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 Older patients 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 After procedure Investigations 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: Factors to consider 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% Mortality 0-26% 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

Thank you