Closure of a Gastropleural Fistula Using Advanced Endoscopy.

Gastropleural fistulas are rare complications with significant mortality and morbidity. There are limited reports on the successful management of gastropleural fistulas with advanced endoscopic procedures. The following case of a 75-year-old woman with a history of recurrent pseudomyxoma peritonei secondary to ruptured low-grade appendiceal mucinous neoplasm status post cytoreductive surgery highlights the successful treatment of a gastropleural fistula with endoscopic suturing.

Racial disparities in the attainment of textbook oncologic outcomes following colectomy for colon cancer: a national cancer database cohort study.

INTRODUCTION: Textbook oncologic outcome (TOO) is attained when all desired short-term quality metrics are met following an oncologic operation. The objective of this study was to determine the impact of race on TOO attainment following colectomy for colon cancer. METHODS: The 2004-2017 National Cancer Database was queried for patients with non-metastatic colon cancer who underwent colectomy. TOO was defined as: negative margins (R0), adequate lymphadenectomy (LAD) (n ≥ 12), no prolonged length of stay (LOS), no 30-day readmission or mortality, and initiation of systemic therapy in ≤ 12 weeks. Racial groups were defined as White, Black, or Hispanic. RESULTS: 508,312 patients were identified of which 34% achieved TOO. Blacks attained the least TOO (31.4%) as well as the TOO criteria of adequate LAD (81.1%), no prolonged LOS (52.3%), and no 30-day readmission (89.7%). Hispanics were least likely to have met the criteria of R0 resection (94.3%), no 30-day mortality (87.3%), and initiation of systemic therapy in ≤ 12 weeks (81.8%). Patients who attained TOO had a higher median overall survival (OS) than those without TOO (148.2 vs. 84.2 months; P < 0.001). Hispanic TOO patients had the highest median OS (181.2 months), while White non-TOO patients experienced the lowest (80.2 months, P < 0.001). Multivariate logistic regression models suggest that Black and Hispanic patients are less likely to achieve TOO than their White counterparts. CONCLUSIONS: Racial disparities exist in the achievement of TOO, with Blacks and Hispanics being less likely to attain TOO compared to their White counterparts.

Impact of Minimally Invasive Approach on Attainment of a Textbook Oncologic Outcome Following Gastrectomy for Gastric Cancer: A Review of the National Cancer Database.

BACKGROUND: Textbook oncologic outcome (TOO) is a composite outcome measure realized when all desired short-term quality metrics are met following an oncologic operation. This study examined whether minimally invasive gastrectomy (MIG) is associated with increased likelihood of TOO attainment. METHODS: The 2010-2016 National Cancer Database was queried for patients with gastric cancer who underwent gastrectomy. Surgical approach was described as open (OG), laparoscopic (LG), or robotic (RG). TOO was defined as having met five metrics: R0 resection, AJCC compliant lymph node evaluation (n ≥ 15), no prolonged length of stay (< 75th percentile by year), no 30-day readmission, and receipt of guideline-accordant systemic therapy. RESULTS: Of 21,015 patients identified, 5708 (27.2%) underwent MIG (LG = 21.9%, RG = 5.3%). Patients who underwent RG were more likely to have met all TOO criteria, and consequently TOO. Logistic regression models revealed that patients undergoing MIG were significantly more likely to attain TOO. MIG was associated with a higher likelihood of adequate LAD, no prolonged LOS, and concordant chemotherapy. Patients who underwent LG and achieved TOO had the highest median OS (86.7 months), while the OG non-TOO cohort experienced the lowest (34.6 months). The median OS for the RG TOO group was not estimable; however, the mortality rate (.7%) was the lowest of the six cohorts. CONCLUSION: RG resulted in a significantly increased likelihood of TOO attainment. Although TOO is associated with increased OS across all surgical approaches, attainment of TOO following MIG is associated with a statistically significantly higher median OS.

Influence of contralateral prophylactic mastectomy on textbook outcome attainment at time of mastectomy.

INTRODUCTION: The objective of this study was to determine the incidence of textbook oncologic outcome (TOO) and its impact on overall survival (OS) among patients with invasive ductal carcinoma (IDC) following modified radical mastectomy (MRM) versus MRM with contralateral prophylactic mastectomy (MRM â€‹+ â€‹CPM). METHODS: The 2004-2017 National Cancer Database was queried for patients with IDC who underwent MRM and MRM â€‹+ â€‹CPM. TOO was defined as: resection with negative margins, adequate lymphadenectomy, length of stay ≤50th percentile, and no 30-day readmission or mortality. RESULTS: 87,573 patients were identified, of which 14.3% underwent MRM â€‹+ â€‹CPM. Logistic regression models revealed that MRM â€‹+ â€‹CPM is independently associated with a reduced likelihood of achieving TOO (AOR â€‹= â€‹0.71; P â€‹< â€‹0.001). MRM patients who achieved TOO had a higher median OS compared to those who did not (164.6 vs.142.2 months, P â€‹< â€‹0.001). CONCLUSIONS: MRM â€‹+ â€‹CPM is associated with a lower incidence of TOO attainment compared to MRM.

Impact of Palliative Interventions on Survival of Patients with Unresected Pancreatic Cancer: Review of the 2010-2016 National Cancer Database.

INTRODUCTION: Palliative interventions (PI) are offered to patients with pancreatic cancer with the aim of enhancing quality of life and improving overall survival (OS). The purpose of this study was to determine the impact of PI on survival amongst patients with unresected pancreatic cancer. METHODS: Patients with stage I-IV unresected pancreatic adenocarcinoma were identified using the 2010-2016 National Cancer Database. The cohort was stratified by PI received: palliative surgery (PS), radiation therapy (RT), chemotherapy (CT), pain management (PM), or a combination (COM) of the preceding. Kaplan-Meier method with log-rank test was used to compare and estimate OS based on the PI received. A multivariate proportional hazards model was utilized to identify predictors of survival. RESULTS: 25,995 patients were identified, of which 24.3% received PS, 7.7% RT, 40.8% CT, 16.6% PM, and 10.6% COM. The median OS was 4.9 months, with stage III patients having the highest and stage IV the lowest OS (7.8 vs 4.0 months). Across all stages, PM yielded the lowest median OS and CT the highest (P < .001). Despite this, the stage IV cohort was the only group in which CT (81%) accounted for the largest proportion of PI received (P < .001). Although all PI were identified as positive predictors of survival on multivariate analysis, CT had the strongest association (HR .43; 95% CI, .55-.60, P = .001). CONCLUSION: PI offers a survival advantage to patients with pancreatic adenocarcinoma. Further studies to examine the observed limited use of CT in earlier disease stages are warranted.

Impact of conversion at time of minimally invasive pancreaticoduodenectomy on perioperative and long-term outcomes: Review of the National Cancer Database.

Backgrounds/Aims: Current literature presents limited data regarding outcomes following conversion at the time of minimally invasive pancreaticoduodenectomy (MI-PD). Methods: The National Cancer Database was queried for patients who underwent pancreaticoduodenectomy. Patients were stratified into three groups: MI-PD, converted to open pancreaticoduodenectomy (CO-PD), and open pancreaticoduodenectomy (O-PD). Multivariable modeling was applied to compare outcomes of MI-PD and CO-PD to those of O-PD. Results: Of 17,570 patients identified, 12.5%, 4.2%, and 83.4% underwent MI-PD, CO-PD, and O-PD, respectively. Robotic pancreaticoduodenectomy (R-PD) resulted in a higher lymph node yield (n = 23.2 ± 12.2) even when requiring conversion (n = 22.4 ± 13.2, p < 0.001). Margin positivity was higher in the CO-PD group (26.6%) than in the MI-PD group (21.3%) and the O-PD (22.6%) group (p = 0.017). Length of stay was shorter in the MI-PD group (laparoscopic pancreaticoduodenectomy 10.4 ± 8.6, R-PD 10.6 ± 8.8) and the robotic converted to open group (10.7 ± 6.4) than in the laparoscopic converted to open group (11.2 ± 9) and the O-PD group (11.5 ± 8.9) (p < 0.001). After adjusting for patient and tumor characteristics, both MI-PD (odds ratio = 1.40; p < 0.001) and CO-PD (odds ratio = 1.24; p = 0.020) were significantly associated with an increased likelihood of long-term survival. Conclusions: CO-PD does not negatively impact perioperative or oncologic outcomes.

Impact of Textbook Oncologic Outcome Attainment on Survival After Gastrectomy: A Review of the National Cancer Database.

BACKGROUND: Textbook oncologic outcome (TOO) is a composite outcome measure realized when all desired short-term quality metrics are met after an oncologic operation. This study examined the incidence and impact of achieving a TOO among patients undergoing resection of gastric adenocarcinoma. METHODS: The 2004-2016 National Cancer Database was queried for patients who underwent curative gastrectomy. Textbook oncologic outcome was defined as having met five metrics: R0 resection, American Joint Committee on Cancer-compliant lymph node evaluation (n ≥ 15), no prolonged hospital stay (< 75th percentile by year), no 30-day readmission, and receipt of guideline-accordant systemic therapy. RESULTS: Of 34,688 patients identified, 8249 (23.8 %) achieved TOO. The patients for whom TOO was achieved were more likely to have traveled farther (p < 0.001) and received care in an academic (p < 0.001) or very high case-volume facility (p < 0.001). The TOO group had a significanty higher median overall survival (OS) than the non-TOO group (80.5 vs 35.3 months; p < 0.001). The Kaplan-Meier curve showed that at 12 months, the survival probability estimate was 92 % for the TOO group versus 77 % for the non-TOO group. At 60 months (long-term survival), survival probability estimates remained higher for the TOO group (57 % vs 38 %). The results of the multivariate Cox regression model found that TOO attainment was significantly associated with a reduced risk of death (hazard ratio, 0.82; p < 0.001). CONCLUSION: The TOO measure is associated with improved OS and reduced risk of death after gastrectomy for gastric adenocarcinoma. Unfortunately, in this study, TOO was obtained in only 23.8 % of cases.

Assessment of Textbook Oncologic Outcomes Following Modified Radical Mastectomy for Breast Cancer.

INTRODUCTION: Textbook oncologic outcome (TOO) is a composite outcome measure attained when all desired short-term quality metrics are met following an oncologic operation. The objective of this study was to determine the incidence of TOO and its impact on the overall survival (OS) among patients with invasive ductal carcinoma (IDC) following modified radical mastectomy (MRM). METHODS: The 2004-2017 National Cancer Database was queried for patients with non-metastatic IDC who underwent MRM. TOO was defined as having attained five metrics: resection with negative microscopic margins, American Joint Committee on Cancer compliant lymph node evaluation (n ≥ 10), no prolonged length of stay (50th percentile by year), no 30-d readmission, and no 30-d mortality. OS was defined as the time in months between the date of diagnosis and the date of death or last contact. RESULTS: A total of 75,063 patients were identified, of which 40.8% achieved TOO. The TOO patients had a lower median age and were more likely to be White, privately insured, and without comorbidities. In terms of facility characteristics, patients with TOO were more likely to be seen in comprehensive community cancer programs with a high case-volume per year. The TOO group had a statistically significant higher median OS compared to the non-TOO group (165.6 versus 142.2 mo; P < 0.001). On multivariate analysis TOO was independently associated with a reduced risk of death (HR = 0.82; P < 0.001). CONCLUSIONS: TOO is achieved in approximately 41% of patients undergoing MRM for IDC. Achieving TOO is associated with improved median OS and reduced risk of death. TOO therefore merits further attention in efforts to improve surgical outcomes.

Intraoperative electron radiation therapy as an important treatment modality in retroperitoneal sarcoma.

BACKGROUND: Local recurrence (LR) rates in patients with retroperitoneal sarcoma (RPS) are high, ranging from 40% to 80%, with no definitive studies describing the best way to administer radiation. Intraoperative electron beam radiation therapy (IOERT) provides a theoretical advantage for access to the tumor bed with reduced toxicity to surrounding structures. The goal of this study was to evaluate the role of IOERT in high-risk patients. METHODS: An institutional review board approved, single institution sarcoma database was queried to identify patients who received IOERT for treatment of RPS from 2/2001 to 1/2009. Data were analyzed using the Kaplan-Meier method, Cox regression, and Fisher Exact tests. RESULTS: Eighteen patients (median age 51 y, 25-76 y) underwent tumor resection with IOERT (median dose 1250 cGy) for primary (n = 13) and recurrent (n = 5) RPS. Seventeen patients received neoadjuvant radiotherapy. Eight high-grade and 10 low-grade tumors were identified. Median tumor size was 15 cm. Four patients died and two in the perioperative period. Median follow-up of survivors was 3.6 y. Five patients (31%) developed an LR in the irradiated field. Three patients with primary disease (25%) and two (50%) with recurrent disease developed an LR (P = 0.5). Four patients with high-grade tumors (57%) and one with a low-grade tumor (11%) developed an LR (P = 0.1). The 2- and 5-y OS rates were 100% and 72%. Two- and 5-y LR rates were 13% and 36%. CONCLUSIONS: Using a multidisciplinary approach, we have achieved low LR rates in our high-risk patient population indicating that IOERT may play an important role in managing these patients.

Utilization of interventional radiology in the postoperative management of patients after surgery for locally advanced and recurrent rectal cancer.

The surgical management of locally advanced primary rectal cancer and locally recurrent rectal cancer requires complex operations frequently resulting in complicated postoperative courses. We sought to evaluate the utilization of interventional radiologic (IR) procedures in the management of postoperative complications. Under Institutional Review Board approval, a prospective database of colorectal cancer patients undergoing resection from July 1999 to January 2010 was analyzed. Data collected included demographics, operative procedure, complications, length of stay, and IR utilization. Fisher's exact tests and logistic regression explored associations with necessitating an IR procedure during the postoperative period. Continuous variables were analyzed using Wilcoxon rank sum tests. One hundred and one patients underwent surgery and 66 received intraoperative electron radiotherapy (IOERT). Primary procedures included pelvic exenteration (n = 35), abdominoperineal resection (n = 25), low anterior resection (n = 23), paraaortic node dissection (n = 7), resection of isolated pelvic/retroperitoneal tumor (n = 7), and colectomy (n = 4). Sixty-two patients required multivisceral resection including partial/total cystectomy (n = 30), small bowel resection (n = 25), oophorectomy (n = 15), vaginectomy (n = 12), hysterectomy (n = 12), hepatectomy (n = 3), and nephrectomy (n = 3). Seventeen partial sacral resections and 47 pelvic sidewall resections were also required. One hundred and thirty-eight complications were identified in 72 patients, 30 of which required a procedural intervention. Twenty-seven IR procedures were performed including drainage of fluid collections (n = 14), nephrostomy tube placement (n = 8), arterial embolization (n = 2), inferior vena cava filter placement (n = 2), and pleural drainage (n = 1). Only three reoperations were required, none related to failure of IR procedures. There were no deaths. Estimated blood loss > 2000 mL (P = 0.002), IOERT (P = 0.03), and incomplete resection (P = 0.02) were found to be associated with postoperative IR utilization. Surgery for locally advanced primary rectal cancer and locally recurrent rectal cancer is associated with significant morbidity but low mortality. IR procedures play a significant role in the postoperative management of these patients and may decrease the need for reoperation.

Utilization and morbidity associated with placement of a feeding jejunostomy at the time of gastroesophageal resection.

BACKGROUND: The purpose of the study was to evaluate the utilization and morbidity associated with feeding jejunostomy tubes (JT) placed at the time of gastroesophageal resection (GER). METHODS: Under institutional review board approval, a prospective database of patients undergoing GER from January 2004 to September 2010 was reviewed. Data analyzed included patient demographics, postoperative complications, JT use, and JT specific complications. Fisher's exact tests explored associations with utilization of a JT following resection. RESULTS: Seventy-three patients (51 men, 22 women, median age of 59) underwent placement of a JT at the time of GER (total gastrectomy = 28, Ivor-Lewis = 28, subtotal gastrectomy = 8, proximal gastrectomy = 6, and transhiatal esophagectomy = 3) of both malignant (97%) and benign (3%) disease processes. Twenty-one JT specific complications (11 minor and 10 major) were identified. Reoperation was required in the management of two complications (small bowel obstructions), while all other complications were easily managed by an interventional radiologist (n = 8), bedside procedure (n = 5), or did not require intervention (n = 6). Eighty-six percent of patients were discharged tolerating a postgastrectomy diet, 10% nothing per orem, and 4% a liquid diet. Inpatient enteral nutrition (EN) was initiated in 68%, but continued on discharge in only 54% secondary to failure to thrive (54%), dysphagia (21%), anastomic leak (15%), chyle leak (3%), esophagostomy (3%), and duodenal stump leak (3%). The mean time to discontinuance of EN and removal of the JT was 44 days (range, 4-203) and 71 days (range, 15-337) respectively. Although only 13% (n = 5) of patients requiring adjuvant therapy were utilizing their JT at the commencement of therapy, 75% (n = 21) required EN during its course. The median time to adjuvant therapy was found to be slightly longer in those who required outpatient EN versus those who did not (61 vs. 90 days, p = 0.08). However, the median time to adjuvant therapy did not differ between those who were and were not receiving EN at the time of adjuvant therapy commencement (80 vs. 92 days, p = 0.2). Age (p = 0.4), number of co-morbidities (p = 0.2), preoperative percent body weight loss (p = 0.9), and clinical stage (p = 0.8) were not significantly associated with outpatient JT use. Patients who suffered a postoperative complication were most likely to require EN (p = 0.002), an association that strengthened as the number of complications increased (p = 0.0008). Although not statistically significant, a trend towards increased outpatient EN was noted in patients who underwent transhiatal esophagectomy and total gastrectomy (p = 0.06). CONCLUSIONS: JT placement carries a considerable morbidity in patients undergoing GER. However, because it is difficult to preoperatively ascertain who will need prolonged EN, the routine placement of a JT is recommended, particularly in those who will likely require adjuvant therapy or are at high risk for postoperative complications. Despite patient desires for early removal of an unused JT, caution should be taken if adjuvant therapy is being considered.

Subcutaneous Metastatic Adenocarcinoma: An Unusual Presentation of Colon Cancer - Case Report and Literature Review.

Subcutaneous metastasis from a visceral malignancy is rare with an incidence of 5.3%. Skin involvement as the presenting sign of a silent internal malignancy is an even rarer event occurring in approximately 0.8%. We report a case of a patient who presented to her dermatologist complaining of rapidly developing subcutaneous nodules which subsequently proved to be metastatic colon cancer, and we provide a review of the literature.

Incidence and risk factors for the development of anemia following gastric bypass surgery.

AIM: To evaluate the incidence and risk factors for the development of anemia after Roux-en-Y gastric bypass (RYGB). METHODS: A retrospective analysis of patients undergoing RYGB from January 2003 to November 2007 was performed. All patients had a preoperative body mass index > 40 kg/m(2). A total of 206 patients were evaluated. All patients were given daily supplements of ferrous sulfate tablets for 2 wk following their operation. Hematological and metabolic indices were routinely evaluated following surgery. Patients were followed for a minimum of 86 wk. RESULTS: There were 41 males and 165 females with an average age of 40.8 years. 21 patients (10.2%) developed post-operative anemia and 185 patients (89.8%) did not. Anemia was due to iron deficiency in all cases. The groups had similar demographics, surgical procedure and co-morbidities. Menstruation (P = 0.02) and peptic ulcer disease (P = 0.01) were risk factors for the development of post-operative anemia. CONCLUSION: Iron deficiency anemia is frequent. RYGB surgery compounds occult blood loss. Increased ferrous sulfate supplementation may prevent iron depletion in populations at increased risk.

Heterotopic mesenteric ossification following gastric bypass surgery: case series and review of literature.

Heterotopic mesenteric ossification (HMO) is a rare entity with few cases reported in the world literature. We report two cases. Both patients underwent an open gastric bypass with Roux-en-Y reconstruction procedure for morbid obesity and subsequently presented with gastrointestinal fistulae associated with HMO.

Incidence and risk factors for the development of incisional hernia following elective laparoscopic versus open colon resections.

BACKGROUND: There are few studies that compare the incidence of incisional hernia following elective laparoscopic colon resection to open colectomy and determine the risk factors for its development. METHODS: Elective open and laparoscopic colon resections performed between February 2002 and May 2007 were reviewed. In the laparoscopic group, mesenteric transection was performed via intracorporeal division for left-sided colectomy and via extracorporeal technique for right-sided colectomy. The ileocolic anastomosis was performed by extracorporeal stapling for right colectomies and by intracorporeal for left colectomies. RESULTS: Two hundred eighteen patients (mean age 62 years, 52% male) underwent elective colon resection (50% open, 5% hand-assisted, and 45% laparoscopic). Six percent of the cases that started as laparoscopic were converted and are included in the open group. Mean follow-up was 26 months. The overall incisional hernia rate was 16% (open and minimally invasive group 17% vs 15%, P = .14). Hernia was not dependent on the type of resection, indication, or extraction site. Body mass index >36 kg/m(2), male gender, and surgical site infection were risk factors for hernia development. CONCLUSIONS: Laparoscopic colectomy does not reduce the development of incisional hernia.

A unique case of recurrent metachronous volvulus of the gastrointestinal tract.

Colonic volvulus is an uncommon disease that predisposes patients to bowel obstruction in both the adult and pediatric population. The international literature offers few reports of synchronous or metachronous volvulus of 2 organs of the gastrointestinal tract. We describe a unique case of a patient who presented with recurrent metachronous volvulus of the sigmoid colon, cecum, and stomach. The patient underwent multiple operations for bowel obstruction, lysis of adhesions, and colon resection. The interesting intraoperative findings were a very long mesentery and peritoneal attachments of the intraabdominal gastrointestinal organs that made the stomach and colon extremely mobile and thus susceptible to volvulus. Prophylactic pexis of the cecum and the stomach during the first operation, in light of the elongated mesentery, may have prevented the subsequent episodes of volvulus.

Management of endoscopic retrograde cholangiopancreatography: related duodenal perforations.

BACKGROUND: As the performance of upper gastrointestinal endoscopy, especially endoscopic retrograde cholangiopancreatography (ERCP), has increased since 1968, so has the incidence of duodenal perforations. The frequency of ERCP use varies among hospitals and depends on the availability of trained endoscopists, equipment, and facilities. METHODS: A retrospective review of ERCP-related perforations to the duodenum was conducted to identify their incidence, optimal management, and clinical outcome. Charts were reviewed for the following data: ERCP indication, clinical presentation, diagnostic methods, time to diagnosis and treatment, type of injury, management, length of hospital stay, and clinical outcome. RESULTS: From April 1999 to February 2008, 4,358 ERCP were performed, 15 of which (0.34%) resulted in perforation to the duodenum. Only four of the perforations were discovered during ERCP, with another eight requiring computed tomography or abdominal radiography for diagnosis. Surgery was performed for 13 of the patients (87%), and 2 patients died (15%). One patient was managed conservatively with a successful outcome. Nine patients underwent surgery within 24 h after the ERCP, with only one patient undergoing surgery after 24 h. The overall mortality rate was 20% (3 of 15 patients). CONCLUSIONS: Clinical and radiographic features can be used to determine the surgical or conservative treatment of ERCP-related duodenal perforations, whereas patient age and intraoperative findings can determine the final outcome and morbidity or mortality. The interval between the perforation and the operation is of great significance. The mortality rate increases dramatically with late surgical management (>24 h). An algorithm for the selective management of ERCP-induced duodenal perforations is proposed.

Myonecrosis secondary to Clostridium Septicum in a patient with Occult Colon Malignancy: a case report.

BACKGROUND: Gas gangrene is a relatively rare event that is typically associated with history of trauma. A non-traumatic history of gas gangrene has been associated with Clostridium septicum and cecal malignancy. CASE PRESENTATION: We present a case of a 54-year-old male patient who presented with myonecrosis secondary to Clostridium septicum septicemia and an occult cecal carcinoma. CONCLUSION: C. septicum and its association with malignancy should be considered in any patient suffering from myonecrosis without a history of trauma.

Evolving management of colonoscopic perforations.

BACKGROUND: Perforations of the large bowel during diagnostic or therapeutic colonoscopy are a rare but significant complication. Their treatment has evolved over the last decade, but there are still no specific guidelines for their optimal management. MATERIALS AND METHODS: Retrospective review of 105,786 consecutive colonoscopies performed in a 21-year period allowed assessment of the medical records in all patients treated at our institution for colonoscopic perforation. RESULTS: Thirty-five patients suffered perforation (perforation rate 0.033%) during colonoscopy from January 1986 to October 2007 (14 men, 21 women; mean age 69.4 years). Twenty-four of the perforations occurred during diagnostic colonoscopy, whereas 11 during therapeutic colonoscopy. Twenty-three (66%) of the patients underwent operative treatment and 12 (34%) were managed nonoperatively. The average length of stay was 15.2 days, and there was one death (2.9% 30-day mortality rate) among the patients. CONCLUSIONS: Perforations from diagnostic colonoscopy usually are large enough to warrant surgical management, whereas perforations from therapeutic colonoscopy usually are small, leading to successful nonoperative treatment. Over the last decade, the surgical treatment of colonoscopic perforations has evolved, as there has been a trend that favors primary repair versus bowel resection with successful outcome. Careful observation and clinical care adherent to strict guidelines for patients treated nonoperatively is appropriate in order to minimize morbidity and mortality and identify early those who may benefit from operation. Each treatment, however, has to be individualized according to the patients' comorbidities and clinical status, as well as the specific conditions during the colonoscopy that lead to the perforation.