2017 WSES guidelines for the management of iatrogenic colonoscopy perforation

A case of delayed perforation after cold snare polypectomy treated conservatively by endoscopic clip closure

We present the case of a 45-year-old man who underwent a screening total colonoscopy and developed delayed perforation after a cold snare polypectomy in the descending colon and sigmoid colon. The patient developed abdominal pain and was referred to our department for further evaluation and treatment. On clinical examination, we noted lower abdominal tenderness, mild rebound pain, and elevated levels of inflammatory markers. Abdominal contrast-enhanced computed tomography confirmed the presence of free air in the abdomen. Since there were no signs of peritoneal inflammation and the vital signs were stable, we planned to perform endoscopic clip closure of the perforated area. The patient's symptoms improved with conservative management thereafter, including fasting, fluid replacement, and antibiotic administration. The patient was discharged on the 6th hospital day. In this case report, we discuss the usefulness of endoscopic clip closure in managing delayed perforation.

Endoclip combined with colonic transendoscopic enteral tubing: a new approach for managing iatrogenic colonoscopy perforation

BACKGROUND

Iatrogenic colonoscopy perforation (ICP) is a rare but most serious complication during colonoscopy investigation. However, endoscopic closure plays an important role in the dealing with ICP with the development of endoscopic techniques presently, there are still some portion of patients transferred to surgery.

METHODS

Once a perforation was detected, endoclips were used to closed the defect of the colon. Then a colonic TET was planted inside the colon. The terminal end of the TET was put proximally to or near the location of the perforation. Then gas and fluid was sucked out through the TET with a syringe every 4 h.

RESULTS

Three cases were treated with endoclip closure and colonic TET drainage. Case 1 was caused by urgent immediate perforation during routine colonoscopy, case 2 was delayed perforation after snare resection, and case 3 was ESD-related perforation. All patients got healed, no one transferred to surgery.

CONCLUSIONS

A combination of endoclip closure and colonic TET drainage might be an easy and potential method in the dealing with different types of ICP. This study may offer a novel paradigm for addressing endoscopy-related intestinal perforations.

MR Enterography in Ulcerative Colitis: Beyond Endoscopy

Ulcerative colitis (UC) is a chronic idiopathic inflammatory bowel disease (IBD) that progressively affects mucosa and submuccosa of the colon and rectum in a continual pattern. In comparison, Crohn disease (CD), the other type of IBD, is a chronic transmural inflammatory disorder that can involve any part of the gastrointestinal tract. MR enterography (MRE) has emerged as an important imaging modality for the diagnosis and detection of disease activity and complications in CD, with comparable results to those of endoscopy. But MRE has been underused for assessment of UC in recent years, and clinicians heavily rely on endoscopic findings for management of UC. Despite UC being considered an endoscopically assessable disease, MRE can provide useful information beyond that obtained with endoscopy about mural or extramural abnormalities, inaccessible parts of the colonic lumen, associated extraintestinal diseases, and superimposed pathologic conditions. Moreover, endoscopy might be contraindicated in some clinical settings due to the risk of colonic perforation. In addition to depicting the features of UC activity in different phases, MRE demonstrates findings of disease chronicity that cannot be achieved with endoscopy, particularly in a patient with colitis of unknown cause. The valuable diagnostic role of MRE to exclude undiagnosed CD in patients with UC who have refractory disease or those with postproctocolectomy complications is also emphasized. Radiologists can play a crucial role in the management of UC with MRE by addressing what is beyond endoscopy. ©RSNA, 2023 Test Your Knowledge questions are available in the supplemental material.

A 37-Year-Old Schizophrenic Woman With Abdominal Pain

Introduction

Internal fistula across the posterior wall of stomach and the transverse colon caused by foreign bodies in the alimentary tract presents an extremely rare medical entity.

Presentation of case

We report an aschizophrenia female patient with onset of internal fistula across the posterior wall of stomach and the transverse colon triggered by swallowed magnetic metal beads. The patient was admitted to the emergency room of Northern Jiangsu People's Hospital because of acute right lower abdominal pain. Emergency routine abdominal CT scan revealed acute appendicitis and a set of foreign body in digestive tract.

Discussion

The foreign body in the stomach was removed by open surgery after tentative Endoscopic foreign body removal and laparoscopic appendectomy and exploration. In the process of exploring the gastric wall, it was found that one of magnet beads was embedded in the posterior wall of stomach and adhered to part of the transverse colon. After separation, it was found that an internal fistula was formed across the posterior wall of stomach and the transverse colon. As the patient ate only a small amount of food within 2 days, and the intestines were in good condition, we performed partial transverse colectomy, end-to-side anastomosis and gastric wall repair.

Conclusion

This case shows that for long-term foreign bodies in the digestive tract, we should be beware of the onset of gastrointestinal perforation. Moreover, perforation caused by the force acting on a blunt foreign body often results in atypical imaging findings, and the diagnosis of perforation cannot be clearly determined by imaging findings such as the presence of free gas downstream of the diaphragm. This poses new challenges for clear diagnosis and treatment.

Cesena guidelines: WSES consensus statement on laparoscopic-first approach to general surgery emergencies and abdominal trauma

BACKGROUND

Laparoscopy is widely adopted across nearly all surgical subspecialties in the elective setting. Initially finding indication in minor abdominal emergencies, it has gradually become the standard approach in the majority of elective general surgery procedures. Despite many technological advances and increasing acceptance, the laparoscopic approach remains underutilized in emergency general surgery and in abdominal trauma. Emergency laparotomy continues to carry a high morbidity and mortality. In recent years, there has been a growing interest from emergency and trauma surgeons in adopting minimally invasive surgery approaches in the acute surgical setting. The present position paper, supported by the World Society of Emergency Surgery (WSES), aims to provide a review of the literature to reach a consensus on the indications and benefits of a laparoscopic-first approach in patients requiring emergency abdominal surgery for general surgery emergencies or abdominal trauma.

METHODS

This position paper was developed according to the WSES methodology. A steering committee performed the literature review and drafted the position paper. An international panel of 54 experts then critically revised the manuscript and discussed it in detail, to develop a consensus on a position statement.

RESULTS

A total of 323 studies (systematic review and meta-analysis, randomized clinical trial, retrospective comparative cohort studies, case series) have been selected from an initial pool of 7409 studies. Evidence demonstrates several benefits of the laparoscopic approach in stable patients undergoing emergency abdominal surgery for general surgical emergencies or abdominal trauma. The selection of a stable patient seems to be of paramount importance for a safe adoption of a laparoscopic approach. In hemodynamically stable patients, the laparoscopic approach was found to be safe, feasible and effective as a therapeutic tool or helpful to identify further management steps and needs, resulting in improved outcomes, regardless of conversion. Appropriate patient selection, surgeon experience and rigorous minimally invasive surgical training, remain crucial factors to increase the adoption of laparoscopy in emergency general surgery and abdominal trauma.

CONCLUSIONS

The WSES expert panel suggests laparoscopy as the first approach for stable patients undergoing emergency abdominal surgery for general surgery emergencies and abdominal trauma.

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.

Methods of Surgical Repair for Iatrogenic Sigmoid Colon Perforation Following Colonoscopy: A Case Report and Literature Review

Iatrogenic colonic perforation is a relatively infrequent yet perilous complication arising from both diagnostic and therapeutic colonoscopies, potentially leading to severe septic complications and increased morbidity or mortality. Given the gravity of potential complications, surgical intervention stands as the principal treatment strategy, with various modalities selected based on clinical discretion. In this context, we present the case of a patient who underwent primary laparoscopic repair following the identification of a sigmoid colon perforation during a routine colonoscopy. Intraoperatively, a Jackson-Pratt drain was placed to facilitate postoperative monitoring and drainage. The patient's hospitalization extended to a total of seven days due to sustained drainage and leukocytosis, highlighting the complexities of managing postoperative complications in such cases. This report underscores the current landscape of published data guiding the surgical management of iatrogenic colonic perforation following colonoscopy and highlights both the existing strengths and gaps within the current body of literature. As colonic perforation remains a critical concern in endoscopic procedures, a comprehensive understanding of optimal surgical interventions is crucial for minimizing patient morbidity and ensuring successful outcomes.

Management of Enterocutaneous Fistula in Crohn's Disease by Embolization With Glue Injection and Coiling: A Case Report

There is one reported case of a pancreatoduodenal fistula that was managed using combined coil embolization and fibrin glue after the failure of other methods. Herein, we document this case to highlight the value of coil embolization and fibrin glue as surgical alternatives for fistula treatment. We present a case of a 39-year-old female patient who has a known case of Crohn's disease (CD) and presented with an enterocutaneous fistula (ECF) after her most recent surgery. With the failure of conservative approaches and as she refused any surgical interventions, fibrin glue injection and coiling were used. As a conclusion, embolization may work well as a surgical management alternative due to its simplicity.

Efficacy and safety analysis of midazolam combined with dezocine sedation and analgesia colonoscopy in patients with inflammatory bowel disease: a prospective single-center open study

Objective: Colonoscopy plays an important role in the diagnosis, prognosis prediction, assessment of disease activity and severity, and treatment of inflammatory bowel disease (IBD)-related complications. However, some patients refuse to undergo colonoscopy due to perceived pain and other discomfort, their diagnosis and treatment are affected. Therefore, we conducted a prospective study to explore the efficacy and safety of midazolam combined with dezocine for sedation in IBD patients undergoing colonoscopy. Methods: 224 patients were divided into sedative-colonoscopy-group (SCG, n = 93), anesthesia-colonoscopy-group (ACG, n = 90) and ordinary-colonoscopy-group (OCG, n = 41). The vital signs (blood pressure, pulse, respiration and blood oxygen saturation), pain degree during colonoscopy, satisfaction and complication rates of the three groups were compared. Results: Before colonoscopy, there was no significant difference among the vital signs of the three groups. The vital signs of the ACG were significantly lower than those of the SEG and the OCG (p < 0.05), and the difference was not significant between the SCG and OCG during colonoscopy. The colonoscopy pain score in the SCG was lower than that in the OCG (0.79 ± 1.09 vs. 2.98 ± 1.27, p < 0.001). The satisfaction score of the SCG (9.26 ± 1.16) was not significantly different from that of the ACG (9.42 ± 1.41) but was higher than that of the OCG (6.63 ± 1.13) (p < 0.001). The total complication rate of the ACG was 45.56% (41/90), which was significantly higher than that of the SCG [20.43% (19/93)] and the OCG [19.51% (8/41)]. Colon perforation, abnormal blood pressure fluctuation and hypoxemia were significantly more common in the ACG than in the SCG and the OCG (p < 0.05). However, there was no significant difference in the incidence of complications between the SCG and OCG. Conclusion: Compared with ordinary-colonoscopy, colonoscopy performed under midazolam and dezocine sedation is more comfortable for patients, thereby increasing satisfaction and compliance. Colonoscopy that is performed under midazolam and dezocine is similar to colonoscopy that is anesthesia with propofol in terms of comfort, satisfaction and compliance and similar to ordinary-colonoscopy in terms of safety. Considering the shortage of anesthesiologists, the application of midazolam combined with dezocine for digestive endoscopy is worthy of clinical promotion.

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.

Endoluminal management of colon perforations during advanced endoscopic procedures

BACKGROUND

Advanced endoscopic procedures are gaining attraction despite a steep learning curve, need for high dexterity, and potential complications. Colonic perforation is the most concerning adverse event during advanced endoscopic procedures. This study presents our experience on endoluminal management of iatrogenic colonic perforations.

METHODS

Patients who underwent advanced endoscopic procedures at a quaternary center from 2016 to 2021 were identified. Patients who had colonic perforations during advanced procedures and treated with endoscopic closure/clipping were included. Retrospective chart review was performed. Figures represent frequency (proportion) or median (interquartile range/range).

RESULTS

There were 22 (2.3%) immediate colonic perforations treated with endoscopic clipping out of 964 advanced endoscopic resections. The median age was 64 (interquartile range = 57-71) years and 50% of the patients were female; 16 (73%) resections were proximal to the splenic flexure. Median polyp size was 36 (20-55) mm. Closure was performed with endoscopic clips in 18 (82%) patients, and over-the-scope clips in 4 patients. Median hospital stay was 0.8 (0-4) days, and 13 (59%) patients were discharged the same day; 2 patients were admitted to the emergency department ≤24 hours of procedure. They underwent subsequent laparoscopic suture repair the same day. No one had segmental colon resection, and there were no complications within postoperative 30 days. Pathology revealed 9 (41%) tubular adenomas, 7 (32%) tubulovillous adenomas, 6 (27%) sessile serrated lesions, and no adenocarcinoma. No recurrence was observed with median follow-up of 24 months (range = 0-90 months).

CONCLUSION

Endoscopic management is an effective treatment approach for the management of iatrogenic colonic perforations.

Quality improvement project on the development of a management algorithm for iatrogenic perforations and the long-term impact on physician knowledge

Background and study aims  Acute iatrogenic endoscopic perforations (AIEPs) can have high morbidity and mortality, especially colonic perforations. Knowledge of diagnosis and AIEP management can improve patient care. The aims of this study were to: develop an evidence-based AIEP management algorithm; study its short-term and long-term impact on physician knowledge; and evaluate physician knowledge using hypothetical clinical scenarios. Methods  An institutional AIEP management algorithm was created using the most current recommendations from the American Society for Gastrointestinal Endoscopy and the European Society of Gastrointestinal Endoscopy. Input from advanced endoscopists, nurses, and anesthesiologists was also obtained. We assessed change in physician knowledge using a 10-item questionnaire before (pretest), a standardized one-page AIEP educational material and algorithm immediately after (post-test) to test short-term retention, and 6 months later (6-month reassessment) to test long-term retention. With the 6-month reassessment, two clinical scenarios based on real AIEP were presented to evaluate application of knowledge. Results  Twenty-eight subjects (8 gastroenterology fellows and 20 practicing gastroenterologists) participated in the assessments. Pretest and immediate post-test accuracies were 75 % and 95 % ( P  < 0.01), respectively. Six-month reassessment accuracies were 83.6 %, significantly worse compared to post-test accuracies ( P  < 0.05), but significantly improved compared to pretest accuracies ( P  < 0.05). Accuracies for clinical scenarios #1 and #2 were 67.5 % and 60.3 %, respectively. Fellows had similar accuracies when compared to practicing gastroenterologists. Conclusions  Using standardized methodology and a multidisciplinary approach, an AIEP management algorithm was created to improve patient care and alleviate physician and staff stress. In addition, we showed that a one-page educational document on perforations can significantly improve short-term and long-term physician knowledge, although periodic reeducation is needed.

Performance measures for the SACRED team-centered approach to advanced gastrointestinal endoscopy: European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative

The European Society of Gastrointestinal Endoscopy and United European Gastroenterology have defined performance measures for upper and lower gastrointestinal, pancreaticobiliary, and small-bowel endoscopy. Quality indicators to guide endoscopists in the growing field of advanced endoscopy are also underway. We propose that equal attention is given to developing the entire advanced endoscopy team and not the individual endoscopist alone.We suggest that the practice of teams intending to deliver high quality advanced endoscopy is underpinned by six crucial principles concerning: selection, acceptance, complications, reconnaissance, envelopment, and documentation (SACRED).

Analysis of the Characteristics of Colonoscopy Perforation and Risk Factors for Failure of Endoscopic Treatment

Background: Many studies have been done regarding perforation after colonoscopy, but few studies analyzed the risk factors of endoscopic treatment failure after colonoscopy perforation. This study aimed to analyze the clinical characteristics and treatment plan of those patients with perforation after colonoscopy diagnosis and the treatment and risk factors of failure to endoscopic treatment.

Method: This was a retrospective observational study of patients who underwent colonoscopy examination and treatment at the Affiliated Hospital of Yangzhou University, from 04/2009 to 03/2020. The patients were grouped as perforation, treatment success, or failure (required laparoscopy or laparotomy).

Results: From April 2009 to March 2020, 43,470 patients were examined and treated with colonoscopy. There were 35 cases of intestinal perforation, for an incidence of 0.081%. Four patients had immediate surgical intervention (two patients with laparoscopic surgery and two with laparotomy surgery). Thirty-one (88.57%) patients underwent endoscopic treatment. Endoscopic treatment was successful in 20 patients and failed in 11. Compared with the failure group, the perforation size in the success group was smaller (7.60±4.85 vs. 14.4±7.03 mm, P=0.004), hospital stay was shorter (26.6±13.1 vs. 14.2±3.0, P=0.011), and hospitalization costs were lower (30,208±9506 vs. 23,053±6227 RMB, P=0.002). Multivariable logistic stepwise analysis showed that the absence of abdominal pain after therapeutic colonoscopy was independently associated with the success of endoscopic treatment.

Conclusions: Endoscopic treatment is logically the preferred modality for perforation management, leading to good recovery, shorter hospital stay, and lower costs of treatment. Postoperative abdominal pain is significantly related to the failure of endoscopic treatment.

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

Background/Aims

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

Methods

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

Results

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

Conclusions

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

Postcolonoscopy Complications

A 62-year-old woman presents for her first screening colonoscopy as recommended by her primary care physician after an initial health maintenance examination to establish care. A 1-cm sessile polyp was found in the cecum during the colonoscopy, which was resected using hot snare polypectomy. After appropriate postprocedure recovery, the patient was sent home and presented 12 hours later to the emergency department with severe abdominal pain.

Digestive perforations related to endoscopy procedures: a local management charter based on local evidence and experts' opinion

Background and study aims  Perforations are a known adverse event of endoscopy procedures; a proposal for appropriate management should be available in each center as recommended by the European Society of Gastrointestinal Endoscopy. The objective of this study was to establish a charter for the management of endoscopic perforations, based on local evidence. Patients and methods  Patients were included if they experienced partial or complete perforation during an endoscopic procedure between 2008 and 2018 (retrospectively until 2016, then prospectively). Perforations (size, location, closure) and management (imagery, antibiotics, surgery) were analyzed. Using these results, a panel of experts was asked to propose a consensual management charter. Results  A total of 105 patients were included. Perforations occurred mainly during therapeutic procedures (91, 86.7%). Of the perforations, 78 (74.3 %) were diagnosed immediately and managed during the procedure; 69 of 78 (88.5 %) were successfully closed. Closures were more effective during therapeutic procedures (60 of 66, 90.9 %) than during diagnostic procedures (9 of 12, 75.0 %, P  = 0.06). Endoscopic closure was effective for 37 of 38 perforations (97.4 %) < 0.5 cm, and for 26 of 34 perforations (76.5 %) ≥ 0.5 cm ( P  < 0.05). For perforations < 0.5 cm, systematic computed tomography (CT) scan, antibiotics, or surgical evaluation did not improve the outcome. Four of 105 deaths (3.8 %) occurred after perforation, one of which was attributable to the perforation itself. Conclusions  Detection and closure of perforations during endoscopic procedure had a better outcome compared to delayed perforations; perforations < 0.5 cm had a very good prognosis and CT scan, surgeon evaluation, or antibiotics are probably not necessary when the endoscopic closure is confidently performed. This work led to proposal of a local management charter.

Current endoscopic closure techniques for the management of gastrointestinal perforations

Acute gastrointestinal perforations occur either from spontaneous or iatrogenic causes. However, particular attention should be made in acute iatrogenic perforations as timely diagnosis and endoscopic closure prevent morbidity and mortality. With the increasing use of diagnostic endoscopy and advances in therapeutic endoscopy worldwide, the endoscopist must be able to recognize and manage perforations. Depending on the size and location of the defect, a variety of endoscopic clips, stents, and suturing devices are available. This review aims to prepare and guide the endoscopist to use the right tools and techniques for optimal patient outcomes.

Bilateral pneumothorax and pneumomediastinum during colonoscopy in a patient with intestinal Behcet’s disease: A case report

BACKGROUND

Colonoscopy is essential for the diagnosis of intestinal Behcet’s disease (BD), which is characterized by a typical oval-shaped ulcer in the ileocecal region. However, potential risks of colonoscopy have rarely been reported.

CASE SUMMARY

Herein, we describe a patient with intestinal BD who presented with decreased oxygen saturation and shortness of breath during a diagnostic colonoscopy. Bilateral pneumothorax, pneumomediastinum, pneumoperitoneum, pneumoretroperitoneum and subcutaneous emphysema of the neck, chest, abdomen, back and scrotum were confirmed by computed tomography scan. The sudden change in condition was considered to be associated with iatrogenic bowel perforation. After receiving closed thoracic drainage and conservative therapy, the patient was discharged in stable condition.

CONCLUSION

Endoscopists should be aware of the risks of colonoscopy in patients with intestinal BD and the possibility of pneumothorax associated with intestinal perforation and make adequate preparations before colonoscopy.

Effectiveness and adverse events of endoscopic clipping versus band ligation for colonic diverticular hemorrhage: a large-scale multicenter cohort study

BACKGROUND : Prior studies have shown the effectiveness of both endoscopic band ligation (EBL) and clipping for colonic diverticular hemorrhage (CDH) but have been small and conducted at single centers. Therefore, we investigated which was the more effective and safe treatment in a multicenter long-term cohort study. METHODS : We reviewed data for 1679 patients with CDH who were treated with EBL (n = 638) or clipping (n = 1041) between January 2010 and December 2019 at 49 hospitals across Japan (CODE BLUE-J study). Logistic regression analysis was used to compare outcomes between the two treatments. RESULTS : In multivariate analysis, EBL was independently associated with reduced risk of early rebleeding (adjusted odds ratio [OR] 0.46; P < 0.001) and late rebleeding (adjusted OR 0.62; P < 0.001) compared with clipping. These significantly lower rebleeding rates with EBL were evident regardless of active bleeding or early colonoscopy. No significant differences were found between the treatments in the rates of initial hemostasis or mortality. Compared with clipping, EBL independently reduced the risk of needing interventional radiology (adjusted OR 0.37; P = 0.006) and prolonged length of hospital stay (adjusted OR 0.35; P < 0.001), but not need for surgery. Diverticulitis developed in one patient (0.16 %) following EBL and two patients (0.19 %) following clipping. Perforation occurred in two patients (0.31 %) following EBL and none following clipping. CONCLUSIONS : Analysis of our large endoscopy dataset suggests that EBL is an effective and safe endoscopic therapy for CDH, offering the advantages of lower early and late rebleeding rates, reduced need for interventional radiology, and shorter length of hospital stay.

Robotic surgery in emergency setting: 2021 WSES position paper

Background

Robotics represents the most technologically advanced approach in minimally invasive surgery (MIS). Its application in general surgery has increased progressively, with some early experience reported in emergency settings. The present position paper, supported by the World Society of Emergency Surgery (WSES), aims to provide a systematic review of the literature to develop consensus statements about the potential use of robotics in emergency general surgery.

Methods

This position paper was conducted according to the WSES methodology. A steering committee was constituted to draft the position paper according to the literature review. An international expert panel then critically revised the manuscript. Each statement was voted through a web survey to reach a consensus.

Results

Ten studies (3 case reports, 3 case series, and 4 retrospective comparative cohort studies) have been published regarding the applications of robotics for emergency general surgery procedures. Due to the paucity and overall low quality of evidence, 6 statements are proposed as expert opinions. In general, the experts claim for a strict patient selection while approaching emergent general surgery procedures with robotics, eventually considering it for hemodynamically stable patients only. An emergency setting should not be seen as an absolute contraindication for robotic surgery if an adequate training of the operating surgical team is available. In such conditions, robotic surgery can be considered safe, feasible, and associated with surgical outcomes related to an MIS approach. However, there are some concerns regarding the adoption of robotic surgery for emergency surgeries associated with the following: (i) the availability and accessibility of the robotic platform for emergency units and during night shifts, (ii) expected longer operative times, and (iii) increased costs. Further research is necessary to investigate the role of robotic surgery in emergency settings and to explore the possibility of performing telementoring and telesurgery, which are particularly valuable in emergency situations.

Conclusions

Many hospitals are currently equipped with a robotic surgical platform which needs to be implemented efficiently. The role of robotic surgery for emergency procedures remains under investigation. However, its use is expanding with a careful assessment of costs and timeliness of operations. The proposed statements should be seen as a preliminary guide for the surgical community stressing the need for reevaluation and update processes as evidence expands in the relevant literature.

Assessment of Vascular Changes in Patients after Pars Plana Vitrectomy Surgery Due to Macula-Off Rhegmatogenous Retinal Detachment

The aim of this study was to investigate the changes in the retinal capillary plexuses in patients after pars plana vitrectomy (PPV), which is used for the treatment of rhegmatogenous retinal detachment (RRD). In this study, we included the results of 114 patients who underwent PPV after total retinal detachment (RRD; retinal detachment group). It should be kept in mind that to qualify for the study group, there was a condition that retinal detachment be only present in one eye, allowing the fellow healthy eye to be used for the control group, and the study, therefore, did not include cases where retinal detachment occurred binocularly. Optical coherence tomography (OCT) and OCT-A images were taken at 9 ± 2 months (median 10 months) after the surgery, with the study conducted in the years 2017–2019. OCT was used to examine the external limiting membrane (ELM), central macular thickness (CMT) and retinal nerve fiber layer (RNFL), while OCT-angiography (OCT-A) was used to examine the extent of the foveal avascular zone (FAZ) in the deep and superficial capillary plexuses. Changes in the FAZ area of the superficial plexus (SCP) between the study and control groups were analyzed over 346 ± 50 days. In our study, we observed changes in the FAZ area between the RRD and control groups in the SCP (203.65 ± 31.69 μm² vs. 215.30 ± 35.82 μm²; p = 0.28733) and DCP (284.79 ± 35.82 µm² vs. 336.84 ± 32.23 µm²; p = 0.00924). Changes in the RNFL thickness between the study and control groups over 346 ± 50 days were as follows: 90.15 μm vs. 82.44 μm; p = 0.19773. Disruption of the external limiting membrane was observed in 78.95% (90 eyes) of the study group. In the control group, it was undamaged, and no integrity disorder was observed. In the RRD, changes occurred in the FAZ of both the SCP and the DCP, which reduced the extent of this zone, an effect that was more pronounced in DCPs. A better understanding of the anatomical and hemodynamic changes taking place in the retina after macula-off RRD might be helpful in answering the question as to why BCVA in these cases is “only” or “as much as” from 0.4 to 0.1, namely, that it might be related to changes in the neurosensory retina after macular peeling.

Anorectal emergencies: WSES-AAST guidelines

Anorectal emergencies comprise a wide variety of diseases that share common symptoms, i.e., anorectal pain or bleeding and might require immediate management. While most of the underlying conditions do not need inpatient management, some of them could be life-threatening and need prompt recognition and treatment. It is well known that an incorrect diagnosis is frequent for anorectal diseases and that a delayed diagnosis is related to an impaired outcome. This paper aims to improve the knowledge and the awareness on this specific topic and to provide a useful tool for every physician dealing with anorectal emergencies.The present guidelines have been developed according to the GRADE methodology. To create these guidelines, a panel of experts was designed and charged by the boards of the World Society of Emergency Surgery (WSES) and American Association for the Surgery of Trauma (AAST) to perform a systematic review of the available literature and to provide evidence-based statements with immediate practical application. All the statements were presented and discussed during the WSES-AAST-WJES Consensus Conference on Anorectal Emergencies, and for each statement, a consensus among the WSES-AAST panel of experts was reached. We structured our work into seven main topics to cover the entire management of patients with anorectal emergencies and to provide an up-to-date, easy-to-use tool that can help physicians and surgeons during the decision-making process.

2020 WSES guidelines for the detection and management of bile duct injury during cholecystectomy

Bile duct injury (BDI) is a dangerous complication of cholecystectomy, with significant postoperative sequelae for the patient in terms of morbidity, mortality, and long-term quality of life. BDIs have an estimated incidence of 0.4-1.5%, but considering the number of cholecystectomies performed worldwide, mostly by laparoscopy, surgeons must be prepared to manage this surgical challenge. Most BDIs are recognized either during the procedure or in the immediate postoperative period. However, some BDIs may be discovered later during the postoperative period, and this may translate to delayed or inappropriate treatments. Providing a specific diagnosis and a precise description of the BDI will expedite the decision-making process and increase the chance of treatment success. Subsequently, the choice and timing of the appropriate reconstructive strategy have a critical role in long-term prognosis. Currently, a wide spectrum of multidisciplinary interventions with different degrees of invasiveness is indicated for BDI management. These World Society of Emergency Surgery (WSES) guidelines have been produced following an exhaustive review of the current literature and an international expert panel discussion with the aim of providing evidence-based recommendations to facilitate and standardize the detection and management of BDIs during cholecystectomy. In particular, the 2020 WSES guidelines cover the following key aspects: (1) strategies to minimize the risk of BDI during cholecystectomy; (2) BDI rates in general surgery units and review of surgical practice; (3) how to classify, stage, and report BDI once detected; (4) how to manage an intraoperatively detected BDI; (5) indications for antibiotic treatment; (6) indications for clinical, biochemical, and imaging investigations for suspected BDI; and (7) how to manage a postoperatively detected BDI.

Endoscopic Treatment of Iatrogenic Perforation of Sigmoid Diverticulum: A Case Report of Multidisciplinary Management

Iatrogenic perforations are severe complications of gastrointestinal endoscopy; therefore, their management should be adequately planned. A 77-year-old man with a history of diverticulosis underwent a colonoscopy for anemia. During the procedure, an iatrogenic perforation occurred suddenly in the sigmoid colon, near a severe angle among the numerous diverticula. Through-the- scope clips were immediately applied to treat it and close mucosal edges. Laboratory tests showed increased inflammation and infection, and although there were no complaints of abdominal pain, the patient had an extremely distended abdomen. A multidisciplinary board began management based on a conservative approach. Pneumoperitoneum was treated with computed tomography-assisted drainage. After 72 hours, his intestinal canalization and laboratory tests were normal. Though this adverse event is rare, a multidisciplinary board should be promptly gathered upon occurrence, even if the patient appears clinically stable, to consider a conservative approach and avoid surgical treatment.

The Association of Coloproctology of Great Britain and Ireland consensus guidelines in emergency colorectal surgery

AIM

There is a requirement for an expansive and up to date review of the management of emergency colorectal conditions seen in adults. The primary objective is to provide detailed evidence-based guidelines for the target audience of general and colorectal surgeons who are responsible for an adult population and who practise in Great Britain and Ireland.

METHODS

Surgeons who are elected members of the Association of Coloproctology of Great Britain and Ireland Emergency Surgery Subcommittee were invited to contribute various sections to the guidelines. They were directed to produce a pathology-based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. Each author was asked to provide a set of recommendations which were evidence-based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after two votes were included in the guidelines.

RESULTS

All aspects of care (excluding abdominal trauma) for emergency colorectal conditions have been included along with 122 recommendations for management.

CONCLUSION

These guidelines provide an up to date and evidence-based summary of the current surgical knowledge in the management of emergency colorectal conditions and should serve as practical text for clinicians managing colorectal conditions in the emergency setting.

A Case of Tension Pneumothorax After Diverticular Rupture During Diagnostic Colonoscopy

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

Delayed perforation after endoscopic resection of a colonic laterally spreading tumor: A case report and literature review

BACKGROUND

Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) have been widely used for the treatment of early gastrointestinal cancer. Endoscopic piecemeal mucosal resection (EPMR) is derived from the combination of EMR and ESD. Delayed perforation with peritonitis after colonic EPMR is a rare but severe complication, sometimes requiring surgery. There are some associated risk factors, including patient- (location, diameter, and presence of fibrosis) and procedure-related factors. Early recognition and timely treatment are crucial for its management.

CASE SUMMARY

We report a case in which delayed perforation with peritonitis was treated using endoscopic closure. A 54-year-old man was diagnosed with a 30-mm-diameter laterally spreading tumor in the colonic hepatic curvature. Fifteen hours after endoscopic resection, peritonitis caused by delayed perforation occurred and gradually aggravated. Conservative treatment was ineffective and no obvious perforation was observed. After timely endoscopic closure, the patient was discharged on postoperative day 4.

CONCLUSION

In occasion of localized peritonitis aggravating without macroscopic perforation, endoscopic closure is an effective treatment for delayed perforation with stable vital signs in the early stage.

Colonoscopy and flexible sigmoidoscopy for follow-up of patients with left-sided diverticulitis

INTRODUCTION

The prevalence of diverticular disease has been increasing in the western world over the last few decades, causing a growing burden on health care systems. This study compared the uses of flexible sigmoidoscopy with colonoscopy as a follow-up investigation for patients diagnosed with acute left-sided diverticulitis and to evaluate the need for using either procedure.

MATERIALS AND METHODS

A retrospective study of 327 patients diagnosed with acute diverticulitis was carried out. Of this total, 240 patients with left-sided diverticulitis diagnosed via computed tomography were included. These patients were categorised into two equal groups: the first 120 patients underwent colonoscopy and the second 120 patients underwent flexible sigmoidoscopy.

RESULTS

All colonoscopes and flexible sigmoidoscopes confirmed the computed tomography diagnosis of sigmoid diverticular disease with no major new findings. All colonoscopes and flexible sigmoidoscopes were reported as having no complications, with nine colonoscopes reported as being difficult compared with only three flexible sigmoidoscopes. All biopsies were reported as no malignancy. Full bowel preparation was required in all colonoscopes, compared with no preparation required for flexible sigmoidoscopes.

CONCLUSIONS

There is no evidence to support the routine use of endoscopic evaluation after an episode of left-sided diverticulitis diagnosed on computed tomography if no worrying radiological findings have been reported. This study supports similar findings from other studies and therefore we disagree with The Royal College of Surgeons of England (Association of Coloproctology of Great Britain and Ireland recommendations) commissioning guide, which advocates routine surveillance of the colon.

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 sedation on quality metrics of colonoscopy: a single-center experience of 48,838 procedures

PURPOSE

Investigation of the role of sedation during colonoscopy is meaningful as the advantages of colonoscopy performing with sedation are still controversial.

METHODS

Medical records of patients who underwent colonoscopy in our institution were retrospectively analyzed. The sedation rate, adenoma detection rate (ADR), polyp detection rate (PDR), cecal intubation rate (CIR), iatrogenic colonic perforation rate (ICP) were calculated.

RESULTS

A total of 48,838 colonoscopies (24,498 in males) dated from July 2007 to February 2017 were analyzed. The median age was 50 years (range 16-85 years). An overall sedation rate was 80.38%. The PDR was 26.77%, and was not statistically different between colonoscopy with or without sedation (26.67% vs 27.22, p = 0.474). ADR was 12.9% regardless of applying sedation or not (13.0% vs 12.44%, p = 0.337). The CIR was 87.42% in all examinations with an adjusted CIR of 90.34%, and was higher when performed with sedation than without sedation (88.92% vs 80.64%, p < 0.0001). Five cases (0.01%) of ICP were reported, all of which occurred in patients under sedation.

CONCLUSIONS

The use of sedation is associated with increased CIR, but ADR and PDR remain unchanged with or without sedation. However, perforation rate, albeit very low, is significantly higher in sedated patients.

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

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

Intraperitoneal and Extraperitoneal Colonic Perforation Following Diagnostic and Therapeutic Colonoscopy with Crohn's-related Stricture Dilation

Colonic perforation is an uncommon but known and feared complication of colonoscopy, which carries a high mortality rate. We present an uncommon case of extensive intra- and extraperitoneal air following colonic perforation in a patient undergoing inpatient colonoscopy for evaluation of unintentional weight loss and constipation. During colonoscopy, a splenic flexure stricture was identified and dilated. Postprocedural hemodynamic instability prompted further imaging which revealed pneumoperitoneum, bilateral pneumothorax, pneumomediastinum, pneumopericardium, and severe subcutaneous emphysema. Emergent exploratory laparotomy found perforation of the proximal transverse colon which required resection and transverse colostomy placement. The patient also underwent bilateral chest tube placement and was treated with antibiotics for peritonitis. The patient was eventually diagnosed with Crohn’s disease and discharged to an extended care facility with outpatient follow-up. Extraperitoneal colonic perforations are fairly rare, and to our knowledge, we present the most severe case that has been published in recent years.

Rectal injury during laparoscopic mesh removal after sacrocervicopexy

In this video we present a case of rectal injury, which occurred during laparoscopic mesh removal following sacrocervicopexy. Four years after sub-total hysterectomy with laparoscopic sacrocervicopexy, a 64-year-old patient still suffered from intense proctalgia and pain while sitting. On physical examination, intense pain could be triggered by palpating the left aspect of the levator ani muscle, raising the suspicion of an association with the mesh and leading to the decision for its removal. The left posterior arm of the mesh was removed completely laparoscopically. During this procedure, a rectal lesion was diagnosed and immediately repaired by a double layer of interrupted sutures. There was an immediate and complete resolution of the symptoms after surgery, with no short-term prolapse recurrence or postoperative complications. Laparoscopy appears to be an efficient approach to mesh excision. A high level of alertness to recognize intraoperative injuries is warranted.

Management of colonoscopic perforation: a systematic review and treatment algorithm

BACKGROUND

The aim of this review is to evaluate and summarize the current strategies used in the management of colonoscopic perforations as well as propose a modern treatment algorithm.

METHODS

Articles published between January 2004 and January 2019 were screened. A total of 167 reports were identified in combined literature search, of which 61 articles were selected after exclusion of duplicate and unrelated articles. Only studies that reported on the management of endoscopic perforation in an adult population were retrieved for review. Case reports and case series of 8 patients or less were not considered. Ultimately, 19 articles were considered eligible for review.

RESULTS

A total of 744 cases of colonoscopic perforations were reported in 19 major articles. The cause of perforation was mentioned in 16 articles. Colonoscopic perforations were reported as a consequence of diagnostic colonoscopies in 222 cases and therapeutic colonoscopies in 248 cases. The site of perforation was mentioned in 486 cases. Sigmoid colon was the predominant site followed by the cecum. The management of colonoscopic perforations was reported in a total of 741 patients. Surgical intervention was employed in 75% of the patients, of these 15% were laparoscopic and 85% required laparotomy. The predominant surgical intervention was primary repair.

CONCLUSION

Management strategies of colon perforations depend upon the etiology, size, severity, location, available expertise, and general health status. Usually, peritonitis, sepsis, or hemodynamic compromise requires immediate surgical management. Endoscopic techniques are under continuous evolution. Newer developments have offered high success rate with least amount of post-procedure complications. However, there is a need for further studies to compare the newer endoscopic techniques in terms of success rate, cost, complications, and the affected part of colon.