270 likes | 858 Views
Management of Colonoscopic Perforation. Joint Hospital Surgical Grand Round Dr Lee Wang Fai Frank Princess Margaret Hospital. Introduction. Colonoscopy is a frequently used diagnostic procedure nowadays Perforation is an uncommon but well recognized complication of colonoscopy
E N D
Management of Colonoscopic Perforation Joint Hospital Surgical Grand Round Dr Lee Wang Fai Frank Princess Margaret Hospital
Introduction • Colonoscopy is a frequently used diagnostic procedure nowadays • Perforation is an uncommon but well recognized complication of colonoscopy • Potentially life threatening • Management remains controversial
Changing Paradigm • Penetrating trauma to the abdomen was the most common cause of colonic perforation in the past • During World War II , routine colostomy for management of trauma of colon • Since 1970s, perforation from colonoscopy became the most common cause of colorectal trauma
Changing Paradigm • Standard treatment: early explorative laparotomy with primary closure or bowel resection, with or without diverting stoma • 1980s: Reports of successful conservative management (Adair and Hishon1981) • 1990s: Use of laparoscopic instruments in management of colonoscopic perforation • 2000s: Endoscopic repair in selected cases • Trend of increasing use of conservative management and minimally-invasive treatment
Causes of perforation • Direct mechanical injury • Forceful passage of tip through diverticulum • Penetration through a tight flexure or loop • Tearing during passage of a narrowed stricture • Lateral pressure of loop of endoscope against a stretched loop of colon • Barotrauma due to over distension • Therapeutic procedures • Mechanical trauma of biopsy and dilatation of stricture • Electrical and thermal injury in polypectomy / cauterization
Causes of perforation • Perforation after therapeutic colonoscopy tend to be smaller and have a delay in presentation when compared with diagnostic colonoscopy
Incidence • Commonly quoted figure: 1 in 1000 (0.1%) • Variable incidence in the literature: • As low as 0.016% in diagnostic colonoscopy • Up to 5% in therapeutic colonoscopy Varut Lohsiriwat. Colonoscopic perforation: Incidence, risk factors, management and outcome. World J Gastroenterol. 2010 January 28; 16(4): 425-430.
Incidence: Figures in literature • T. H Luning, etc. Colonoscopic perforations: a review of 30,366 patients. Surg Endosc. 2007 Jun;21(6):994-7.
Incidence: More recent figures Varut Lohsiriwat. Colonoscopic perforation: Incidence, risk factors, management and outcome. World J Gastroenterol. 2010 January 28; 16(4): 425-430.
Site of perforation • Most common site: rectosigmoid colon • Sharp angulation • Mobility of sigmoid colon • Common diverticular formation • Pelvic adhesions due to previous operation or inflammation Farley DR, etc. Management of colonoscopic perforations. Mayo Clin Proc. 1997 Aug;72(8):729-33.
Risk factors • Therapeutic procedures • Polypectomy • Dilatation of stricture • Argon plasma coagulation • EMR / ESD • Older patients • Declining mechanical wall strength due to diverticular disease • Greater frequency of colonic pathology requiring therapeutic procedures • Complete colonoscopy vs flexible sigmoidoscopy • Multiple comorbidities • DM, cerebrovascular disease, renal impairment, liver disease, dementia • History of diverticular disease • Previous intra-abdominal surgery Varut Lohsiriwat. Colonoscopic perforation: Incidence, risk factors, management and outcome. World J Gastroenterol. 2010 January 28; 16(4): 425-430.
Diagnosis • At the time of colonoscopy • Visualization of extra-intestinal structure • “Difficult procedure” • After procedure • From several hours to days • Early symptoms: Abdominal pain and distension • Late presentation: Fever, peritonitis, shock • 10% asymptomatic • Investigations • Leukocytosis • Free intraperitoneal air in X-ray (65-87%)1,2 • CT scan / Contrast study Farley DR, etc. Management of colonoscopic perforations. Mayo Clin Proc. 1997 Aug;72(8):729-33. Castellví J, etc. Colonoscopic perforation: useful parameters for early diagnosis and conservative treatment. Int J Colorectal Dis. 2011 Sep;26(9):1183-90.
Management • Options: • Non-operative • Operative • Laparotomy / laparoscopic / endoscopic • Repair / bowel resection • Primary anastomosis / staged operation • Diverting stoma • Factors to consider • Mechanism and size of perforation • Severity of symptoms • Duration of time between procedure and diagnosis • Adequacy of pre-colonoscopic bowel preparation • Site of perforation (e.g. retroperitoneal) • Patient’s general condition and comorbidities Holzheimer RG, Mannick JA, editors. Surgical Treatment: Evidence-Based and Problem-Oriented. Munich: Zuckschwerdt; 2001.
Management: Non-operative • Patient selection: • Good general condition • Without sign of peritonitis • Conservative management: • Intravenous fluid • Absolute bowel rest • Broad-spectrum antibiotics • Frequent reassessment • Surgical intervention should be considered when there is sign of deterioration • Overall success rate 33-73% Varut Lohsiriwat. Colonoscopic perforation: Incidence, risk factors, management and outcome. World J Gastroenterol. 2010 January 28; 16(4): 425-430.
Management: Operative • Patient selection: • Sign of peritoneal irritation or free gas in X-ray • Concomitant colonic pathology that requires surgery • Options: • Simple closure of perforation • Small perforation • No fecal contamination • No concomitant colonic pathology • Bowel resection with primary anastomosis • Large perforation • Concomitant colonic pathology • No significant intra-abdominal contamination • Bowel resection without anastomosis / anastomosis with diverting stoma • Fecal peritonitis or extensive tissue inflammation
Management:Laparoscopy • Diagnostic laparoscopy • Laparoscopic repair / resection of bowel • Reports of successful laparoscopic repair initially appeared in the late 1990s • Early diagnosis is crucial • Various techniques described, including usage of interrupted suture, and endoscopic linear stapler • Good operative results, shorter hospital stay • Selection bias? Ballester RA, et al. Laparoscopic treatment of endoscopic sigmoid colon perforation: A case report and literature review. Surg Laparosc Endosc Percutan Tech 2006;16:44-46. Mattei P, et al. Laparoscopic repair of colon perforation after colonoscopy in children: report of 2 cases and review of literature. J Ped Surg 2005; 40:1652-2653.
Management:Endoscopic repair • First report of successful endoscopic repair of colonoscopic perforation in 19971 • Only 75 cases reported in literature as at 20082 • Most are small perforations after therapeutic colonoscopy • Early diagnosis, good bowel preparation, small perforation size • Some reports of successful repair of large perforations (up to 35x10mm) • As little air insufflation as possible • Bowel rest, broad-spectrum antibiotics, intravenous fluid, and close monitoring after procedure • Success rate 69-93% Yoshikane H, et al. Endoscopic repair by clipping of iatrogenic colonic perforation. Gasrointest Endosc 1997; 46: 464-466. Trecca A, et al. Our experience with endoscopic repair of lage colonoscopic perforations and review of the literature. Tech Coloproctol (2008) 12:315-322.
Outcome • Morbidity 21-53% • Surgical site infection is the most common complication • Mortality 0-26% • Cardiopulmonary complication and multi-organ failure are the leading causes of death • Average length of hospital stay 1-3 weeks • Factors predisposing for poor outcome: • Large perforation site • Delayed diagnosis • Extensive peritoneal contamination • Poor bowel preparation • Corticosteroid, anticoagulants or antiplatelet therapy • Prior hospital stay • Advanced age and comorbid diseases Varut Lohsiriwat. Colonoscopic perforation: Incidence, risk factors, management and outcome. World J Gastroenterol. 2010 January 28; 16(4): 425-430.
Controversies • Lower mortality rate in non-operative management than operative treatment?1 • Selection bias? • Different selection criteria for non-operative management in different centers • Inconsistency in current literature • Importance of free gas in X-ray? • Importance of time between procedure and diagnosis? • Published data in the literature mainly consist of case series only • Uncommon complication • Difficult to perform randomized controlled trials • Spectrum of illness depending on many variables • Faecal peritonitis vs Clean perforation without soiling Hall C, et al. Colon perforation during colonoscopy: surgical versus conservative management. Br J Surg 1991; 78: 542-544.
Conclusion • Colonoscopic perforation is a rare complication following lower gastrointestinal endoscopy • Associated with high morbidity and even mortality • Increasing use of colonoscopy nowadays resulted in increasing frequency of perforation • No prospective, randomized controlled trials to define the optimal management • Management should be individualized • Prompt operative management remained standard treatment • Trend of increasing use of conservative management, laparoscopic surgical approach, and endoscopic repair in selected patients