Optimal Methods for the Management of Iatrogenic Colonoscopic Perforation

BACKGROUND/AIMS: Colonoscopic perforations have been managed with exploratory laparotomy, and have resulted in some morbidity and mortality. Recently, laparoscopic surgery is commonly performed for this purpose. The aim of this study was to compare the outcomes of several management strategies for iatrogenic colonoscopic perforations. METHODS: We retrospectively reviewed the medical records of patients who had been treated for colonoscopic perforation between January 2004 and April 2013 at CHA Bundang Medical Center in Korea. RESULTS: A total of 41 patients with colonoscopic perforation were enrolled. Twenty patients underwent conservative management with a success rate of 90%. Surgical management was performed in 23 patients including two patients who were converted to surgical management after the failure of the initial conservative management. Among 14 patients who underwent surgery at 8 hours after the perforation, there was no considerable difference in adverse outcomes between the laparotomy group and the laparoscopic surgery group. The medical costs and claim rate were 1.45 and 1.87 times greater in the exploratory laparotomy group, respectively. CONCLUSIONS: Conservative management of colonoscopic perforation could be an option for patients without overt symptoms of peritonitis or with a small defect size. If surgical management is required, laparoscopic surgery may be considered as the initial procedure even with a delayed diagnosis.

Colonoscopic Perforations: 4 Years' Experience / 대한소화기내시경학회지

BACKGROUND/AIMS: Many physicians agree that colonoscopy is the best modality for either the diagnostic evaluation or use in therapy for colorectal disease. Although the incidence of perforations that occur after colonoscopy is low, the increasing number of performed colonoscopies may pose a relevant health problem with including the often lethal consequences. This study aimed to determine the frequency of perforation and the management of colonoscopic perforation. Modern Korean society has adopted westernized dietary habits, and this has led to an increased incidence of colorectal disease such as colorectal cancer, polyps and diverticulosis. METHODS: We conducted a retrospective review of the medical records of all the patients who underwent colonoscopy complicated by colon perforation between January 2004 and December 2007. The patients' demographics, the purpose of colonoscopy, the location of the perforation, the management and the outcome were compared. RESULTS: A total of 5254 patients underwent either a diagnostic or therapeutic colonoscopy procedure during four consecutive years at a single institution. Iatrogenic colonoscopic perforations (0.2%) were diagnosed in 11 patients (seven males and four females). Perforations occurred in six patients during a diagnostic colonoscopy and these occurred in five patients during a therapeutic colonoscopy. Free air in the peritoneum or retroperitoneum was seen in all the patients, as depicted on plain X-rays. Seven patients were treated with surgical intervention and four patients were treated with conservative management. One of the 11 patients with a perforation expired on postoperative day 47 due to infective endocarditis. CONCLUSIONS: The rate of iatrogenic colonoscopic perforation is still very low. Although perforation is a very serious complication and it can be a lethal malady, early recognition and treatment are very critical factors to optimize the patient outcome. Although a gold standard therapeutic modality has not been established, the patients who present with the signs and symptoms of generalized peritonitis are recommended to undergo early surgical intervention.

Surgical Management of Colonoscopic Perforations

PURPOSE: The purpose of this study is to evaluate the clinical features that necessitate a temporary stoma for the treatment of colonoscopic perforations. RESULTS: Between January 2000 and July 2006, 30 patients were treated for colonoscopic perforation. Based on the perforation sites, we classified these patients into the following groups: proximal colon, sigmoid colon, and rectum; we then reviewed clinical data, including the time to operation and management. RESULTS: Seventeen patients had a perforation during the diagnostic colonoscopy. Of these patients, 14 patients had sigmoid colon perforation. Six underwent an operation within 10 hours after perforation. Of these six, four were managed by primary repair or resection with anastomosis, one sigmoid colon cancer patient by anterior resection, and one rectal cancer patient by low anterior resection with diverting ileostomy. Eight patients underwent more than 12 hours after perforation. Of these eight, three were managed by resection with anastomosis and diverting ileostomy and five by resection with end colostomy. Thirteen patients had a perforation during the therapeutic colonoscopy. Of these patients, 10 patients had a proximal colon perforation. Of these 10, 3 without fever or peritonitis symptom were managed by conservative management, 6 by primary repair or resection with anastomosis, and 1 transverse colon cancer patient by right hemicolectomy. Three patients had sigmoid colon perforation. Of these three, one was managed by primary repair, one by resection with anastomosis, and one sigmoid colon cancer patient by anterior resection. CONCLUSIONS: The mechanism of perforation, the site of the perforation, and the time to operation are associated with intraperitoneal contamination and have an influence on surgical treatment.

Recurrent Colonic Perforation after Successful Conservative Treatment of Colonoscopic Perforation

Although the management of a colonic perforation after a colonoscopy is still controversial, conservative therapy is commonly used in those whose colonoscopy reveals a small perforation, those whose condition is relatively good, those who were diagnosed belatedly, or those who have not developed the symptoms of generalized peritonitis. We encountered a case of recurrent colonic perforation after successful conservative treatment for a colonoscopic perforation of the sigmoid colon in a 69-year-old female, who was treated with tube sigmoidostomy.

Safety of Conservative Treatment of Colonoscopic Perforation

PURPOSE: Colonoscopy is a relatively safe procedure. However, various complications, such as hemorrhage or perforation, can occur, and among them, perforation can lead to death. This study was designed to evaluate the clinical characteristics and the treatment of colonoscopic perforation, as well as the availability of conservative treatment as the initial management. METHODS: We reviewed the medical records of the 11 patients who had been treated for colonoscopic perforation from May 2003 to April 2005. RESULTS: Six perforations were related to diagnostic colonoscopy whereas five occurred from therapeutic colonoscopy. The sigmoid colon was the most common perforation site (6 patients), followed by the cecum 2 patients and the transverse colon, splenic flexure, and the rectum 1 patient each. Five patients were diagnosed during colonoscopy. Six patients were diagnosed 12~48 hours after the colonoscopy. Three patients who showed definite signs of peritonitis underwent emergency operations. A conservative treatment was done in eight patients; among them, one patient had an operation on the 3rd. day after the perforation. The remaining seven patients underwent conservative treatment and were followed for up to 1 month without complications. Among these patients, one patient had a recurrent perforation on the 33rd day after the initial perforation, and an operation was done. CONCLUSIONS: These results suggest that conservative treatment in patients with colon perforations is safe and effective unless there are obvious signs of generalized peritonitis.