|
1
|
Soheilipour M, Momenzadeh M, Aria A, Saghar F, Tabesh E. A Case of Pneumoperitoneum after Colonoscopy without Frank Perforation. Adv Biomed Res 2023; 12:177. [PMID: 37694258 PMCID: PMC10492600 DOI: 10.4103/abr.abr_376_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 12/27/2022] [Accepted: 01/01/2023] [Indexed: 09/12/2023] Open
Abstract
Benign pneumoperitoneum can happen after colonoscopy, which shows itself as free air in the abdomen without symptoms or pneumoperitoneum without peritonitis. In this case, we reported a rare case of an elderly man who had acute abdominal stiffness after colonoscopy and observation of free air under the diaphragm that no perforation was observed in the intestine during laparoscopy and only one tiny intestinal tumor was randomly reported. There is no consensus on the treatment of pneumoperitoneum after colonoscopy. Patients with peritonitis benefit from laparoscopy but patients with micro perforation and asymptomatic patients benefit from intravenous antibiotic treatment and bowel rest.
Collapse
Affiliation(s)
- Maryam Soheilipour
- Isfahan Gastroenterology and Hepatology Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mahnaz Momenzadeh
- Department of Clinical Pharmacy and Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, Isfahan, Iran
| | - Amir Aria
- Department of Internal Medicine, Al-Zahra Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Fatemeh Saghar
- Isfahan Gastroenterology and Hepatology Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Elham Tabesh
- Isfahan Gastroenterology and Hepatology Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| |
Collapse
|
|
2
|
Atemnkeng F, Al-Ttkrit A, David S, Alataby H, Nagaraj A, Diaz K, Nfonoyim J. An Unusual Case of Intraabdominal Abscess After a Colonoscopy With Polypectomy. J Med Cases 2021; 12:301-305. [PMID: 34434477 PMCID: PMC8383595 DOI: 10.14740/jmc3730] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 06/15/2021] [Indexed: 11/11/2022] Open
Abstract
The use of colonoscopies in the screening of colorectal cancers has helped in the early detection and treatment of these cancers. Less than 0.5% of patients develop colonoscopy complications, mostly bleeding, and less frequently, perforations. There have been very few reported cases of micro-perforations following colonoscopies. We present a case of a 66-year-old female smoker who had undergone a screening colonoscopy for colorectal cancer with two polyps removed 3 weeks prior, who was brought to the hospital because of altered mental status and hypotension. A computed tomography (CT) scan of the abdomen and pelvis with contrast demonstrated intraabdominal abscess which was drained by interventional radiology. A culture of the pus grew Streptococcus constellatus, a pus-forming bacterium. She was treated with ceftriaxone and metronidazole for a total of 6 weeks, and a repeat CT of abdomen and pelvis demonstrated complete resolution. The only contributing factor to the formation of the intraabdominal abscess was a screening colonoscopy with polypectomy, which might have caused micro-perforations in the colon with the seeding of Streptococcus constellatus. The occurrence of intraabdominal abscess following a colonoscopy is very rare, and requires a high index of suspicion in patients who present with sepsis following colonoscopies.
Collapse
Affiliation(s)
| | - Amna Al-Ttkrit
- Richmond University Medical Center, Staten Island, NY, USA
| | - Sharoon David
- Richmond University Medical Center, Staten Island, NY, USA
| | - Harith Alataby
- Richmond University Medical Center, Staten Island, NY, USA
| | | | - Keith Diaz
- Richmond University Medical Center, Staten Island, NY, USA
| | - Jay Nfonoyim
- Richmond University Medical Center, Staten Island, NY, USA
| |
Collapse
|
|
3
|
Pedersen L, Sorensen N, Lindorff-Larsen K, Carlsen CG, Wensel N, Torp-Pedersen C, Bernstein I. Colonoscopy adverse events: are we getting the full picture? Scand J Gastroenterol 2020; 55:979-987. [PMID: 32693644 DOI: 10.1080/00365521.2020.1792541] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Colonoscopy adverse events (AEs) are commonly underreported and standardised reporting is rarely used. We aimed to investigate AEs associated with colonoscopy in a real world setting, using the American Society of Gastrointestinal Endoscopy (ASGE) lexicon. METHODS This retrospective cohort study of AEs related to outpatient colonoscopies performed in the North Denmark Region from 2015 to 2018 identified AEs from readmission within eight days or death within 30 days of colonoscopy. AEs were investigated in electronic health records and categorised, attributed and graded according to the ASGE lexicon. RESULTS Of 49,445 colonoscopies performed, 1141 were potentially associated with AEs (23.07‰). Electronic health record review left 489 AEs attributed to colonoscopy (9.9‰); categorised as cardiovascular (0.65‰), pulmonary (0.36‰), thromboembolic (0.10‰), instrumental incl. perforations (0.99‰), bleeding (3.07‰), infection (0.87‰), drug reactions (0.04‰), pain (2.00‰), integument (damage to skin/bones) (0.34‰) and other (1.62‰) AEs. Ten (0.20‰) AEs were fatal, but only one was procedure related (perforation). All shearing force perforations occurred in the sigmoid colon. Most polypectomy perforations occurred in the caecum (60%). CONCLUSIONS Colonoscopy carries important procedure and non-procedure related risks. Non-procedure related AEs are likely underreported. Better attention to patients with pre-existing diseases and further colonoscopist training may lower AE rates. A standardised colonoscopy AE reporting system is warranted.
Collapse
Affiliation(s)
- Lasse Pedersen
- Department of Surgical Gastroenterology, Aalborg University Hospital, Aalborg, Denmark
| | - Nina Sorensen
- Department of Surgical Gastroenterology, Aalborg University Hospital, Aalborg, Denmark
| | - Karen Lindorff-Larsen
- Nordsim: Center for Skills Training and Simulation, Aalborg University Hospital, Aalborg, Denmark
| | | | - Nina Wensel
- Department of Surgical Gastroenterology, North Denmark Regional Hospital, Hjørring, Denmark
| | - Christian Torp-Pedersen
- Department of Cardiology and Clinical Investigation, Hillerod and Department of Cardiology, Nordsjaellands Hospital, Aalborg University Hospital, Aalborg, Denmark
| | - Inge Bernstein
- Department of Surgical Gastroenterology, Aalborg University Hospital, Aalborg, Denmark
| |
Collapse
|
|
4
|
Alsowaina KN, Ahmed MA, Alkhamesi NA, Elnahas AI, Hawel JD, Khanna NV, Schlachta CM. Management of colonoscopic perforation: a systematic review and treatment algorithm. Surg Endosc 2019; 33:3889-3898. [PMID: 31451923 DOI: 10.1007/s00464-019-07064-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 08/11/2019] [Indexed: 02/06/2023]
Abstract
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.
Collapse
Affiliation(s)
- Khalid N Alsowaina
- Canadian Surgical Technologies & Advanced Robotics (CSTAR), 339 Windermere Road, P.O. Box 5339, London, ON, N6A 5A5, Canada. .,Department of Surgery, Western University, London, ON, Canada.
| | - Mooyad A Ahmed
- Canadian Surgical Technologies & Advanced Robotics (CSTAR), 339 Windermere Road, P.O. Box 5339, London, ON, N6A 5A5, Canada.,Department of Surgery, Western University, London, ON, Canada
| | - Nawar A Alkhamesi
- Canadian Surgical Technologies & Advanced Robotics (CSTAR), 339 Windermere Road, P.O. Box 5339, London, ON, N6A 5A5, Canada.,Department of Surgery, Western University, London, ON, Canada
| | - Ahmad I Elnahas
- Canadian Surgical Technologies & Advanced Robotics (CSTAR), 339 Windermere Road, P.O. Box 5339, London, ON, N6A 5A5, Canada.,Department of Surgery, Western University, London, ON, Canada
| | - Jeffrey D Hawel
- Canadian Surgical Technologies & Advanced Robotics (CSTAR), 339 Windermere Road, P.O. Box 5339, London, ON, N6A 5A5, Canada.,Department of Surgery, Western University, London, ON, Canada
| | - Nitin V Khanna
- Department of Medicine, Western University, London, ON, Canada
| | - Christopher M Schlachta
- Canadian Surgical Technologies & Advanced Robotics (CSTAR), 339 Windermere Road, P.O. Box 5339, London, ON, N6A 5A5, Canada.,Department of Surgery, Western University, London, ON, Canada
| |
Collapse
|
|
5
|
Daher S, Khoury T, Benson AA, Tsvang E, Elazary R, Jacob H. Hospital management of colonic perforations complicating ambulatory outpatient colonoscopy via over-the-scope clips or surgery: a case series. Tech Coloproctol 2019; 23:681-685. [PMID: 31338712 DOI: 10.1007/s10151-019-02045-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 07/17/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND Colonoscopy is the standard of care for the diagnosis and treatment of many colonic disorders. Over the past few years, endoscopic closure of colonoscopy-related perforation has become more common. Endoscopic closure of perforation secondary to colonoscopy has been undertaken in patients in the hospital setting and often during the same colonoscopic procedure in which the perforation itself occurred. The aim of our study was to analyze our experience with emergency endoscopic closure of colonoscopy-related perforation with over-the-scope clip (OTSC) technique. METHODS We report five cases of colonic perforation that occurred during colonoscopy in an outpatient facility remotely located from our hospital and then referred as an emergency to our institution for endoscopic closure. RESULTS Bowel preparation was reported to be adequate in all cases. Prior to attempting endoscopic closure of colonic perforation, all patients were in stable clinical condition, early broad-spectrum antibiotic coverage was initiated, and a surgical consult was obtained. All patients had sigmoidoscopy and were found to have sigmoid colon perforations. In three cases, the perforations were closed successfully using an OTSC clip device 14 mm type t. Two patients were found to have greater than 4-cm sigmoid perforations with irregular margins, incompatible with OTSC closure, and were referred for emergency surgery. All patients had an uneventful course following either OTSC closure or surgery. CONCLUSIONS Based on the characteristics of the five cases and a review of the literature, we suggest a practical approach for undertaking closure of colonic perforations occurring during colonoscopy in the outpatient setting, focusing on clinical criteria to determine eligibility of patients for attempted endoscopic closure and outlining required therapeutic and monitoring steps needed to optimize outcomes.
Collapse
Affiliation(s)
- S Daher
- Division of Medicine, Institute of Gastroenterology and Liver Disease, Hadassah-Hebrew University Medical Center, P.O.B. 12000, 91120, Jerusalem, Israel
| | - T Khoury
- Division of Medicine, Institute of Gastroenterology and Liver Disease, Hadassah-Hebrew University Medical Center, P.O.B. 12000, 91120, Jerusalem, Israel.
- Department of Gastroenterology, Galilee Medical Center, Nahariya, Israel.
- Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel.
| | - A A Benson
- Division of Medicine, Institute of Gastroenterology and Liver Disease, Hadassah-Hebrew University Medical Center, P.O.B. 12000, 91120, Jerusalem, Israel
| | - E Tsvang
- Division of Medicine, Institute of Gastroenterology and Liver Disease, Hadassah-Hebrew University Medical Center, P.O.B. 12000, 91120, Jerusalem, Israel
| | - R Elazary
- Department of General Surgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - H Jacob
- Division of Medicine, Institute of Gastroenterology and Liver Disease, Hadassah-Hebrew University Medical Center, P.O.B. 12000, 91120, Jerusalem, Israel
| |
Collapse
|
|
6
|
Thompson EV, Snyder JR. Recognition and Management of Colonic Perforation following Endoscopy. Clin Colon Rectal Surg 2019; 32:183-189. [PMID: 31061648 DOI: 10.1055/s-0038-1677024] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Although rare, perforation can be a devastating complication of colonoscopy. Incidence ranges from 0.012 to 0.65% during diagnostic procedures and is higher in therapeutic procedures. Early diagnosis and management are of paramount importance to decrease morbidity. Diagnostic imaging after colonoscopy can reveal extraintestinal air, but overall clinical status including leukocytosis, fever, pain, and peritonitis is equally important to determine management. With the expanding availability of complex endoscopic interventions, an increasing number of perforations are recognized during colonoscopy or immediately afterward based on high degree of suspicion. Colonoscopic management of these early perforations may be feasible and avoid the morbidity of surgery. Patients who require surgery may be managed with laparoscopic or open surgical techniques. Surgical management may consist of primary repair of the injury, resection with anastomosis, or resection with ostomy. Mechanical bowel preparation before endoscopy decreases fecal contamination after perforation, often obviating the need for ostomy creation.
Collapse
Affiliation(s)
- Earl V Thompson
- Division of Colon and Rectal Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Jonathan R Snyder
- Division of Colon and Rectal Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| |
Collapse
|
|
7
|
Mege D, Beyer-Berjot L, Ezzedine W, Loundou A, Grimaud JC, Barthet M, Berdah S. Endoscopic perforations: what are the indications for surgery? Surg Endosc 2018; 32:3247-3255. [PMID: 29340823 DOI: 10.1007/s00464-018-6043-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 01/03/2018] [Indexed: 10/18/2022]
Abstract
BACKGROUND Despite their low occurrence, endoscopic perforations (EPs) are concerning. Some predictive factors have been identified, and EP management is debated, whether non-surgical (medical and/or endoscopic) or surgical. The objective was to elaborate a predictive score for surgical management of EP. METHODS All the patients addressed for upper and lower EP, except oesophageal EP, were retrospectively included (2004-2015). Demographic data, endoscopic features (indication, location, type), clinical, biological and radiological presentations of EP were reviewed. Management of EP and outcomes were recorded. A predictive score was constructed by multiple linear regression and a cut-off value for surgical management was identified. Additional subgroup analysis was performed according to the location of EP (upper and lower). RESULTS Among 41150 endoscopic procedures, 44 patients (22 males, median age = 65 years [22-87]) presenting with EP were included (0.09%). Lower gastrointestinal (GI) endoscopy was mostly performed (66%). EP diagnosis was immediate in 73% of the cases (n = 32). Non-surgical management was efficient in 2/3 cases treated medically alone, and 18/20 cases treated by endoscopy. Surgical management was always successful (n = 24/24). In case of peritonitis, surgery was systematically required, whereas easily required in case of delayed diagnostic of EP. The EP score was based on the presence of previous abdominal surgery, lower GI endoscopy and diagnostic endoscopy. A cut-off EP score of 22.8% for surgery was chosen; it was associated with a specificity and sensitivity of 40 and 100%, respectively. When subgroups were analysed according to EP location, the EP score was still based on the presence of previous abdominal surgery and diagnostic endoscopy. The cut-off was 6.3 and 73.3% for upper (specificity: 73%, sensitivity: 100%) and lower (89 and 45%) locations, respectively. CONCLUSION The predictive EP score may avoid inappropriate surgical management, as well as delayed surgery after non-surgical management failure. Forthcoming study should prospectively validate this score.
Collapse
Affiliation(s)
- Diane Mege
- Department of Digestive Surgery, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Aix-Marseille Université, chemin des Bourrely, 13015, Marseille, France.
| | - Laura Beyer-Berjot
- Department of Digestive Surgery, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Aix-Marseille Université, chemin des Bourrely, 13015, Marseille, France
| | - Walid Ezzedine
- Department of Digestive Surgery, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Aix-Marseille Université, chemin des Bourrely, 13015, Marseille, France
| | - Anderson Loundou
- Department of Public Health, Timone Faculty, Aix-Marseille Université, boulevard Jean Moulin, 13005, Marseille, France
| | - Jean-Charles Grimaud
- Department of Gastroenterology, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Aix-Marseille Université, chemin des Bourrely, 13015, Marseille, France
| | - Marc Barthet
- Department of Gastroenterology, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Aix-Marseille Université, chemin des Bourrely, 13015, Marseille, France
| | - Stéphane Berdah
- Department of Digestive Surgery, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Aix-Marseille Université, chemin des Bourrely, 13015, Marseille, France
| |
Collapse
|
|
8
|
Facciorusso A, Muscatiello N. Conclusive Remarks and New Perspectives. COLON POLYPECTOMY 2018:147-155. [DOI: 10.1007/978-3-319-59457-6_11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2025]
|
|
9
|
Inoki K, Sakamoto T, Sekiguchi M, Yamada M, Nakajima T, Matsuda T, Saito Y. Successful endoscopic closure of a colonic perforation one day after endoscopic mucosal resection of a lesion in the transverse colon. World J Clin Cases 2016; 4:238-242. [PMID: 27574613 PMCID: PMC4983696 DOI: 10.12998/wjcc.v4.i8.238] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 05/04/2016] [Accepted: 06/02/2016] [Indexed: 02/05/2023] Open
Abstract
A 73-year-old man underwent endoscopic mucosal resection (EMR) of a 20-mm flat elevated lesion on the transverse colon. The morning after the procedure, he started to have severe right upper quadrant pain after his first meal. A computed tomography scan revealed free air and a stomach filled with food. He was diagnosed to have delayed post-EMR intestinal perforation. He underwent emergent colonoscopy and clipping of the perforated site. He was discharged 8 d after the endoscopic closure without the need for surgical intervention. The meal was not the cause of the colon transversum perforation.
Collapse
|
|
10
|
Angsuwatcharakon P, Rerknimitr R. Endoscopic closure of iatrogenic perforation. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2016. [DOI: 10.18528/gii150009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Affiliation(s)
- Phonthep Angsuwatcharakon
- Department of Anatomy, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Rungsun Rerknimitr
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| |
Collapse
|
|
11
|
An SB, Shin DW, Kim JY, Park SG, Lee BH, Kim JW. Decision-making in the management of colonoscopic perforation: a multicentre retrospective study. Surg Endosc 2015; 30:2914-21. [PMID: 26487233 DOI: 10.1007/s00464-015-4577-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Accepted: 09/19/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND The incidence of colonoscopic perforation has increased following the widespread use of colonoscopy for the diagnosis and treatment of colorectal disease. The purpose of our study was to compare the clinical outcomes between surgical and non-surgical treatment of colonoscopic perforation. METHODS We retrospectively reviewed the medical records of patients with colonoscopic perforation, which was treated between January 2005 and December 2014. Patients were divided into two groups depending on whether they received non-surgical (conservative management or endoscopic clipping) or surgical (primary closure, bowel resection and anastomosis, and/or faecal diversion) initial treatment for the perforation. Conversion was defined as the change from a non-surgical to surgical procedure after treatment failure. RESULTS One hundred and nine patients were analysed. Surgical treatment was more common following diagnostic than therapeutic colonoscopic procedures (74.5 vs. 53.7 %, P = 0.023). Of 55 patients in the non-surgical group, 11 patients required conversion to surgery. The surgical group comprised 54 patients. The complication rate (P = 0.001), and the length of hospital stay (P < 0.001) were significantly greater in the patients requiring conversion than in the surgical group. Multivariate analysis showed that old age, American Society for Anesthesiologists score ≥ 3, and conversion were independent predictors of poor outcomes (P = 0.048, 0.032, and 0.001, respectively). Only perforation size was associated with conversion in multivariate analysis (P = 0.022). CONCLUSION It is important to select an appropriate treatment in patients with colonoscopic perforation. To avoid non-surgical treatment failure, surgery should be considered in patients with a large perforation. By decreasing the rate of conversion, we might reduce the complication and mortality rates associated with colonoscopic perforation.
Collapse
Affiliation(s)
- Sung Bak An
- Department of Surgery, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, 40 Sukwoo-Dong, Hwaseong-Si, Gyeonggi-Do, 445-170, Republic of Korea
| | - Dong Woo Shin
- Department of Surgery, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, 40 Sukwoo-Dong, Hwaseong-Si, Gyeonggi-Do, 445-170, Republic of Korea
| | - Jeong Yeon Kim
- Department of Surgery, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, 40 Sukwoo-Dong, Hwaseong-Si, Gyeonggi-Do, 445-170, Republic of Korea
| | - Sung Gil Park
- Department of Surgery, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, 40 Sukwoo-Dong, Hwaseong-Si, Gyeonggi-Do, 445-170, Republic of Korea
| | - Bong Hwa Lee
- Department of Surgery, Hallym Sacred Heart Hospital, Hallym University College of Medicine, 896 Pyengchon-Dong Dongan-gu, Anyang-Si, Gyeonggi-Do, 431-070, Republic of Korea
| | - Jong Wan Kim
- Department of Surgery, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, 40 Sukwoo-Dong, Hwaseong-Si, Gyeonggi-Do, 445-170, Republic of Korea.
| |
Collapse
|
|
12
|
Abstract
Colonoscopy is a relatively invasive modality for the diagnosis and treatment of colorectal disease and for the prevention or early detection of colorectal neoplasia. Millions of colonoscopies are performed each year in the United States by endoscopists with varying levels of skill in colons that present varying levels of challenge. Although better scope technology has made colonoscopy gentler and more accurate, the sheer number of examinations performed means that complications inevitably occur. This article considers the most common complications of colonoscopy, and advises how to minimize their incidence and how to treat them if they do occur.
Collapse
|
|
13
|
Avital I, Langan RC, Summers TA, Steele SR, Waldman SA, Backman V, Yee J, Nissan A, Young P, Womeldorph C, Mancusco P, Mueller R, Noto K, Grundfest W, Bilchik AJ, Protic M, Daumer M, Eberhardt J, Man YG, Brücher BL, Stojadinovic A. Evidence-based Guidelines for Precision Risk Stratification-Based Screening (PRSBS) for Colorectal Cancer: Lessons learned from the US Armed Forces: Consensus and Future Directions. J Cancer 2013; 4:172-92. [PMID: 23459409 PMCID: PMC3584831 DOI: 10.7150/jca.5834] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2013] [Accepted: 02/01/2013] [Indexed: 12/16/2022] Open
Abstract
Colorectal cancer (CRC) is the third most common cause of cancer-related death in the United States (U.S.), with estimates of 143,460 new cases and 51,690 deaths for the year 2012. Numerous organizations have published guidelines for CRC screening; however, these numerical estimates of incidence and disease-specific mortality have remained stable from years prior. Technological, genetic profiling, molecular and surgical advances in our modern era should allow us to improve risk stratification of patients with CRC and identify those who may benefit from preventive measures, early aggressive treatment, alternative treatment strategies, and/or frequent surveillance for the early detection of disease recurrence. To better negotiate future economic constraints and enhance patient outcomes, ultimately, we propose to apply the principals of personalized and precise cancer care to risk-stratify patients for CRC screening (Precision Risk Stratification-Based Screening, PRSBS). We believe that genetic, molecular, ethnic and socioeconomic disparities impact oncological outcomes in general, those related to CRC, in particular. This document highlights evidence-based screening recommendations and risk stratification methods in response to our CRC working group private-public consensus meeting held in March 2012. Our aim was to address how we could improve CRC risk stratification-based screening, and to provide a vision for the future to achieving superior survival rates for patients diagnosed with CRC.
Collapse
Affiliation(s)
- Itzhak Avital
- 1. Bon Secours Cancer Institute, Richmond VA ; 2. Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD ; 3. United States Military Cancer Institute, Bethesda, MD ; 4. INCORE, International Consortium of Research Excellence of the Theodor-Billroth-Academy, Munich, Germany
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
|
14
|
Sagawa T, Kakizaki S, Iizuka H, Onozato Y, Sohara N, Okamura S, Mori M. Analysis of colonoscopic perforations at a local clinic and a tertiary hospital. World J Gastroenterol 2012; 18:4898-4904. [PMID: 23002362 PMCID: PMC3447272 DOI: 10.3748/wjg.v18.i35.4898] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2012] [Revised: 04/19/2012] [Accepted: 04/22/2012] [Indexed: 02/06/2023] Open
Abstract
AIM To define the clinical characteristics, and to assess the management of colonoscopic complications at a local clinic. METHODS A retrospective review of the medical records was performed for the patients with iatrogenic colon perforations after endoscopy at a local clinic between April 2006 and December 2010. Data obtained from a tertiary hospital in the same region were also analyzed. The underlying conditions, clinical presentations, perforation locations, treatment types (operative or conservative) and outcome data for patients at the local clinic and the tertiary hospital were compared. RESULTS A total of 10 826 colonoscopies, and 2625 therapeutic procedures were performed at a local clinic and 32 148 colonoscopies, and 7787 therapeutic procedures were performed at the tertiary hospital. The clinic had no perforations during diagnostic colonoscopy and 8 (0.3%) perforations were determined to be related to therapeutic procedures. The perforation rates in each therapeutic procedure were 0.06% (1/1609) in polypectomy, 0.2% (2/885) in endoscopic mucosal resection (EMR), and 3.8% (5/131) in endoscopic submucosal dissection (ESD). Perforation rates for ESD were significantly higher than those for polypectomy or EMR (P < 0.01). All of these patients were treated conservatively. On the other hand, three (0.01%) perforation cases were observed among the 24 361 diagnostic procedures performed, and these cases were treated with surgery in a tertiary hospital. Six perforations occurred with therapeutic endoscopy (perforation rate, 0.08%; 1 per 1298 procedures). Perforation rates for specific procedure types were 0.02% (1 per 5500) for polypectomy, 0.17% (1 per 561) for EMR, 2.3% (1 per 43) for ESD in the tertiary hospital. There were no differences in the perforation rates for each therapeutic procedure between the clinic and the tertiary hospital. The incidence of iatrogenic perforation requiring surgical treatment was quite low in both the clinic and the tertiary hospital. No procedure-related mortalities occurred. Performing closure with endoscopic clipping reduced the C-reactive protein (CRP) titers. The mean maximum CRP titer was 2.9 ± 1.6 mg/dL with clipping and 9.7 ± 6.2 mg/dL without clipping, respectively (P < 0.05). An operation is indicated in the presence of a large perforation, and in the setting of generalized peritonitis or ongoing sepsis. Although we did not experience such case in the clinic, patients with large perforations should be immediately transferred to a tertiary hospital. Good relationships between local clinics and nearby tertiary hospitals should therefore be maintained. CONCLUSION It was therefore found to be possible to perform endoscopic treatment at a local clinic when sufficient back up was available at a nearby tertiary hospital.
Collapse
|
|
15
|
Vagholkar K. Laparoscopic perforostomy for treating a delayed colonoscopic perforation: Novel approach. J Minim Access Surg 2012. [PMID: 22623832 DOI: 10.4103/0972-9941.95543.] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Ketan Vagholkar
- Department of Surgery, Padmashree Dr. D. Y. Patil Medical College, Nerul, Navi Mumbai, Maharashtra, India
| |
Collapse
|
|
16
|
Abstract
AIM The aetiology of colonoscopic perforation and factors related to poor outcome of surgical treatment were studied. METHOD A single-centre review was conducted of all patients who underwent surgical treatment of a colonoscopic perforation, identified from a prospective registry of 21,981 consecutive colonoscopies carried out between 1993 and 2009. RESULTS There were 29 (eight women) patients of mean age 73 years including 10 who had a nonelective colonoscopy. The perforation was not immediately recognized in 12 patients and in the remaining 17, seven were initially managed conservatively. The causes of perforation were barotrauma (11), mechanical force (14) and polypectomy-related (3). Barotrauma was more frequent in emergency colonoscopy and mechanical force in elective colonoscopy. The outcome of surgery was as follows: mortality 10%, complications 34.5%, reoperation 14%, secondary surgery 23% and permanent colostomy 3%. The only factor related to in-hospital mortality was an increased American Society of Anesthesiologists (ASA) score. CONCLUSION Colonoscopic perforation requiring surgery is a catastrophic event with high mortality, morbidity and reoperation rates.
Collapse
Affiliation(s)
- F J van der Sluis
- Departments of Surgery Gastroenterology, Zaans Medical Center, Zaandam, The Netherlands
| | | | | |
Collapse
|
|
17
|
Vagholkar K. Laparoscopic perforostomy for treating a delayed colonoscopic perforation: Novel approach. J Minim Access Surg 2012; 8:65-66. [PMID: 22623832 PMCID: PMC3353619 DOI: 10.4103/0972-9941.95543] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Affiliation(s)
- Ketan Vagholkar
- Department of Surgery, Padmashree Dr. D. Y. Patil Medical College, Nerul, Navi Mumbai, Maharashtra, India
| |
Collapse
|
|
18
|
Abstract
The frequency of endoscopic complications is likely to rise owing to the increased number of indications for therapeutic procedures and also to the increased complexity of endoscopic techniques. Informed patient consent should be obtained as part of the procedure. Prevention of endoscopic adverse events is based on knowledge of the relevant risk factors and their mechanisms of occurrence. Thus, suitable training of future gastroenterologists and endoscopists is required for these complex procedures. When facing a complication, appropriate management is generally provided by an early diagnosis followed by prompt therapeutic care tailored to the situation. The most common complications of diagnostic and therapeutic upper gastrointestinal endoscopy, retrograde cholangiopancreatography, small bowel endoscopy and colonoscopy are reviewed here. Different modalities of medical, endoscopic or surgical management are also considered.
Collapse
Affiliation(s)
- Daniel Blero
- ISPPC, 1 Boulevard Zoé Drion, 6000 Charleroi, Belgium.
| | | |
Collapse
|
|
19
|
Jones AE, Godfrey D, Nash GF. Tension pneumoperitoneum: innovative decompression of this general surgical emergency. SURGICAL TECHNIQUES DEVELOPMENT 2011. [DOI: 10.4081/std.2011.e21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
We describe the novel use of a cannula in decompressing a large tension pneumoperitoneum secondary to perforated sigmoid diverticulum, in which the patient did not subsequently require an emergency laparotomy. Needle decompression was successfully used as part of a conservative regimen, thus avoiding potentially high-risk surgery.
Collapse
|
|
20
|
Fisher DA, Maple JT, Ben-Menachem T, Cash BD, Decker GA, Early DS, Evans JA, Fanelli RD, Fukami N, Hwang JH, Jain R, Jue TL, Khan KM, Malpas PM, Sharaf RN, Shergill AK, Dominitz JA. Complications of colonoscopy. Gastrointest Endosc 2011; 74:745-52. [PMID: 21951473 DOI: 10.1016/j.gie.2011.07.025] [Citation(s) in RCA: 229] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2011] [Accepted: 07/15/2011] [Indexed: 12/17/2022]
|
|
21
|
Chiapponi C, Stocker U, Körner M, Ladurner R. Emergency percutaneous needle decompression for tension pneumoperitoneum. BMC Gastroenterol 2011; 11:48. [PMID: 21545727 PMCID: PMC3112115 DOI: 10.1186/1471-230x-11-48] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2011] [Accepted: 05/05/2011] [Indexed: 12/28/2022] Open
Abstract
Background Tension pneumoperitoneum as a complication of iatrogenic bowel perforation during endoscopy is a dramatic condition in which intraperitoneal air under pressure causes hemodynamic and ventilatory compromise. Like tension pneumothorax, urgent intervention is required. Immediate surgical decompression though is not always possible due to the limitations of the preclinical management and sometimes to capacity constraints of medical staff and equipment in the clinic. Methods This is a retrospective analysis of cases of pneumoperitoneum and tension pneumoperitoneum due to iatrogenic bowel perforation. All patients admitted to our surgical department between January 2005 and October 2010 were included. Tension pneumoperitoneum was diagnosed in those patients presenting signs of hemodynamic and ventilatory compromise in addition to abdominal distension. Results Between January 2005 and October 2010 eleven patients with iatrogenic bowel perforation were admitted to our surgical department. The mean time between perforation and admission was 36 ± 14 hrs (range 30 min - 130 hrs), between ER admission and begin of the operation 3 hrs and 15 min ± 47 min (range 60 min - 9 hrs). Three out of eleven patients had clinical signs of tension pneumoperitoneum. In those patients emergency percutaneous needle decompression was performed with a 16G venous catheter. This improved significantly the patients' condition (stabilization of vital signs, reducing jugular vein congestion), bridging the time to the start of the operation. Conclusions Hemodynamical and respiratory compromise in addition to abdominal distension shortly after endoscopy are strongly suggestive of tension pneumoperitoneum due to iatrogenic bowel perforation. This is a rare but life threatening condition and it can be managed in a preclinical and clinical setting with emergency percutaneous needle decompression like tension pneumothorax. Emergency percutaneous decompression is no definitive treatment, only a method to bridge the time gap to definitive surgical repair.
Collapse
Affiliation(s)
- Costanza Chiapponi
- Department of Surgery, Hospital of the Ludwig-Maximilians-University, Nussbaumstr, 20, 80336 Munich, Germany.
| | | | | | | |
Collapse
|
|
22
|
Cappell MS. Rigorous scientific study of endoscopic adverse events requires not only a lexicon but a reliable reporting system. Gastrointest Endosc 2010; 72:1324. [PMID: 21111877 DOI: 10.1016/j.gie.2010.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2010] [Accepted: 04/01/2010] [Indexed: 12/10/2022]
|
|
23
|
Lorenzo-Zúñiga V, Moreno de Vega V, Doménech E, Mañosa M, Planas R, Boix J. Endoscopist experience as a risk factor for colonoscopic complications. Colorectal Dis 2010; 12:e273-7. [PMID: 19930145 DOI: 10.1111/j.1463-1318.2009.02146.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
AIM We aimed to determine the incidence of colonic perforation (CP) following colonoscopy and postpolypectomy bleeding (PPB) in a teaching hospital, assessing the influence of endoscopist experience as a risk factor. METHOD All colonoscopies performed between 1995 and 2008 were reviewed. Demographic data, endoscopic procedure information, incidence of CP and PPB, and endoscopist experience were recorded. RESULTS In the 14-year period, 25,214 endoscopic colonic procedures were performed, and 3991 patients underwent polypectomy. The overall CP risk was 0.51/1000 procedures; and PPB 14.7/1000. The relative risk (RR) ratio of complications was 2.8/1000 procedures. The RR rate was highest for endoscopists performing less than 591 procedures per year (4.0/1000 [95% CI, 3.7-4.3] vs 2.9/1000 [95% CI, 2.6-3.2]), P < 0.001). CONCLUSION The complication rate after colonoscopy was comparable to that previously reported. Colonoscopy carried out by a low-volume endoscopist was independently associated with bleeding and perforation.
Collapse
Affiliation(s)
- V Lorenzo-Zúñiga
- Endoscopy Unit, Department of Gastroenterology, Hospital Universitari Germans Trias i Pujol, Badalona, Spain.
| | | | | | | | | | | |
Collapse
|
|
24
|
Tissue apposition system: new technology to minimize surgery for endoscopically unresectable colonic polyps. Surg Endosc 2010; 24:3113-8. [PMID: 20490565 DOI: 10.1007/s00464-010-1098-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2009] [Accepted: 01/03/2010] [Indexed: 12/27/2022]
Abstract
OBJECTIVE This is the first clinical series using the Tissue Apposition System (TAS) device in a feasibility study of polypectomy as an alternative to laparoscopic colectomy (LC) for endoscopically unresectable polyps. TAS is a novel T-tag system for endoscopic placement of sutures, facilitating closure of larger defects from advanced endoluminal or transluminal endoscopic procedures. Such novel instrumentation may reduce risk and accelerate recovery. METHODS After institutional review board approval, patients with endoscopically unresectable polyps who would otherwise require LC were enrolled. The polyp site was visualized by colonoscopy and resected with laparoscopic assistance, using endoscopic mucosal resection (EMR) or submucosal dissection. After confirming benign disease by frozen section, the polypectomy site was closed by TAS under laparoscopic observation to avoid injury to surrounding structures. Follow-up colonoscopy was performed at 3 months. RESULTS Seven patients were recruited (5 men; mean age, 66 years). Polyps were from 20 to 50 (mean, 30) mm in diameter; six were in the right colon, and three were on the mesenteric border of the bowel. All final pathology was benign. Mean EMR time was 29 min, mean time taken for TAS was 37 min, and mean total operative time was 199 min. Two TAS procedures required conversion to LC (one unresectable polyp and one device failure). Five TAS procedures were completed, with a mean hospital stay of 1.2 days, and no complications. Follow-up colonoscopy revealed healing without polyp recurrence in any case. One patient (initial 5-cm sigmoid polyp) developed a very mild clinically asymptomatic stricture in the sigmoid colon. CONCLUSIONS This initial human experience demonstrates that TAS can be used safely in the colon under laparoscopic control. TAS permits safe closure of defects after endoscopic polypectomy of selected and otherwise unresectable polyps. Such technology may potentially avoid the need for LC and permit rapid recovery with short hospital stay.
Collapse
|
|
25
|
Mai CM, Wen CC, Wen SH, Hsu KF, Wu CC, Jao SW, Hsiao CW. Iatrogenic colonic perforation by colonoscopy: a fatal complication for patients with a high anesthetic risk. Int J Colorectal Dis 2010; 25:449-54. [PMID: 19855987 DOI: 10.1007/s00384-009-0822-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/09/2009] [Indexed: 02/04/2023]
Abstract
PURPOSE Colonoscopy is currently a standard and widespread technique used in screening for colorectal cancer. Iatrogenic colonic perforation during colonoscopy is an unfortunate complication that can induce significant morbidity and even death. Here, we reviewed the clinical results of iatrogenic colonoscopic perforation in our hospital. METHODS This was a retrospective review of 35,186 colonoscopies performed in the Tri-Service General Hospital, Taipei, Taiwan from January 1998 to December 2007. Patient demographic data, indications, comorbidities, operative history, perforation site, time of diagnosis, management, complications, hospital stay, and outcomes were recorded. RESULTS In this 10-year period, 23 cases of iatrogenic colonic perforation were recorded (0.065%) affecting 11 men and 12 women. The mean age was 71.2 years. There were 13 patients in American Society of Anesthesiology (ASA) classifications 1 or 2 (low anesthetic risk, group A), and ten patients in ASA classes 3 or 4 (high anesthetic risk, group B). The mean hospital stay was 12 days in group A versus 23.5 days in group B (P = 0.002). Moreover, four patients in group B died (17%; P = 0.024). CONCLUSION Colonoscopy-related perforation can progress to peritonitis and sepsis, resulting in serious morbidity or death. High-anesthetic risk patients with colonic perforation have a longer hospital stay and a poor prognosis. Hence, patients need to be informed of the complications of colonoscopy, and clinicians must be cautioned about the potential problems for patients with a high-anesthetic risk when performing the procedure.
Collapse
Affiliation(s)
- Chen-Ming Mai
- Division of Colon and Rectal Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Nei-Hu District 114, Taipei, Taiwan, Republic of China
| | | | | | | | | | | | | |
Collapse
|
|
26
|
Abstract
IMPORTANCE OF THE FIELD: The high prevalence of colon carcinoma combined with the low compliance of currently recommended screening guidelines explains the continued high mortality rate of colon cancer. Utilizing a strategy of virtual colonoscopy (VC) in asymptomatic patients over 50, with optical colonoscopy (OC) follow-up for removal of detected adenomatous polyps may result in lowering the colon cancer death rate. However, the screening potential of VC has not yet been widely recognized. Debates and doubts of its potential benefits have been frequently seen in the literature since VC was first reported in 1994. AREAS COVERED IN THIS REVIEW: This article reviews the currently available screening options and discuss their advantages and drawbacks. TAKE HOME MESSAGE: VC has many advantages over the existing screening options and its several drawbacks can be mitigated so that it would become a valuable screening modality. A strategy that utilizes VC for population-based screening over the age of 50 and OC for screening high-risk individuals and those with positive VC findings would result in a significantly reduced rate of colon cancer deaths.
Collapse
Affiliation(s)
- Zhengrong Liang
- IEEE Fellow, Professor of Radiology, Computer Science and Biomedical Engineering, School of Medicine, L4-120, Health Sciences Center, Stony Brook University, Stony Brook, NY 11794-8460, USA, (Tel): +1 631-444-7837, (Fax): +1 631-444-6450
| | - Robert Richards
- Associate Professor, Program Director - GI Fellowship, Department of Medicine/Gastroenterology, Health Science Center, Level 17, Room 060, Stony Brook University, Stony Brook, NY 11794-8173, USA, (Tel): +1 631-444-7623
| |
Collapse
|
|
27
|
Lohsiriwat V. Colonoscopic perforation: incidence, risk factors, management and outcome. World J Gastroenterol 2010; 16:425-430. [PMID: 20101766 PMCID: PMC2811793 DOI: 10.3748/wjg.v16.i4.425] [Citation(s) in RCA: 157] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2009] [Revised: 11/09/2009] [Accepted: 11/16/2009] [Indexed: 02/06/2023] Open
Abstract
This review discusses the incidence, risk factors, management and outcome of colonoscopic perforation (CP). The incidence of CP ranges from 0.016% to 0.2% following diagnostic colonoscopies and could be up to 5% following some colonoscopic interventions. The perforations are frequently related to therapeutic colonoscopies and are associated with patients of advanced age or with multiple comorbidities. Management of CP is mainly based on patients' clinical grounds and their underlying colorectal diseases. Current therapeutic approaches include conservative management (bowel rest plus the administration of broad-spectrum antibiotics), endoscopic management, and operative management (open or laparoscopic approach). The applications of each treatment are discussed. Overall outcomes of patients with CP are also addressed.
Collapse
|
|
28
|
Oh JE, Shim SG. [Colonoscopic perforation; a 10-year experience in single general hospital]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2010; 54:371-6. [PMID: 20026891 DOI: 10.4166/kjg.2009.54.6.371] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND/AIMS Colonoscopy is the principal method for diagnosis, treatment, and follow up of colorectal disease. The study aimed to assess the incidence, clinical features, and management of colonoscopic perforations at a local general hospital. METHODS A retrospective review of patient record was performed for all patients with iatrogenic colonic perforation after sigmoidoscopy and colonoscopy between 1997 and 2007. RESULTS In the 10-year period, 16,388 colonoscopic and sigmoidscopic procedure were performed. All 10 cases of procedure related colonic perforation were developed. Perforation occurred in 9 cases during therapeutic procedure; 5 cases due to polypectomy and 4 cases due to endoscopic submucosal dissection. Perforation occurred in one case during diagnostic procedure. CONCLUSIONS Therapeutic procedure is a clear risk factor of colonic perforation. When colonic perforation occurs, we should be able to make early diagnosis. Early diagnosis can lead to a good treatment and can produce good prognosis with short hospital days.
Collapse
Affiliation(s)
- Ji Eun Oh
- Department of Gastroenterology, Masan Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | | |
Collapse
|
|
29
|
The role of laparoscopy in the treatment of complications after colonoscopy. Surg Laparosc Endosc Percutan Tech 2009; 18:561-4. [PMID: 19098660 DOI: 10.1097/sle.0b013e318182b025] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Perforations of the colonic wall or splenic injury during colonoscopy are rare complications. Treatment of these complications by laparoscopy is an advisable compromise instead of an invasive surgery with a laparotomy or a noninvasive and potentially risky nonoperative therapy. All surgical procedures that can be performed by open approach can also be performed laparoscopically. We present in this report 15 patients who were treated for a perforation after colonoscopy. In addition, 2 cases of splenic injury after colonoscopy are described. Twelve perforations were sutured laparoscopically and 3 perforations were sutured via laparotomy. Except for 1 minor wound infection, there were no complications. One splenic injury was treated by spleen wrapping via an open approach due to former pancreatic surgery, and 1 injury was treated laparoscopically with a hemostypticum. Mortality was 0%. Early laparoscopic intervention is a safe and effective method in the treatment of serious complications after colonoscopy.
Collapse
|
|
30
|
Lohsiriwat V, Sujarittanakarn S, Akaraviputh T, Lertakyamanee N, Lohsiriwat D, Kachinthorn U. Colonoscopic perforation: A report from World Gastroenterology Organization endoscopy training center in Thailand. World J Gastroenterol 2008; 14:6722-6725. [PMID: 19034978 PMCID: PMC2773317 DOI: 10.3748/wjg.14.6722] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2008] [Revised: 10/28/2008] [Accepted: 11/04/2008] [Indexed: 02/06/2023] Open
Abstract
AIM To determine the incidence of colonoscopic perforation (CP), and evaluate clinical findings, management and outcomes of patients with CP from the World Gastroenterology Organization (WGO) Endoscopy Training Center in Thailand. METHODS All colonoscopies and sigmoidoscopies performed between 1999 and 2007 in the Endoscopic unit, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok were reviewed. Incidence of CP, patients' characteristics, endoscopic information, intra-operative findings, management and outcomes were analyzed. RESULTS A total of 17357 endoscopic procedures of the colon (13699 colonoscopies and 3658 flexible sigmoidoscopies) were performed in Siriraj hospital over a 9-year period. Fifteen patients (0.09%) had CP: 14 from colonoscopy and 1 from sigmoidoscopy. The most common site of perforation was in the sigmoid colon (80%), followed by the transverse colon (13%). Perforations were caused by direct trauma from either the shaft or the tip of the endoscope (n = 12, 80%) and endoscopic polypectomy (n = 3, 20%). All patients with CP underwent surgical management: primary repair (27%) and bowel resection (73%). The mortality rate was 13% and postoperative complication rate was 53%. CONCLUSION CP is a rare but serious complication following colonoscopy and sigmoidoscopy, with high rates of morbidity and mortality. Incidence of CP was 0.09%. Surgery is still the mainstay of CP management.
Collapse
|
|
31
|
Our experience with endoscopic repair of large colonoscopic perforations and review of the literature. Tech Coloproctol 2008; 12:315-21; discussion 322. [DOI: 10.1007/s10151-008-0442-6] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2008] [Accepted: 09/21/2008] [Indexed: 12/15/2022]
|
|
32
|
Ignjatović M, Jović J. Tension pneumothorax, pneumoretroperitoneum, and subcutaneous emphysema after colonoscopic polypectomy: a case report and review of the literature. Langenbecks Arch Surg 2008; 394:185-9. [DOI: 10.1007/s00423-008-0309-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2007] [Accepted: 12/14/2007] [Indexed: 01/28/2023]
|
|
33
|
Rumstadt B, Schilling D. [Iatrogenic colon perforation: experiences with early laparoscopy]. Chirurg 2007; 79:346-50. [PMID: 17960349 DOI: 10.1007/s00104-007-1408-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Perforation during colonoscopy is a rare but severe complication. PATIENTS AND METHODS Retrospective analysis was done of 15 patients operated on for perforation from colonoscopy between January 2000 and December 2006. RESULTS Three perforations occurred during diagnostics and 12 during interventional colonoscopy. Two perforations occurred as transmural thermal injury to the colon wall. Peritonitis was found in four cases and correlated significantly with mean time between perforation and operation. Twelve perforations were sutured laparoscopically and three by laparotomy. Hospital stay was significantly shorter after laparoscopic treatment than by laparotomy. One patient had a postoperative wound infection, and mortality was 0%. CONCLUSION Early laparoscopic suturing is a safe and effective method in the treatment of perforation from colonoscopy.
Collapse
Affiliation(s)
- B Rumstadt
- Chirurgische Klinik, Diakoniekrankenhaus Mannheim, Mannheim, Germany.
| | | |
Collapse
|
|
34
|
Taku K, Sano Y, Fu KI, Saito Y, Matsuda T, Uraoka T, Yoshino T, Yamaguchi Y, Fujita M, Hattori S, Ishikawa T, Saito D, Fujii T, Kaneko E, Yoshida S. Iatrogenic perforation associated with therapeutic colonoscopy: a multicenter study in Japan. J Gastroenterol Hepatol 2007; 22:1409-14. [PMID: 17593224 DOI: 10.1111/j.1440-1746.2007.05022.x] [Citation(s) in RCA: 136] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIM Colonic perforation is the serious accidental complication. The aim of this study is to analyze the clinical presentation and management of recent iatrogenic perforations during therapeutic colonoscopy. METHODS Consecutive patients referred to four academic cancer centers in Japan were retrospectively reviewed using each center's endoscopy database of medical records. Data was obtained by means of an extensive data collection sheet. Since we evaluated the data including iatrogenic perforation during newly developed therapeutic procedure such as endoscopic submucosal dissection (ESD) or hemoclips, the collection of patient data was set from the period of the beginning of ESD technique in each hospital in this study. RESULTS The overall rate of occurrence of perforation was 0.15% (23/15, 160). Perforation rate for EMR (0.58%) showed a significantly higher rate (P < 0.0001) than that for hot biopsy and polypectomy. The rate for ESD (14%) showed a markedly higher rate (P < 0.0001) than that for other standard procedures. Of those perforations, endoscopic clipping was performed in 56.5% of the patients, and conservative treatment was successful in 100% of the patients with successful closure. Both CT scan findings and serology results (WBC, CRP) after perforation were poor predictors for need for surgery as opposed to conservative management. CONCLUSIONS Further improvements in EMR with special knife techniques are required to simply and safely remove large colorectal neoplasms, because perforation rate for ESD shows a markedly higher. Conservative management may be possible in patients who have undergone complete endoscopic clipping.
Collapse
Affiliation(s)
- Keisei Taku
- Division of Endoscopy and Gastrointestinal Oncology, National Cancer Center Hospital East, Chiba, Japan
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
|
35
|
Belo-Oliveira P, Curvo-Semedo L, Rodrigues H, Belo-Soares P, Caseiro-Alves F. Sigmoid colon perforation at CT colonography secondary to a possible obstructive mechanism: report of a case. Dis Colon Rectum 2007; 50:1478-80. [PMID: 17665253 DOI: 10.1007/s10350-007-0309-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
We report a case of colonic perforation in CT colonography, which was observed in a sigmoid colon segment contained within an inguinal hernia. At surgery, apart from the perforation, a normal large-bowel wall was found. Although rare, perforation may occur in patients with normal bowel wall, possibly resulting from a mechanical strain caused by gaseous overdistention. Radiologists performing the procedure must be aware of this possibility.
Collapse
Affiliation(s)
- Pedro Belo-Oliveira
- Department of Radiology, Coimbra University Hospital, Praceta Mota Pinto 3000-075, Coimbra, Portugal
| | | | | | | | | |
Collapse
|
|
36
|
Abstract
Perforation is an uncommon but important complication of colonoscopy. This review looks at the incidence, clinical features, diagnosis and treatment of this condition.
Collapse
Affiliation(s)
- Alok Tiwari
- Department of Surgery, North Middlesex University Hospital, London N18 1QX
| | | |
Collapse
|
|
37
|
Abstract
Perforation of the colon during colonoscopy can occur for a variety of reasons. When it is caused directly by the endoscope itself, operative intervention is virtually unavoidable. Current practice is laparotomy and repair or resection. Simple oversewing of the defect in a well-prepared colon is safe and effective if the diagnosis is made early. This can be carried out by the laparoscopic route; however, there are few cases of this being performed. We describe our technique for laparoscopic repair here, reviewing the literature on perforation and its management. With advanced laparoscopic techniques such as intracorporeal suturing becoming more widely practiced, a mind shift toward considering laparoscopy for treatment of these patients should be made. Laparoscopy does not exclude the conversion to laparotomy if required.
Collapse
|
|
38
|
Raju GS, Ahmed I, Shibukawa G, Poussard A, Brining D. Endoluminal clip closure of a circular full-thickness colon resection in a porcine model (with videos). Gastrointest Endosc 2007; 65:503-9. [PMID: 17321256 DOI: 10.1016/j.gie.2006.06.085] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2006] [Accepted: 06/29/2006] [Indexed: 12/13/2022]
Abstract
BACKGROUND Linear perforations of the colon can be closed by the application of clips through a colonoscope. It is unclear whether circular perforations after full-thickness resection of the colon can be closed with clips. OBJECTIVE To develop an animal model for circular perforation of the colon and to study different techniques to accomplish a leakproof sealing of the circular perforation of the colon. DESIGN Pilot study. SETTING University medical center. ANIMALS Ten pigs: 2 perforations in the 1st pig and 1 perforation in the 2nd to 9th pigs were closed with clips. In the 10th pig, 5 perforations were created, and the dimensions of the perforation were measured. INTERVENTIONS Creation of a circular full-thickness resection of the colon with a band-ligation-resection device, followed by longitudinal or transverse endoluminal closure of the perforation by using the first clip opened and applied in the 3- to 9-o'clock or the 6- to 12-o'clock direction in relation to the circular perforation, respectively. MAIN OUTCOME MEASUREMENTS The mean (standard deviation) size of circular perforation was 1.7 +/- 0.075 cm (range, 1.5-2.0 cm). Necropsy immediately after closure of the perforation was done to examine the closure and to confirm the quality of sealing with the methylene blue dye leak test. RESULTS The transverse closure was unsuccessful in the closure of 3 perforations, whereas the longitudinal closure resulted in a leakproof sealing in 6 of the 7 closures. LIMITATIONS Perforation of the adjacent viscera limits it to a nonsurvival study. CONCLUSIONS Endoluminal application of clips by using the longitudinal closure technique results in a leak proof sealing of circular perforations of the colon.
Collapse
Affiliation(s)
- Gottumukkala S Raju
- Center for Endoscopic Research, Training, and Innovation (CERTAIN), Department of Internal Medicine, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX 77555, USA
| | | | | | | | | |
Collapse
|
|
39
|
Lovisetto F, Zonta S, Rota E, Mazzilli M, Faillace G, Bianca A, Fantini A, Longoni M. Left Pneumothorax Secondary to Colonoscopic Perforation of the Sigmoid Colon: A Case Report. Surg Laparosc Endosc Percutan Tech 2007; 17:62-4. [PMID: 17318062 DOI: 10.1097/01.sle.0000213753.31020.92] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
We present here the case of a 75-year-old woman who complained of acute abdominal pain after a diagnostic colonoscopy. Abdominal x-rays demonstrated pneumoperitoneum, whereas chest x-rays showed pneumomediastinum and left pneumothorax. A chest drain was placed and subsequently an exploratory laparoscopy was performed, during which air was found in the subserosa of the sigmoid colon and in the mesosigmoid secondary to perforation of a sigmoid diverticulum. The perforation was repaired and a protective loop colostomy was fashioned. The patient was discharged 8 days postoperatively in a good general condition. Although numerous cases of pneumoretroperitoneum and pneumomediastinum secondary to iatrogenic perforation of the colon have been described, reports of pneumothorax are much rarer. We, therefore, discuss the anatomic bases and the possible physiopathologic mechanisms responsible for this clinical complication.
Collapse
Affiliation(s)
- Federico Lovisetto
- Dipartimento di Scienze Chirurgiche, Facoltà di Medicina, University of Pavia, Italy.
| | | | | | | | | | | | | | | |
Collapse
|
|
40
|
Park HC, Kim DW, Kim SG, Park KJ, Park JG. Surgical Management of Colonoscopic Perforations. JOURNAL OF THE KOREAN SOCIETY OF COLOPROCTOLOGY 2007. [DOI: 10.3393/jksc.2007.23.5.287] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Affiliation(s)
- Hyoung-Chul Park
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Duck-Woo Kim
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Sang Gyun Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Kyu-Joo Park
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Jae-Gahb Park
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| |
Collapse
|
|
41
|
Tulchinsky H, Madhala-Givon O, Wasserberg N, Lelcuk S, Niv Y. Incidence and management of colonoscopic perforations: 8 years' experience. World J Gastroenterol 2006; 12:4211-4213. [PMID: 16830377 PMCID: PMC4087376 DOI: 10.3748/wjg.v12.i26.4211] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2005] [Revised: 07/10/2005] [Accepted: 07/15/2005] [Indexed: 02/06/2023] Open
Abstract
AIM To review the experience of a major medical teaching center with diagnostic and therapeutic colonoscopies and to assess the incidence and management of related colonic perforations. METHODS All colonoscopies performed between January 1994 and December 2001 were studied. Data on patients, colonoscopic reports and procedure-related complications were collected from the departmental computerized database. The medical records of the patients with post procedural colonic perforation were reviewed. RESULTS A total of 120067 colonoscopies were performed during the 8 years of the study. Seven colonoscopic perforations (4 females, 3 males) were diagnosed (0.058%). Five occurred during diagnostic and two during therapeutic colonoscopy. Six were suspected during or immediately after colonoscopy. All except one had signs of diffuse tenderness and underwent immediate operation with primary repair done in 4 patients. No deaths were reported. CONCLUSION Perforation rate during colonoscopy is low. Nevertheless, it is a serious complication and its early recognition and treatment are essential to optimize outcome. In patients with diffuse peritonitis early operative intervention makes primary repair a safe option.
Collapse
Affiliation(s)
- Hagit Tulchinsky
- Department of Surgery B, Sourasky Medical Center, 6 Veizman St., Tel Aviv 64239, Israel.
| | | | | | | | | |
Collapse
|
|
42
|
Iqbal CW, Chun YS, Farley DR. Colonoscopic perforations: a retrospective review. J Gastrointest Surg 2005; 9:1229-35: discussion 1236. [PMID: 16332478 DOI: 10.1016/j.gassur.2005.06.023] [Citation(s) in RCA: 107] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2005] [Accepted: 06/16/2005] [Indexed: 01/31/2023]
Abstract
Colonic perforation is no longer a rare complication of colonoscopy. Our previous report identified 45 such iatrogenic injuries from 1980 through 1994 (3082 colonoscopies per year). This follow-up of the ensuing 7 years examines changing trends of endoscopic usage in addition to management and prognosis of patients with colonoscopic perforations. Retrospective analysis of 78,702 colonoscopies (1994 through 2000, 11,243 colonoscopies per year) allowed assessment of medical records in all patients treated at our institution for colonic perforation. Sixty-six patients from our institution (perforation rate, 0.084%; 1 per 1192 procedures) and six patients from outside institutions were treated for colonic perforation following colonoscopy (41 women, 31 men; ages, 30-92 years; median, 73 years). Sixty-two patients underwent laparotomy, while 10 were managed nonoperatively. All 10 patients managed nonoperatively were void of peritoneal irritation by physical examination; eight patients did well (median hospital stay, 5.5 days; range, 0-12), but one death (family declined operative intervention) and one pelvic abscess requiring percutaneous drainage were noted. Peritoneal irritation by physical examination was evident in 57 of 62 patients undergoing laparotomy. Perforations occurred throughout the colon: right, 22 (31%); transverse, 5 (7%); left, 44 (61%); and unknown, 1 (1%). Thirty-eight patients (61%) underwent primary repair or resection with anastomosis. Fecal diversion was used in 100% of patients with extensive peritoneal contamination (n = 12) and 40% of patients with moderate contamination (12 of 30). Perioperative morbidity (39%) and mortality (8%) were significant. Factors predicting a poor outcome included delayed diagnosis, extensive peritoneal contamination, and patients using anticoagulants (P < .05). Compared with our prior study, the present review highlights a higher prevalence of injury based on more frequent use of colonoscopy. Perforation rates remain around 0.08%. While nonoperative management is viable in patients void of peritonitis, expedient surgical intervention seems to facilitate patient recovery.
Collapse
Affiliation(s)
- Corey W Iqbal
- Division of Gastroenterologic and General Surgery, Mayo Clinic, Rochester, Minnesota 55905, USA
| | | | | |
Collapse
|
|
43
|
Abstract
Self-induced injuries of the bowel have various accidental mechanisms. This is a report of a 35-year-old patient with disruption of the recto-sigmoid junction caused by carbon dioxide (CO2) originating from a bottle of sparkling wine, which was introduced transanally for sexual stimulation. The patient underwent resection of the recto-sigmoid junction and primary anastomosis. The postoperative course was uneventful except for wound infection. The patient was discharged 12 days later. The physical backgrounds, the pathological pathways for perforation and diagnostic modalities including diagnostic pitfalls are critically discussed.
Collapse
Affiliation(s)
- Matthias Ikapischke
- Department of General and Thoracic Surgery, University Hospital of Schleswig-Holstein, Campus Kiel, Germany.
| | | | | | | |
Collapse
|
|
44
|
Abstract
Traditionally the placement of a peritoneal dialysis (PD) catheter in a patient with end-stage renal disease (ESRD) has been accomplished by a surgeon and using general anesthesia. This approach often introduces delays in starting PD, incurs additional costs in utilizing an operating room as well as anesthesia services, and introduces the mortality risk associated with general anesthesia. Recent data have emphasized that interventional nephrologists can safely and successfully perform PD access procedures. In this context, operating room facilities and staff and anesthesia services are not required and catheter insertion can be performed in a procedure room using local anesthesia, thereby reducing costs and completely bypassing the mortality risk associated with general anesthesia. When performed by a nephrologist, the catheter insertion can be accomplished swiftly and dialysis therapy initiated in a timely manner. Once begun, the success of PD hinges on reliable and long-term access to the peritoneal cavity. Prospective randomized and nonrandomized studies have shown that PD catheters peritoneoscopically placed by nephrologists have fewer complications (infection, exit site leak) and longer catheter survival rates than those inserted surgically. Although PD offers a variety of advantages, it remains an underutilized form of renal replacement therapy. To counteract PD underutilization, at least two separate centers have demonstrated a positive impact on the growth of the PD population when catheter insertion is performed by nephrologists. This article presents PD access-related procedures currently performed by interventional nephrologists. Furthermore, some of the complicating issues (bowel perforation, catheter migration, prior abdominal surgery) related to PD catheter insertion and management are also discussed.
Collapse
Affiliation(s)
- Arif Asif
- Division of Nephrology, Department of Medicine, University of Miami School of Medicine, Miami, Florida, USA.
| |
Collapse
|
|
45
|
Allen E, Nicolaidis C, Helfand M. The evaluation of rectal bleeding in adults. A cost-effectiveness analysis comparing four diagnostic strategies. J Gen Intern Med 2005; 20:81-90. [PMID: 15693933 PMCID: PMC1490043 DOI: 10.1111/j.1525-1497.2005.40077.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Though primary care patients commonly present with rectal bleeding, the optimal evaluation strategy remains unknown. OBJECTIVE To compare the cost-effectiveness of four diagnostic strategies in the evaluation of rectal bleeding. DESIGN Cost-effectiveness analysis using a Markov decision model. DATA SOURCES Systematic review of the literature, Medicare reimbursement data, Surveillance, Epidemiology, and End Results (SEER) Cancer Registry. TARGET POPULATION Patients over age 40 with otherwise asymptomatic rectal bleeding. TIME HORIZON The patient's lifetime. PERSPECTIVE Modified societal perspective. INTERVENTIONS Watchful waiting, flexible sigmoidoscopy, flexible sigmoidoscopy followed by air contrast barium enema (FS+ACBE), and colonoscopy. OUTCOME MEASURES Incremental cost-effectiveness ratio. RESULTS OF BASE-CASE ANALYSIS The incremental cost-effectiveness ratio for colonoscopy compared with flexible sigmoidoscopy was 5,480 dollars per quality-adjusted year of life saved (QALY). Watchful waiting and FS+ACBE were more expensive and less effective than colonoscopy. RESULTS OF SENSITIVITY ANALYSES The cost of colonoscopy was reduced to 1,686 dollars per QALY when age at entry was changed to 45. Watchful waiting became the least expensive strategy when community procedure charges replaced Medicare costs, when age at entry was maximized to 80, or when the prevalence of polyps was lowered to 7%, but the remaining strategies provided greater life expectancy at relatively low cost. The strategy of FS+ACBE remained more expensive and less effective in all analyses. In the remaining sensitivity analyses, the incremental cost-effectiveness of colonoscopy compared with flexible sigmoidoscopy never rose above 34,000 dollars. CONCLUSIONS Colonoscopy is a cost-effective method to evaluate otherwise asymptomatic rectal bleeding, with a low cost per QALY compared to other strategies.
Collapse
Affiliation(s)
- Elizabeth Allen
- Portland Veterans Affairs Medical Center, Portland, OR 97207, USA.
| | | | | |
Collapse
|
|
46
|
|
|
47
|
Ker TS, Wasserberg N, Beart RW. Colonoscopic Perforation and Bleeding of the Colon Can be Treated Safely without Surgery. Am Surg 2004. [DOI: 10.1177/000313480407001021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
The incidence of colonoscopic perforation of colon is about 0.3 per cent. The incidence of colonoscopic bleeding is about 0.6 per cent. Many of those patients undergo unnecessary operations. In order to assess the outcome of nonoperative management of those patients with postcolonoscopic perforation and bleeding, the records of 5120 patients who underwent colonoscopies from September 1, 1988 to June 30, 2003 were retrospectively reviewed with attention paid to colonoscopic perforation and bleeding. Their symptoms, management, and outcome were reviewed. There were 2765 male and 2355 female patients. Ages ranged from 9 to 91 years. A total of 1902 patients (37.1%) had polyps removed. Six patients (0.1%) had colonoscopic perforation. All of them presented with abdominal pain 1 to 4 days after colonoscopic polypectomy. All had subphrenic free air or subcutaneous emphysema on the radiogram. All were treated nonoperatively with nothing by mouth and intravenous fluids and antibiotics in the hospital and recovered uneventfully. Six patients (0.1%) had colonic bleeding that occurred 1 to 14 days after colonoscopic polypectomy. All of them were managed by repeat colonoscopy with injection of epinephrine. All recovered without further bleeding. Therefore, postcolonoscopic perforation and bleeding can be treated nonoperatively. It is safe and cost effective. The mortality and morbidity are very low.
Collapse
Affiliation(s)
- Tim S. Ker
- From the Department of Colon and Rectal Surgery, University of Southern California, Los Angeles, California
| | - Nir Wasserberg
- From the Department of Colon and Rectal Surgery, University of Southern California, Los Angeles, California
| | - Robert W. Beart
- From the Department of Colon and Rectal Surgery, University of Southern California, Los Angeles, California
| |
Collapse
|
|
48
|
Cobb WS, Heniford BT, Sigmon LB, Hasan R, Simms C, Kercher KW, Matthews BD. Colonoscopic Perforations: Incidence, Management, and Outcomes. Am Surg 2004. [DOI: 10.1177/000313480407000902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Fiberoptic colonoscopy provides superior diagnostic and therapeutic capabilities in the treatment of lower gastrointestinal disease processes. A well-recognized, but uncommon, complication during the procedure is perforation. The purpose of this study was to determine the incidence of colonoscopic perforation, define risk factors, assess the management of these complications, and evaluate outcomes. From January 1997 through December 2003, 43,609 colonoscopies were performed in our medical center. There were 14 (0.032%) perforations (1 in 3115 procedures); 7 from diagnostic and 7 from therapeutic procedures. General surgeons performed 1243 procedures (2.9%), and their rate of perforation was 0.080 per cent compared with 0.031 per cent for gastroenterologists during the same period. Half of the perforations occurred in the rectosigmoid, and the most common mechanism was mechanical (n = 6). Perforation was identified immediately during endoscopy in 50 per cent of the patients. Thirteen of 14 perforations were treated within 24 hours; 1 was delayed 48 hours. Initial surgical management was undertaken in 11/14 patients. Initial nonoperative treatment was attempted in three and was successful in only one patient. The mean length of stay following perforation was 11.2 days (range, 4–36 days). Three patients (21.4%) had 7 postoperative complications. Colonoscopic perforations are uncommon but can be recognized early and managed surgically with acceptable morbidity and postoperative length of stay.
Collapse
Affiliation(s)
- William S. Cobb
- From the Carolinas Laparoscopic and Advanced Surgery Program, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - B. Todd Heniford
- From the Carolinas Laparoscopic and Advanced Surgery Program, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Lee B. Sigmon
- From the Carolinas Laparoscopic and Advanced Surgery Program, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Reem Hasan
- From the Carolinas Laparoscopic and Advanced Surgery Program, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Connie Simms
- From the Carolinas Laparoscopic and Advanced Surgery Program, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Kent W. Kercher
- From the Carolinas Laparoscopic and Advanced Surgery Program, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Brent D. Matthews
- From the Carolinas Laparoscopic and Advanced Surgery Program, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| |
Collapse
|
|
49
|
Asif A, Byers P, Vieira CF, Merrill D, Gadalean F, Bourgoignie JJ, Leclercq B, Roth D, Gadallah MF. Peritoneoscopic placement of peritoneal dialysis catheter and bowel perforation: experience of an interventional nephrology program. Am J Kidney Dis 2004; 42:1270-4. [PMID: 14655200 DOI: 10.1053/j.ajkd.2003.08.029] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Bowel perforation is an uncommon but serious complication of peritoneoscopic peritoneal dialysis (PD) catheter insertion. The approach to diagnosis of bowel perforation utilizing this technique has not been previously published. The authors report their experience with the diagnosis and management of bowel perforation in the context of peritoneoscopic placement of PD catheters. METHODS The authors retrospectively reviewed the records of 750 PD catheters inserted over a 12-year period (January 1991 to May 2003) utilizing peritoneoscopic technique. RESULTS Six (0.8%) patients experienced bowel perforation during the procedure. The diagnosis was made immediately during the procedure in 5 (83%) of the 6 patients. Of these 5, peritoneoscopy confirmed intrabowel position of the cannula by visualizing bowel mucosa (n = 3) and hard stool (n = 1). The fifth patient showed extrusion of fecal matter upon trocar withdrawal before peritoneoscopy. All 5 had emanation of foul-smelling gas through the cannula. Bowel rest and broad-spectrum intravenous antibiotics were initiated. Of the 5, 1 required surgery, whereas the others were discharged home after 3 days. The sixth patient had fever, severe peritoneal irritation, and polymicrobial peritonitis the morning after the procedure. In this patient, no evidence of bowel injury was noted during the procedure except for brief emanation of foul-smelling gas. He required surgical intervention. CONCLUSION Bowel perforation can be diagnosed immediately in most patients undergoing peritoneoscopic PD catheter insertion. A majority of these patients can be treated medically. The surgical team should be consulted if the patient shows clinical deterioration or has signs of peritoneal irritation.
Collapse
Affiliation(s)
- Arif Asif
- Department of Nephrology, Cleveland Clinic, Naples, FL 34119, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
|
50
|
Gerson LB, Triadafilopoulos G, Gage BF. The management of anticoagulants in the periendoscopic period for patients with atrial fibrillation: a decision analysis. Am J Med 2004; 116:451-9. [PMID: 15047034 DOI: 10.1016/j.amjmed.2003.10.035] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2003] [Revised: 10/03/2003] [Accepted: 10/03/2003] [Indexed: 12/12/2022]
Abstract
PURPOSE The management of patients who undergo endoscopy while being treated with warfarin is challenging. We used decision analysis to determine the preferred strategy to manage anticoagulants in the periendoscopic period. METHODS We designed a Markov model to estimate costs and quality-adjusted survival during a 10-year period in patients with nonvalvular atrial fibrillation undergoing screening colonoscopy. We compared six alternatives to the continue-warfarin strategy, which was to perform colonoscopy while the patient was taking full-dose warfarin. The hold-warfarin strategy was to stop warfarin 5 days before the colonoscopy. The repeat endoscopy strategy was to continue warfarin for a diagnostic colonoscopy, followed by a repeat procedure after cessation of warfarin if polypectomy was required. The dose-reduction strategy was to reduce the warfarin dose before colonoscopy. The low molecular weight heparin strategy was to administer subcutaneous low molecular weight heparin for 2 days before and 2 days after colonoscopy. The unfractionated heparin strategy was to administer intravenous unfractionated heparin for 2 days before and 2 days after the procedure. The vitamin K strategy was to hold warfarin for 4 days and to administer vitamin K if the international normalized ratio (INR) exceeded 2.0 the day before the procedure, or low molecular weight heparin if the INR was less than 1.5. RESULTS For screening colonoscopy, assuming that polyps would be removed in 35% of examinations, the hold-warfarin and dose-reduction arms were both cost-effective strategies. The hold-warfarin arm was most cost-effective if the likelihood of polypectomy exceeded 60%, or if there was a low risk of stroke despite atrial fibrillation. The continue-warfarin strategy was preferred if the probability of polypectomy was 1% or less. CONCLUSION Temporary warfarin cessation or halving the warfarin dose for several days before endoscopy was the preferred strategy for most patients. Periendoscopic heparin therapy was not cost-effective for patients with nonvalvular atrial fibrillation.
Collapse
Affiliation(s)
- Lauren B Gerson
- Division of Gastroenterology, Stanford University School of Medicine, California 94305-5202, USA.
| | | | | |
Collapse
|