The role of laparoscopy in the treatment of complications after colonoscopy

Laparoscopic management of iatrogenic colon perforation

BACKGROUND

Iatrogenic colon perforation (ICP) due to colonoscopy is a severe complication and is associated with significant morbidity and mortality. The global estimated incidence of ICP is 0.03% and up to 3% for diagnostic and therapeutic colonoscopies, respectively. Treatment options include endoscopic repair, conservative therapy, and surgery. Treatment decision is based on the time and the setting of the diagnosis, the type, and location of the perforation, the presence of related pathologies, the clinical status and characteristic of the patient, and surgeon's skills. We present our experience in the treatment of ICPs.

METHODS

A retrospective review was undertaken of all patients suffering from ICP at Bnai-Zion Medical Center between 1/1/2010 and 1/3/2021. Clinical presentation, therapeutic approach, and short-term outcomes were analyzed.

RESULTS

There were 51 cases of ICPs. Fourteen (27%) were diagnosed by the gastroenterologist during the procedure, 2 of whom were treated with endoscopic clips. The rest of the patients (72.5%) were diagnosed in the ER after a CT scan. Forty-three patients (84%) went on to operative management: 5 (11%) operations started with laparotomy-all were conducted in the early study period (until 2013). All other operations (88%) started with a diagnostic laparoscopy, 4 of whom (10%) were converted to laparotomy. Out of the 38 laparoscopic cases 29 (80%) were treated with primary suturing. Seven patients went on to colon resection (5 of whom with primary anastomosis). Six patients required ICU admission-with 1/38 (2%) from the laparoscopic cases, and 5/9 (55%) from the laparotomy cases. A total of 49/51 (96%) patients recovered and were discharged after 5 ± 2 for conservative and laparoscopic cases, and 12 ± 9 for open cases.

CONCLUSION

Laparoscopic treatment of ICP is safe and feasible in most cases. Our data supports a laparoscopic attempt at any such scenario.

Clinical outcomes of laparoscopic versus open surgery for repairing colonoscopic perforation: a multicenter study

PURPOSE

We conducted this study to compare the perioperative outcomes of laparoscopic surgery (LS) vs. open surgery (OS) for repairing colonoscopic perforation, and to evaluate the possible predictors of complications.

METHOD

We reviewed the medical records of patients who underwent surgical repair of colonoscopic perforation by LS or OS between January 2005 and June 2019 at six Hallym University-affiliated hospitals. Multivariable analysis was performed to identify the predictors of postoperative complications.

RESULTS

Of the total 99 patients, 40 underwent OS and 59 underwent LS. The postoperative hospital stay and the time to resuming a soft diet were shorter in the LS group than in the OS group (P = 0.017 and 0.026, respectively). The complication rate and Clavien-Dindo classification were not significantly different between the two groups. Multivariable analysis revealed that an American Society of Anesthesiologists score (ASA) ≥ 3 and switching from non-operative management to surgical treatment were independently associated with complications (P = 0.025 and 0.010, respectively).

CONCLUSION

LS may be a safe alternative to OS for repairing colonoscopic perforation with a shorter postoperative hospital stay and time to resuming a soft diet. Patients with an ASA score ≥ 3 and those with changes to their planned treatment should be monitored carefully to minimize their risk of complications.

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

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

Efficacy of Laparoscopic Primary Repair in the Treatment of Colonic Perforation After Colonoscopy: A Review of 40,127 Patients

BACKGROUND

In recent years, increasing colonoscopy use increases the incidence of colonic perforation. Colonic perforation during colonoscopy is a rare but extremely serious complication. Traditionally, the management of colonic perforation is explorative laparotomy with bowel resection. Treatment using laparoscopic approach is a novel approach, and has been reported in some recent literatures. Nowadays, the using of laparoscopic primary repair in treatment of colonoscopic perforations has not been confirmed. This study retrospectively reviewed our experiences in treating colonoscopic perforations by laparoscopic primary repair.

OBJECTIVE

The aim of this study was to evaluate the safety and efficacy of the laparoscopic primary repair in the treatment of colonic perforations during colonoscopy.

METHODS

Between January 2003 and December 2014, data were collected retrospectively on all patients who underwent colonoscopy and compared the recovery parameters and morbidity of patients who underwent laparoscopic primary repair versus those who had open surgery.

RESULTS

A total of 40,127 colonoscopies were performed during the study period. There were 24 patients who underwent primary repair [13 underwent laparoscopic surgery (LS) and 8 underwent open surgery (OS)]. There were no demographic differences between the LS and OS groups (P>0.05). Compared with OS group, patients who underwent laparoscopic repair had a significantly shorter incision length (LS: 3.15±0.35 mm vs. OS: 12.60±2.87 mm, P=0.000), fewer blood loss (LS: 28.54±10.82 mL vs. OS: 159.25±46.90 mL, P=0.000), shorter postoperative hospital stay (LS: 8.31±1.93 d vs. OS: 12.38±1.41 d, P=0.000), and shorter postoperative fasting time (LS: 3.38±0.7 d vs. OS: 5.25±0.71 d, P=0.000). The operative time of LS group was a little longer than OS group, but there were no significant differences (LS: 86.31±22.22 min vs. OS: 75.125 ±14.24 min, P=NS).

CONCLUSIONS

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

The role of surgery in the treatment of endoscopic complications

As the number, diversity, and complexity of endoscopic complications has increased, so too has the number, diversity, and complexity of operative interventions required to treat them. The most common complications of endoscopy in general are bleeding and perforation, but each endoscopic modality has specific nuances of these and other complications. Accordingly, this review considers the surgical complications of endoscopy by location within the gastrointestinal tract, as opposed to by complication types, since there are many complication types that are specific for only one or few locations, such as buried-bumper syndrome after percutaneous endoscopic gastrostomy and pancreatitis after endoscopic retrograde cholangiopancreatography, and since the management of a given complication, such as perforation, may be vastly different in one area than in another area, such as perforations of the esophagus versus the retroperitoneal duodenum versus the intraperitoneal duodenum. It is hoped that this review will provide guidance for gastroenterologists considering a particular procedure, either to assess the risks for surgical complications in preparation for patient counseling, or assist in assessing a patient who seems to be having a severe complication, or to learn what operation might be required to treat a given complication and how that operation might be performed. As with many operations, those for the treatment of endoscopic complications are typically performed only when less invasive, nonoperative strategies fail.

Diagnosis and management of splenic injury following colonoscopy: algorithm and case series

BACKGROUND

Splenic injury following colonoscopy is a rare yet life-threatening complication. These injuries are often associated with delayed diagnosis and may require invasive intervention. We sought to study the emergent presentation associated with splenic injury post-colonoscopy and to suggest a new treatment algorithm.

METHODS

Six cases of splenic injury following colonoscopy were collected from three medical centers. Data regarding patient medical history, clinical presentation, laboratory and imaging findings and clinical management were recorded. A systematic PubMed/MEDLINE search was performed. Non-English-language publications and publications dating earlier than 2010 were excluded. An emergency department trauma-based management algorithm was designed according to the identified publications and review of the available trauma literature.

RESULTS

The mean age was 65.3 years and the male-to-female ratio was 1:5. Five of the cases presented within 24 h of the colonoscopy complaining of severe abdominal pain. Hemodynamic instability was noted in four patients who presented with tachycardia (105-130), hypotension and/or a rapid drop in hemoglobin levels. All of the patients underwent initial resuscitation and a computerized abdominal tomography scan. Four of them required emergent splenectomy. No mortality or major morbidity was reported following the hospitalization.

CONCLUSIONS

Although very rare, splenic injury during colonoscopy is an acute, severe and possible fatal complication. Patients may present with a rapid clinical deterioration and hemodynamic instability. Physicians should be familiar with the practical management of this surgical emergency and the treatment options available.

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.

Complications of colonoscopy

Colonoscopy is a relatively invasive modality for the diagnosis and treatment of colorectal disease and for the prevention or early detection of colorectal neoplasia. Millions of colonoscopies are performed each year in the United States by endoscopists with varying levels of skill in colons that present varying levels of challenge. Although better scope technology has made colonoscopy gentler and more accurate, the sheer number of examinations performed means that complications inevitably occur. This article considers the most common complications of colonoscopy, and advises how to minimize their incidence and how to treat them if they do occur.

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 Primary Colorrhaphy for Acute Iatrogenic Perforations during Colonoscopy

Purpose. We present our experience with laparoscopic colorrhaphy as definitive surgical modality for the management of colonoscopic perforations. Methods. Over a 17-month period, we assessed the outcomes of consecutive patients presenting with acute colonoscopic perforations. Patient characteristics and perioperative parameters were tabulated. Postoperative outcomes were evaluated within 30 days following discharge. Results. Five female patients with a mean age of 71.4 ± 9.7 years (range: 58–83), mean BMI of 26.4 ± 3.4 kg/m² (range: 21.3–30.9), and median ASA score of 2 (range: 2-3) presented with acute colonoscopic perforations. All perforations were successfully managed through laparoscopic colorrhaphy within 24 hours of development. The perforations were secondary to direct trauma (n = 3) or thermal injury (n = 2) and were localized to the sigmoid (n = 4) or cecum (n = 1). None of the patients required surgical resection, diversion, or conversion to an open procedure. No intra- or postoperative complications were encountered. The mean length of hospital stay was 3.8 ± 0.8 days (range: 3–5). There were no readmissions or reoperations. Conclusion. Acute colonoscopic perforations can be safely managed via laparoscopic primary repair without requiring resection or diversion. Early recognition and intervention are essential for successful outcomes.

2013 WSES guidelines for management of intra-abdominal infections

Despite advances in diagnosis, surgery, and antimicrobial therapy, mortality rates associated with complicated intra-abdominal infections remain exceedingly high.The 2013 update of the World Society of Emergency Surgery (WSES) guidelines for the management of intra-abdominal infections contains evidence-based recommendations for management of patients with intra-abdominal infections.

Splenic injury during colonoscopy--a complication that warrants urgent attention

INTRODUCTION

Colonoscopy is a safe procedure that is performed routinely worldwide. There is, however, a small but significant risk of splenic injury that is often under-recognized. Due to a lack of awareness about this injury, the diagnosis may be delayed, which can lead to an increased risk of morbidity as well as mortality. This paper presents a comprehensive review of the medical literature on colonoscopy-associated splenic injury and describes the clinical presentation and management of this rare but potentially life-threatening complication.

MATERIALS AND METHODS

A comprehensive literature search identified 102 patients worldwide, including patients from our experience, with splenic injury during colonoscopy. A meta-regression analysis was completed using a mixed generalized linear model for repeated measures to identify risk factors for this rare complication.

RESULTS

A total of 75 articles were identified and 102 patients were studied. The majority of the papers were in English (92 %). Only 23.4 % of patients (26/102) were reported prior to the year 2000. Among the patients reported after the year 2000, the majority (84.2 %, 64/76) were reported after 2005. There were more females (76.5 %), median age was 65 years (range, 29-90 years), and most of the colonoscopies were performed without difficulty (66.6 %). Nearly 67 % of patients presented within 24 h of colonoscopy with complaints ranging from abdominal pain to dizziness. The most common symptom was left upper quadrant pain (58 %), and CT scan was found to be the most sensitive tool for diagnosis. Seventy-three patients underwent operative intervention; 96 % of these were treated with splenectomy. Hemoglobin drop of more than 3 gm/dL was identified as the only significant predictor of operative intervention. The overall mortality rate was 5 %.

CONCLUSION

Splenic injury during colonoscopy is rare; however, it is associated with significant morbidity and mortality. Splenic injury warrants a high degree of clinical suspicion critical to prompt diagnosis, and early surgical consultation is warranted.

The Indications for Nonsurgical Management in Patients with Colorectal Perforation after Colonoscopy

Recently, the risk of colonic perforation has been increasing with the increased frequency of advanced therapeutic endoscopy. However, guidelines for the management of colon perforations after colonoscopy have not been established. This study aimed to evaluate the indications for nonsurgical management. This study was conducted as a case–control study with 22 patients who were managed for colorectal perforations after colonoscopy from June 2004 to July 2009. Colonoscopy was performed in 12 patients (54.4%) for diagnostic purposes and 10 (45.5%) for therapeutic reasons. The most common site of perforation was the sigmoid colon (77.3%). Five patients underwent nonsurgical treatment, and 17 patients received surgical treatment. The duration of hospital stay did not differ significantly between the two groups. Abdominal pain and fever were significantly more commonly encountered in the surgical management group ( P = 0.043 and 0.011, respectively). All of the patients who were suitable for nonsurgical treatment were diagnosed within 24 hours and received bowel preparation before the colonoscopy. The nonsurgical treatment of colonic perforation after colonoscopy could be feasible in afebrile patients with less severe abdominal pain. Moreover, cases that were diagnosed within 24 hours and received bowel preparation before colonoscopy were associated with better outcomes.

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.

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.

Laparoscopy in Non-Trauma Abdominal Emergencies

The role for laparoscopy has evolved throughout the years and more evidence has become available to support its use in abdominal emergencies. Although the literature has expanded and more randomized controlled trials are available, skepticism persists concerning the use of laparoscopy in emergency situations. We attempt to provide the readers with a concise review and highlight the most relevant issues and available evidence in seven different non-trauma abdominal emergencies.