Laparoscopic treatment of endoscopic sigmoid colon perforation: a case report and literature review

Perforation of a Long-standing Ileocolonic Anastomosis During Colonoscopy

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

Management of iatrogenic colorectal perforation: From surgery to endoscopy

Iatrogenic colon perforation is one the most pernicious complications for patients undergoing endoscopic screening or therapy. It is a serious but rare complication of colonoscopy. However, with the expansion of the indications for endoscopic therapies for gastrointestinal diseases, the frequency of colorectal perforation has increased. The management of iatrogenic colorectal perforation is still a challenge for many endoscopists. The methods for treating this complication vary, including conservative treatment, surgical treatment, laparoscopy and endoscopy. In this review, we highlight the etiology, recognition and treatment of colorectal iatrogenic perforation. Specifically, we shed light on the endoscopic management of this rare complication.

Colonoscopic perforation management by laparoendoscopy: an algorithm

Laparoscopic intervention may be a safe and effective alternative to open surgery for management of perforation during colonoscopic examination. A simple algorithm is presented that may be helpful for those considering a laparoscopic approach to managing this condition.

Background and Objectives:

The role of laparoscopy in the management of iatrogenic colonoscopic injuries has increased with surgeons becoming facile with minimally invasive methods. However, with a limited number of reported cases of successful laparoscopic repair, the exact role of this modality is still being defined. Drawing from previous literature and our own experiences, we have formulated a simple algorithm that has helped us treat colonoscopic perforations.

Methods:

A retrospective review was undertaken of patients treated for colonoscopic perforations since the algorithm's introduction. For each patient, initial clinical assessment, management, and postoperative recovery were carefully documented. A Medline search was performed, incorporating the following search words: colonoscopy, perforation, and laparoscopy. Twenty-three articles involving 106 patients were identified and reviewed.

Results:

Between May 2009 and August 2012, 7 consecutive patients with colonoscopic perforations were managed by 2 surgeons using the algorithm. There were no complications and no deaths, with a mean length of stay of 4.43 days (range, 2–7 days). Of the 7 patients, 6 required surgery. A single patient was managed conservatively and later underwent an elective colon resection.

Conclusions:

Traditionally, laparotomy was the preferred method for treating colonoscopic perforations. Our initial experience reinforces previous views that laparoendoscopic surgery is a safe and effective alternative to traditional surgery for managing this complication. We have formulated a simple algorithm that we have found helpful for surgeons considering a laparoscopic approach to managing this condition.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Laparoscopic repair of colonic anastomotic leak in an elderly patient

The authors suggest that the small bowel be assessed in all appendectomy cases for a pathological Meckel's diverticulum.

Background:

Meckel's diverticulum is a congenital anomaly resulting from incomplete obliteration of the omphalomesenteric duct. The incidence ranges from 0.3% to 2.5% with most patients being asymptomatic. In some cases, complications involving a Meckel's diverticulum may mimic other disease processes and obscure the clinical picture.

Methods:

This case presents an 8-year-old male with abdominal pain, nausea, and vomiting and an examination resembling appendicitis.

Results:

A CT scan revealed findings consistent with appendicitis with dilated loops of small bowel. During laparoscopic appendectomy, the appendix appeared unimpressive, and an inflamed Meckel's diverticulum was found with an adhesive band creating an internal hernia with small bowel obstruction. The diverticulum was resected after the appendix was removed.

Conclusion:

The incidence of an internal hernia with a Meckel's diverticulum is rare. A diseased Meckel's diverticulum can be overlooked in many cases, especially in those resembling appendicitis. It is recommended that the small bowel be assessed in all appendectomy cases for a pathological Meckel's diverticulum.

Laparoscopic repair of colonic anastomotic leak in an elderly patient

Laparoscopic surgery may be extended to a wider variety of colorectal emergencies in a carefully selected group of patients, including the elderly.

Background:

Laparoscopy to repair iatrogenic colonoscopic perforation of the colon has proven to be a safe, effective, and reproducible means to treat these potentially devastating emergencies. The use of the laparoscope provides exceptional diagnostic yield, and under the hand of a trained surgeon, produces excellent therapeutic results while minimizing recovery time for the patient.

Methods:

We report the case of an 86-year-old man who underwent emergent laparoscopic repair of a postoperative anastomotic leak following sigmoid colectomy.

Results:

The patient underwent laparoscopic oversewing of a colonic anastomotic leak, omental patch, and diverting loop ileostomy. The patient recovered fully from his emergency procedure without any further complications.

Conclusion:

Laparoscopic surgery can be extended to a wider variety of colorectal emergencies in a carefully selected group of patients, including the elderly.

Endoscopic complications--avoidance and management

The frequency of endoscopic complications is likely to rise owing to the increased number of indications for therapeutic procedures and also to the increased complexity of endoscopic techniques. Informed patient consent should be obtained as part of the procedure. Prevention of endoscopic adverse events is based on knowledge of the relevant risk factors and their mechanisms of occurrence. Thus, suitable training of future gastroenterologists and endoscopists is required for these complex procedures. When facing a complication, appropriate management is generally provided by an early diagnosis followed by prompt therapeutic care tailored to the situation. The most common complications of diagnostic and therapeutic upper gastrointestinal endoscopy, retrograde cholangiopancreatography, small bowel endoscopy and colonoscopy are reviewed here. Different modalities of medical, endoscopic or surgical management are also considered.

Laparoscopic perforostomy for treating a delayed colonoscopic perforation: Novel approach

INTRODUCTION:

With the implementation of bowel cancer screening programmes, more and more colonic polyps are detected, requiring hot biopsies or resections with an attendant risk of perforation. Laparoscopy is increasingly performed for assessing colonoscopic perforations, usually repaired by stitching or stapling, which is associated with a risk of a leak from the suture line.

CASE REPORT:

We describe a novel approach of laparoscopic exteriorisation of a delayed colonoscopic perforation which resolved without any further intervention.

DISCUSSION:

Laparoscopic perforostomy is an alternative minimally invasive laparoscopic approach which respects all the rules by allowing a single-stage procedure including thorough toilet with defunctioning and diversion.

Colonoscopic perforation: useful parameters for early diagnosis and conservative treatment

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Tulip bundle technique and fibrin glue injection: Unusual treatment of colonic perforation

We report a case of a 63-year-old male who experienced an iatrogenic sigmoid perforation repaired combining three endoscopic techniques. The lesion was large and irregular with three discrete perforations, therefore, we decided to close it by placing one clip per perforation, and then connecting all the clips with two endoloops. Finally we chose to use a fibrin glue injection to obtain a complete sealing. Four days after the colonoscopy the patient underwent a laparoscopic right hemicolectomy due to evidence of a large polyp of the caecum with high grade dysplasia and focal carcinoma in situ. Inspection of the sigma showed complete repair of the perforation. This report underlines how a conservative approach, together with a combination of various endoscopic techniques, can resolve complicated iatrogenic perforations of the colon.

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.

Laparoscopic repair of colonoscopic perforation: a new standard?

BACKGROUND

Scientific evidence demonstrating interest in the laparoscopic approach for surgical repair of colonoscopic perforations is still lacking. The authors retrospectively reviewed the records of 43 patients who suffered from colonic perforations after colonoscopy between 1989 and 2008 in two tertiary centers in order to compare the results of the laparoscopic and the open approaches to repair.

METHODS

The patients' demographic data, perforation location, therapy, and outcome were recorded from the medical charts. Forty-two patients were managed operatively (19 laparoscopies and 23 laparotomies). In three patients who underwent explorative laparoscopy, the procedure had to be converted to laparotomy due to surgical difficulties. The patients who underwent laparotomy management had a longer period between the colonoscopy and the surgery (P=0.056) and more stercoral contaminations.

RESULTS

The mean hospital stay was shorter for the laparoscopy group (P=0.02), which had fewer postoperative complications (P=0.01) and no mortality (NS).

CONCLUSION

This series demonstrates that early laparoscopic management of colonoscopic perforation is safe. Laparoscopic management may lead to reduced surgical and psychological stress for the patient because of its low morbidity and mortality rates and shorter hospital stay. However, the procedure should be converted to a laparotomy if necessary.

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.

Evolving management of colonoscopic perforations

BACKGROUND

Perforations of the large bowel during diagnostic or therapeutic colonoscopy are a rare but significant complication. Their treatment has evolved over the last decade, but there are still no specific guidelines for their optimal management.

MATERIALS AND METHODS

Retrospective review of 105,786 consecutive colonoscopies performed in a 21-year period allowed assessment of the medical records in all patients treated at our institution for colonoscopic perforation.

RESULTS

Thirty-five patients suffered perforation (perforation rate 0.033%) during colonoscopy from January 1986 to October 2007 (14 men, 21 women; mean age 69.4 years). Twenty-four of the perforations occurred during diagnostic colonoscopy, whereas 11 during therapeutic colonoscopy. Twenty-three (66%) of the patients underwent operative treatment and 12 (34%) were managed nonoperatively. The average length of stay was 15.2 days, and there was one death (2.9% 30-day mortality rate) among the patients.

CONCLUSIONS

Perforations from diagnostic colonoscopy usually are large enough to warrant surgical management, whereas perforations from therapeutic colonoscopy usually are small, leading to successful nonoperative treatment. Over the last decade, the surgical treatment of colonoscopic perforations has evolved, as there has been a trend that favors primary repair versus bowel resection with successful outcome. Careful observation and clinical care adherent to strict guidelines for patients treated nonoperatively is appropriate in order to minimize morbidity and mortality and identify early those who may benefit from operation. Each treatment, however, has to be individualized according to the patients' comorbidities and clinical status, as well as the specific conditions during the colonoscopy that lead to the perforation.

Laparoscopic treatment of iatrogenic endoscopic sigmoid colon perforation: a case report and literature review

Iatrogenic colon injury during a colonoscopy procedure is rare. The controversy exists when the surgical treatment of such lesions is concerned: operative or conservative. This case report is in favor of the operative endoscopic approach, with a literature review. An 80-year-old male sustained an iatrogenic endoscopic sigmoid colon perforation. Laparoscopic suturing was done within 5 hours after the perforation, with no complications after 4 months of follow-up.