1. Colonoscopic Perforation Jared Torkington Cardiff

4. Incidence Aetiology Avoidance Treatment

5. Incidence Rates vary 1 in 200 to 1 in 5000 St Marks – no rate quoted BUPA hospitals – no rate quoted Cleveland Clinic – no rate quoted ACPGBI/BSG – no info Mayo – 1-3/1000, 23/1000 for polypectomy

6. Incidence 5% random sample of medicare patients >65 years 1991-1998 39 286 colonoscopies 35 298 flexi sig Gatto et al 2003

7. Results Colonoscopy 1.96/1000 Flexi sig 0.88/1000 OR 1.8 (CI 1.2-2.8) Increasing age, diverticular disease 2 or more comorbidities Risk of perforation decreased during the study period Gatto et al 2003

9. Polypectomy 34,620 colons over 30 years 31 perforations (0.09%) 18 (58%) in therapeutic 13 (42%) in diagnostic Araghizadeh 2001

10. Site Iqbal 2005 31% 7% 64%

11. Aetiology Direct penetration

12. Aetiology Direct penetration Bowing

13. Aetiology Direct penetration Bowing Across a stricture

14. Aetiology Direct penetration Bowing Across a stricture Barotrauma

15. Diagnosis of perforation Subtle signs or acute abdomen 50% at colonoscopy, rest usually within 48 hrs Sepsis CXR or CT

16. Operation? Mechanism of perforation Age and co-morbidity Bowel prep Severity of symptoms Degree of sepsis

17. Post polypectomy syndrome Localized signs No systemic sepsis Analogous to diverticulitis Regular review Systemic antibiotics

18. Results 31 perforations 16 (52%) after hot biopsy or polypectomy 3 (9%) barotrauma 16 (52%) identified at the time Araghizadeh 2001

19. Results - conservative 11 (35%) managed conservatively Afebrile, localised tenderness and mild WBC rise 3 went onto surgery, 1 closure and defunction, 2 closure only 1 percutaneous abscess drained 1 death Araghizadeh 2001

20. Results - surgery 20 (65%) 9 direct closure 7 resection, primary anastomosis 4 resection and diversion

21. Stable, CVS Localised signs Good health Peritonitis Large defect Poor bowel prep LAPAROTOMY Erect CXR Free AirNo Free Air CT scanBig Perforation Contained Perforation Conservative Treatment NBO, IVI, Abs Deterioration Kavic 2001

22. Other complications

23. Summary Incidence 1:750 Several mechanisms Role for conservative management in small selected group