recurrent Clostridium difficile infection (CDI) has been recognized by the American College of Gastroenterology in the latest guidelines. There is also emerging evidence that FMT may be beneficial in the treatment of severe and/or complicated CDI refractory to medical therapy, resulting in decreased rates of colectomy and mortality. In the elderly, CDI is associated with markedly higher rates of mortality and colectomy; outcomes are even worse when patients have underlying inflammatory bowel disease (IBD). While the majority of patients who receive FMT for CDI are older, only a handful of studies focused specifically on FMT treatment outcomes and safety in this age group. Current data corroborate the efficacy and safety profile of FMT, while also supporting its use for recurrent, severe, and/or complicated CDI in the elderly population. FMT is recommended for the treatment of recurrent, severe, and/or complicated CDI in patients older than 65 years of age. It may be prudent to offer FMT earlier in the disease course, possibly after just the second recurrence and for the first episode of severe CDI to avert complications including colectomy and end-organ failure that elderly patients are more prone to developing.

Post-Colonoscopy Colonic Perforation Presenting With Subcutaneous Emphysema: A Case Report

Colonoscopy is performed for both diagnostic and therapeutic indications. Although rare, associated complications can be quite serious. The frequency of these complications depends mainly on the skills of the physicians doing the procedure, and the diagnostic or therapeutic indications. Major complications include adverse anesthetic related events, aspiration pneumonia, bleeding, and colonic perforation. We present a rare case of a post-colonoscopy perforation presenting with subcutaneous emphysema and free mediastinal, and intra-peritoneal air. The patient was successfully managed conservatively with complete resolution of symptoms.

Screening and Surveillance of Colorectal Cancer Using CT Colonography

OPINION STATEMENT

Colorectal cancer (CRC) is a common cancer among throughout the world with the highest rates in developed countries such as the USA. There is ample evidence demonstrating the beneficial effects of colorectal cancer screening and, largely thanks to screening initiatives and insurance coverage, epidemiologic analyses show a steady decline in both CRC incidence and mortality rates over the last several decades. However, screening rates for CRC in the US remain low and approximately 1 in 3 adults between the ages of 50 and 75 years has not undergone any form of CRC screening, highlighting the need for additional accurate, minimally invasive, and acceptable screening options. Computed tomography colonography (CTC) has emerged as a viable alternative to existing CRC screening tests and research continues to enhance our knowledge regarding the ability of CTC to play a meaningful role in optimizing CRC screening in areas where it is available. This review highlights recent publications of salient research in the field of CTC. CTC continues to evolve, with lower radiation doses and greater evidence of its ability to identify clinical relevant colonic and extracolonic abnormalities. Recent evidence has bolstered the currently recommended CTC screening interval of 5 years and has reiterated the cost-effectiveness of CTC as a CRC screening examination. Additionally, emerging evidence suggests a role for CTC as a polyp and CRC surveillance modality as well as a preoperative adjunct in patients with established CRC. Data supporting the safety and patient acceptance of CTC also has continued to accumulate and CTC has recently been endorsed as an appropriate test for CRC screening in multiple important guidelines and recommendations. CTC is poised to become an important option in the CRC screening and surveillance arena.

UK key performance indicators and quality assurance standards for colonoscopy

Colonoscopy should be delivered by endoscopists performing high quality procedures. The British Society of Gastroenterology, the UK Joint Advisory Group on GI Endoscopy, and the Association of Coloproctology of Great Britain and Ireland have developed quality assurance measures and key performance indicators for the delivery of colonoscopy within the UK. This document sets minimal standards for delivery of procedures along with aspirational targets that all endoscopists should aim for.

Expert opinions and scientific evidence for colonoscopy key performance indicators

Colonoscopy is a widely performed procedure with procedural volumes increasing annually throughout the world. Many procedures are now performed as part of colorectal cancer screening programmes. Colonoscopy should be of high quality and measures of this quality should be evidence based. New UK key performance indicators and quality assurance standards have been developed by a working group with consensus agreement on each standard reached. This paper reviews the scientific basis for each of the quality measures published in the UK standards.

Effect of Previous Gastrectomy on the Performance of Postoperative Colonoscopy

Purpose

The purpose of this study was to determine the effect of a prior gastrectomy on the difficulty of subsequent colonoscopy, and to identify the surgical factors related to difficult colonoscopies.

Materials and Methods

Patients with a prior gastrectomy who had undergone a colonoscopy between 2011 and 2014 (n=482) were matched (1:6) to patients with no history of gastrectomy (n=2,892). Cecal insertion time, intubation failure, and bowel clearance score were compared between the gastrectomy and control groups, as was a newly generated comprehensive parameter for a difficult/incomplete colonoscopy (cecal intubation failure, cecal insertion time >12.9 minutes, or very poor bowel preparation scale). Surgical factors including surgical approach, extent of gastrectomy, extent of lymph node dissection, and reconstruction type, were analyzed to identify risk factors for colonoscopy performance.

Results

A history of gastrectomy was associated with prolonged cecal insertion time (8.7±6.4 vs. 9.7±6.5 minutes; P=0.002), an increased intubation failure rate (0.1% vs. 1.9%; P<0.001), and a poor bowel preparation rate (24.7 vs. 29.0; P=0.047). Age and total gastrectomy (vs. partial gastrectomy) were found to be independent risk factors for increased insertion time, which slowly increased throughout the postoperative duration (0.35 min/yr). Total gastrectomy was the only independent risk factor for the comprehensive parameter of difficult/incomplete colonoscopy.

Conclusions

History of gastrectomy is related to difficult/incomplete colonoscopy performance, especially in cases of total gastrectomy. In any case, it may be that a pre-operative colonoscopy is desirable in selected patients scheduled for gastrectomy; however, it should be performed by an expert endoscopist each time.

Complications of diagnostic colonoscopy, upper endoscopy, and enteroscopy

Endoscopy is an inherent and an invaluable tool in every gastroenterologist's armamentarium. The prerequisite for quality and safety remains foremost. Adverse events should be minimized and proactive steps should taken before, during and after the endoscopic procedure. Upper endoscopy and colonoscopy are part of basic endoscopy and their major complications will be reviewed here, together with those of enteroscopy. The most common of all endoscopy related complications are cardiopulmonary and thus they will be addressed in detail first. Colonoscopy's major complications are bleeding and perforation. Their epidemiology, mechanisms/risk factors, diagnosis, treatment and prevention will be addressed. The incidence of both of these complications increases significantly with polypectomy. Thus clinical judgment and experience in both polypectomy techniques and the ways to treat these complications, especially with the advanced endoscopic options advanced in the last decade, are of paramount importance. Post-polypectomy syndrome, infection and gas explosion are less frequent and will be reviewed briefly. Bleeding and perforation are upper endoscopy's major complications as well. Advances in endoscopic techniques in recent years offer endoscopic treatment instead of directly resorting to surgery, as was used to be the case and still is if the first fails. Enteroscopy is generally a more advanced procedure and overall complication rate is often quoted as 1%, most of them have been attributed to the passage of the overtube. Perforation and bleeding are the major complications, and a unique upper enteroscopy-associated complication is pancreatitis.

Endoscopy in the Diagnosis and Management of Complications of Inflammatory Bowel Disease

The role of endoscopy in inflammatory bowel disease (IBD) has grown over the last decade in both diagnostic and therapeutic realms. It aids in the initial diagnosis of the disease and also in the assessment of the extent and severity of disease. IBD is associated with development of multiple complications such as strictures, fistulae, and colon cancers. Endoscopy plays a pivotal role in the diagnosis of colon cancer in patients with IBD through incorporation of chromoendoscopy for surveillance. In addition, endoscopic resection with surveillance is recommended in the management of polypoid dysplastic lesions without flat dysplasia. IBD-associated benign strictures with obstructive symptoms amenable to endoscopic intervention can be managed with endoscopic balloon dilation both in the colon and small intestine. In addition, endoscopy plays a major role in assessing the neoterminal ileum after surgery to risk-stratify patients after ileocolonic resection and assessment of a patient with ileoanal pouch anastomosis surgery and management of postsurgical complications. Our article summarizes the current evidence in the role of endoscopy in the diagnosis and management of complications of IBD.

Diagnostic Role of Colon Capsule Endoscopy in Patients with Optimal Colon Cleaning

Background. Colon capsule endoscopy (CCE) is a diagnostic test with relatively rare usage. In this study, we aimed to evaluate both the optimal cleaning regimen for CCE and the diagnostic value of test in the study group. Methods. A total of 62 patients were enrolled in this study. In the first step, 3 different colon preparing regimens were given to 30 patients [Group A: 3 days of liquid diet, sodium phosphate (NaP) (90 mL), and NaP enema; Group B: 3 days of liquid diet, 4 L of polyethylene glycol (PEG), and metoclopramide; Group C: 3 days of liquid diet, 4 L of PEG, NaP (45 mL), and bisacodyl after capsule ingestion] (10 patients in each group). The other consecutive 32 patients were cleaned with the best regimen which was NaP + PEG and CCE was performed. The results of CCE were controlled with colonoscopy in 28 patients. Results. Group C had the highest cleaning score, compared with the other groups (2.2 ± 0.4 versus 2.7 ± 0.4 versus 3.7 ± 0.4, p value = 0.000). The CCE findings were as follows in 28 patients who were also examined with colonoscopy: polyp (range: 5-10 mm) in 6 patients, internal hemorrhoids in 3 patients, angiodysplasia in 1 patient, diverticula in 1 patient, and ulcerative colitis in 1 patient. The sensitivity, specificity, PPV, and NPV of CCE were 100%, 92%, 93%, and 100%, respectively. Conclusions. Low dosage NaP combined with PEG provides optimal bowel preparation for CCE. CCE appears to be a highly sensitive diagnostic modality for detecting colonic pathologies.

Diagnostic value of terminal ileum biopsies in patients with abnormal terminal ileum mucosal appearance

OBJECTIVE

To investigate the necessity of obtaining routine ileal biopsy during colonoscopy in the patients with abnormal terminal ileum mucosal appearance if the inflammatory bowel disease is not considered.

MATERIAL AND METHODS

A retrospective analysis was performed for 57 patients who were referred to a private hospital for colonoscopy between January 2008 and February 2009, in whom terminal ileum intubation was achieved and an abnormal appearance was observed.

RESULTS

There were 33 men and 24 women; the mean age was 44.12±11.42 years. In 22 patients, the abnormality was ulcers and/or erosions. In 10 patients, there were mucosal nodularity and in 24, the finding was erythema. The time to reach to ileum from cecum was 28.78±24.30 s. The mean length of the examined ileum was 12.93±6.05 cm. There was no difference between groups according to distance covered in the ileum for diagnostic yield, but going further than 2 cm was important.

CONCLUSION

There should be no need to obtain routine biopsy in patients with abnormal terminal ileum mucosa appearance, when inflammatory bowel disease is not considered. In these patients, histopathology also reveals non-specific ileitis. Furthermore, in these patients, the macroscopic pathological diagnosis overlaps the histopathology, and it has a low diagnostic yield and lower clinical significance.

The role of virtual colonoscopy in colorectal screening

Colorectal cancer is the second leading cause of cancer-related deaths in the United States. The earlier colorectal cancer is detected, the better chance a person has of surviving 5 years after being diagnosed, emphasizing the need for effective and regular colorectal screening. Computed tomographic colonography has repeatedly demonstrated sensitivities equivalent to the current gold standard, optical colonoscopy, in the detection of clinically relevant polyps. It is an accurate, safe, affordable, available, reproducible, quick, and cost-effective option for colorectal screening and should be considered for mass screening.

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.

Laparoscopic endoloop technique - A novel approach of managing iatrogenic caecal perforation and literature review

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With our case we have adopted an innovative approach of using endolooping for an early perforation that was within a short distance of the appendicular base, applied proximal to the site of the perforation.

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In our surgery, the area of ischemic injury can be easily visualized through the laparoscopy and including fresh and healthy tissue margins in the loop is the hallmark of safety for this simple technique.

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The endoloop technique described, undertaken during a laparoscopy is a novel approach. It is a simple and effective method, reminding clinicians to adapt techniques when necessary.

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Nevertheless, it is only limited to perforations around the appendicular base. The endolooping technique may not be suitable for late presentation, large perforations with ischemic or friable tissue, and severe peritonitis. In such cases, the use of other methods, such as wedge resection or stapling would be safer.

Introduction

An iatrogenic caecal perforation is rare, but a serious complication associated with significant morbidity and mortality. We present a 4 min and 50 s video on a new improvisation undertaken during laparoscopic management of post-polypectomy caecal perforation.

Presentation of case

Our patient presented with an acute abdomen following endoscopic polypectomy. At surgery, the site of caecal perforation was close to the appendicular base with devitalization tissue, secondary to diathermy usage. The hallmark of safety within this novel technique included fresh healthy tissue margins within the endoloop (detachable snare ligation) and ensuring no ischemic tissue was gathered. Complete freeing of the appendix and meso-appendicular base was required and securing three endoloops proximal to the site of perforation. The post-operative course was uneventful.

Discussion

The World Society of Emergency Surgery (WSES) 2013 guidelines suggested an early laparoscopic approach is a safe and effective treatment for colonoscopy-related colonic perforation. There are no national guidelines and the management is dictated by the clinical condition of the patient, co-morbidity, size and site of perforation as well as the scale of bowel preparation, and surgical experience.

Conclusion

The endoloop technique described, undertaken during a laparoscopy is a novel approach. It is a simple and effective method, reminding clinicians to adapt techniques when necessary. Nevertheless, it is only limited to perforations around the appendicular base.

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.

Foregut and colonic perforations: practical measures to prevent and assess them

Acute endoscopic perforations of the foregut and colon are rare but can have devastating consequences. There are several principles and practices that can lower the risk of perforation and guide the endoscopist in early assessment when they do occur. Mastery of these principles will lead to overall improved patient outcomes.

Consent, common adverse events, and post-adverse event actions in endoscopy

Endoscopy constitutes a wide range of procedures with many indications. Esophagogastroduodenoscopy, colonoscopy, endoscopic retrograde cholangiopancreatography, endoscopic ultrasonography, and enteroscopy comprise the most commonly performed procedures. These examinations all carry risk to the patient, and incumbent in this is some legal risk with regard to how the procedure is conducted, decisions made based on the intraprocedure findings, and the postprocedure results, in addition to events that occur following the procedure. This article provides an overview of consent and complications of endoscopy.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Management of bleeding and perforation after colonoscopy

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

Prospective evaluation of adverse events following lower gastrointestinal tract EUS FNA

OBJECTIVES

There are virtually no data concerning the risk of adverse events (AEs) following lower gastrointestinal (LGI) endoscopic ultrasound (EUS). Our aim was to determine the incidence and factors associated with AEs following LGI EUS fine needle aspiration (FNA).

METHODS

We conducted a prospective cohort study at a tertiary referral center. Five hundred and sixty-three patients underwent LGI EUS FNA between 1 January 2004 and 1 January 2012. We analyzed the 502 patients who had complete follow-up. AE severity was graded (1-5) utilizing Common Terminology Criteria or Visual Analog Scale. AEs were assessed during the procedures, in clinical follow-up, during phone interviews conducted at 7-14 days, and final clinical and/or phone interviews at 2-4 months.

RESULTS

AEs developed in 103 (20.5%) patients and were classified as grade 1, 2, 3, or 4 in 34 (6.8%), 41 (8.2%), 23 (4.6%), and 5 (1.0%) patients, respectively. Bleeding and pain were the commonest AEs. No deaths occurred. On multivariate analysis, AEs were associated with prior pain (odds ratio (OR): 3.83, 95% confidence interval (CI): 2.35-6.25), FNA from a site other than a lymph node (LN) or gut wall (OR: 2.26, 95% CI: 1.10-4.70), and malignant FNA cytology (OR: 1.80, 95% CI: 1.10-2.97); serious (grade 3-4) AEs were associated with prior pain (OR: 15.21, 95% CI: 5.04-45.85) and FNA from a site other than a LN or gut wall (OR: 3.25, 95% CI: 1.15-9.20).

CONCLUSIONS

LGI EUS FNA is associated with a high rate of serious grades 3-4 AEs. This may reflect the total number of associated interventions and the frequency of underlying pathology and symptoms.

Lower rate of colonoscopic perforation: 110,785 patients of colonoscopy performed by colorectal surgeons in a large teaching hospital in China

BACKGROUND

Colonoscopic perforation (CP) has a low incidence rate. However, with the extensive use of colonoscopy, even low incidence rates should be evaluated to identify and address risks. Information on CP is quite limited in China.

OBJECTIVE

Our study aimed to determine the frequency of CP in colonoscopies performed by surgeons at a large teaching hospital in China over a 12-year period.

METHODS

A retrospective review of medical records was performed for all patients who had CPs from 1 January 2000 to 31 December 2012. Iatrogenic perforations were identified mainly by abdominal X-ray or computed tomography scan. Follow-up information of adverse events post-colonoscopy was identified from the colorectal surgery database of our hospital. Patients' demographic data, colonoscopy procedure information, location of perforation, treatment, and outcome were recorded.

RESULTS

A total of 110,785 diagnostic and therapeutic colonoscopy procedures were performed (86,800 diagnostic cases and 23,985 therapeutic cases) within the 12-year study period. A total of 14 incidents (0.012%) of CP were reported (seven males and seven females), of which nine cases occurred during diagnostic colonoscopy (0.01%) and five after therapeutic colonoscopy (three polypectomy cases, one endoscopic mucosal resection, and one endoscopic mucosal dissection). Mean patient age was 67.14 years. One case of CP (7.14%) after colonoscopy polypectomy was treated using curative colonoscopy endoclips. Other patients underwent operations: six cases (46.15%) of primary repair, four cases (28.57%) of resection with anastomosis, and two cases (15.38%) of resection without anastomosis. No obvious perforation was found in one patient (7.69%). Surgeons attempted to treat one case laparoscopically but eventually resorted to open surgery. The postoperative course was uncomplicated in eight cases (57.14%) and complicated in six cases (42.86%) but without mortality.

CONCLUSION

CP is a serious but rare complication of colonoscopy. A perforation risk of 0.012% was found in our study. The optimal management of CP remains controversial. Treatment for CP should be individualized according to the patient's condition, related devices, and surgical skills of endoscopists or surgeons. Selective measures such as colonoscopy without intravenous sedation and decrease of loop formation can effectively reduce rates of perforation.

Proteomic analysis of colorectal cancer: discovering novel biomarkers

Colorectal cancer is one of the most common cancers in the Western world. When detected at an early stage, the majority of cancers can be cured with current treatment modalities. However, most cancers present at an intermediate stage. The discovery of sensitive and specific biomarkers has the potential to improve preclinical diagnosis of primary and recurrent colorectal cancer, and holds the promise of prognostic and therapeutic application. Current biomarkers such as carcinoembryonic antigen lack sensitivity and specificity for general population screening. This review aims to highlight the role of current proteomic technologies in the discovery and validation of potential biomarkers with a view to translation to the clinic.

Quality in colonoscopy: European perspectives and practice

Colonoscopy is the 'gold standard' investigation of the colon. High quality colonoscopy is essential to diagnose early cancer and reduce its incidence through the detection and removal of pre-malignant adenomas. In this review, we discuss the key components of a high quality colonoscopy, review methods for improving quality, emerging technologies that have the potential to improve quality and highlight areas for future work.

“Cat Scratch Colon” and Cecal Barotrauma perforation during colonoscopy using CO2 insufflation

Cecal perforation due to barotrauma is an increasingly recognized complication of colonoscopy when using room air for insufflation. CO2 is increasingly being utilized for insufflation due to more rapid absorption compared to ambient air and results in reduced post-procedural pain and flatulence. Use of CO2 is thought to protect against barotrauma injury, and use of CO2 during endoscopy has not previously been reported to cause barotrauma perforation during colonoscopy. We present a case of cecal perforation secondary to barotrauma during routine screening colonoscopy with CO2.

Surgical emphysema following therapeutic colonoscopy

Colonoscopy is an invasive procedure used in the detection of colon cancer, inflammatory bowel disease and investigation of bleeding from the rectum. In addition to diagnostic procedures, colonoscopy also has therapeutic indications such as polypectomy and dilation of strictures. We present a case of a patient who presented with cervical emphysema following a therapeutic colonoscopy. The patient had no abdominal or chest pain, shortness of breath and was managed conservatively. Perforation following colonoscopy is a rare complication; however, it is essential that doctors recognize and are aware of the different presentations and management options for this complication.

Magnetic endoscopic imaging vs standard colonoscopy: Meta-analysis of randomized controlled trials

AIM: To assess the theoretical advantages of magnetic endoscope imaging (MEI) over standard colonoscopies (SCs) and to compare their efficacies.

METHODS: Electronic databases, including PubMed, EMBASE, the Cochrane library and the Science Citation Index, were searched to retrieve relevant trials. In addition, abstracts from papers presented at professional meetings and the reference lists of retrieved articles were reviewed to identify additional studies. The meta-analyses were performed using RevMan 5.1. A random effect model with the Mantel-Haenszel method was used for pooling dichotomous and continuous data. A sensitivity analysis was performed by excluding the trials with a small number of patients and by excluding the trials performed by inexperienced providers.

RESULTS: Eight randomized controlled trials (RCTs), including 2967 patients, were included in the meta-analysis to compare cecal intubation rates and times, sedation dose, abdominal pain scores and the use of ancillary maneuvers between MEI and SC. The overall OR was 1.92 (95%CI: 1.13-3.27, eight RCTs), as indicated by the cecal intubation rate of MEI compared with SC, but MEI did not have any distinct advantage over SC for cecal intubation time (MD = -0.07, 95%CI: -0.16-0.02; three RCTs). MEI did not generally result in lower pain scores. Outcomes were also analyzed for the two subgroups based on the endoscopists’ experience level to evaluate cecal intubation rates. MEI presented better outcomes for non-experienced colonoscopists than experienced colonoscopists.

CONCLUSION: The real-time magnetic imaging system is of benefit in training and educating inexperienced endoscopists and improves the cecal intubation rate for experienced and inexperienced endoscopists.