Key points

General principles: prevention of acute endoscopic perforations

Like death and taxes, iatrogenic bowel perforation is a near certainty at some point during the life of a gastrointestinal (GI) endoscopist. Even the most skilled endoscopist who adheres to all of the principles of prevention will almost certainly face a situation whereby he or she has caused a foregut or colon perforation during endoscopy. Therefore, one should more realistically think of the clinical principles and pearls presented in this article as approaches to minimizing risk, as the only guaranteed way to avoid a perforation is to not perform the endoscopy at all.

Acute endoscopic perforations are, fortunately, a rare adverse event ( Box 1 ). When they do occur, however, they typically instill a great amount of fear in the endoscopist because of their potential to not only result in substantial morbidity and mortality, including sepsis and the need for surgery, but also strain the patient-physician relationship. The goal of this article is to assist in mitigating these fears by providing the endoscopist with practical measures to reduce the risk of iatrogenic foregut and colon perforations, and to discuss the appropriate means of assessing perforations when they inevitably occur.

Before every endoscopic procedure, the endoscopist should ask himself or herself, “Is this procedure truly indicated?” Though an obvious question, it should be answered from the perspective of not only the endoscopist but also the patient.

Next, it is important for the endoscopist to be prepared for the task at hand, whether that be resecting a polyp, dilating a stricture, or performing a sphincterotomy. Preparation includes several factors: (1) know the patient’s history, in addition to any underlying comorbidities and medications that increase the risk for perforation (eg, connective tissue disorder, chronic steroid use); (2) schedule the procedure for the appropriate amount of time (eg, 30 minutes may not be reasonable for endoscopic mucosal resection of a large colon adenoma); (3) have expert mastery of the endoscopic equipment and devices that will be used, including their Food and Drug Administration–approved uses, how they work, and troubleshooting them when they malfunction. It is equally important that the staff (eg, nurses, technicians) in the room also have proficiency using the equipment and devices including, but is not limited to, operation of electrosurgical generators and their different settings, the characteristics of different snares, the differences in deploying different brands of endoclips, setting up band ligators, and use of devices or equipment that may be used infrequently such as polyvinyl endoloops or mechanical lithotripters. Some suggestions for ensuring that physicians and staff remain up to date and proficient in handling endoscopic equipment include working with representatives of the various device manufacturers to arrange for regular, periodic “in-services” where hands-on demonstrations and instructions are provided in detail; encouraging staff to attend conferences or hands-on workshops geared toward GI nurses and technicians; and creating specialized nurse/technician teams to regularly staff the more advanced cases that use unique equipment (eg, endoscopic retrograde cholangiopancreatography [ERCP], endoscopic ultrasonography [EUS], luminal stenting, GI bleeding).

Even the best-prepared endoscopists, however, should know their capabilities and their limitations. Such knowledge will minimize the risk of perforation from maneuvers for which the endoscopist is inadequately trained or skilled in performing. For example, the decision may be made to refer a large, complicated colon polyp to a therapeutic endoscopist at a tertiary center. By doing so, the risk of perforation by both the referring physician and the endoscopist who will eventually perform the endoscopic mucosal resection can be reduced. Directors of endoscopy units can refer to published guidelines suggesting appropriate credentialing criteria.

Finally, GI endoscopists and endoscopic units as a whole should participate in 1 or more programs focusing on ongoing practice performance (quality) improvement. For example, this may take the form of tracking adverse events and presenting them in hospital morbidity and mortality conferences, or comparing them with peers across the country via a database system such as the GI Quality Improvement Consortium (GiQuIC), attending hospital morbidity and mortality conferences, and/or enrolling in the American Society for Gastrointestinal Endoscopy (ASGE) Endoscopic Unit Recognition Program. By focusing on metrics of quality, including adverse events such as perforation, patterns and trends can be identified early so that a process to identify the etiology of a high perforation rate, for example, can be initiated, and a means to remediate the problem implemented.

General principles: prevention of acute endoscopic perforations

Like death and taxes, iatrogenic bowel perforation is a near certainty at some point during the life of a gastrointestinal (GI) endoscopist. Even the most skilled endoscopist who adheres to all of the principles of prevention will almost certainly face a situation whereby he or she has caused a foregut or colon perforation during endoscopy. Therefore, one should more realistically think of the clinical principles and pearls presented in this article as approaches to minimizing risk, as the only guaranteed way to avoid a perforation is to not perform the endoscopy at all.

Acute endoscopic perforations are, fortunately, a rare adverse event ( Box 1 ). When they do occur, however, they typically instill a great amount of fear in the endoscopist because of their potential to not only result in substantial morbidity and mortality, including sepsis and the need for surgery, but also strain the patient-physician relationship. The goal of this article is to assist in mitigating these fears by providing the endoscopist with practical measures to reduce the risk of iatrogenic foregut and colon perforations, and to discuss the appropriate means of assessing perforations when they inevitably occur.

Before every endoscopic procedure, the endoscopist should ask himself or herself, “Is this procedure truly indicated?” Though an obvious question, it should be answered from the perspective of not only the endoscopist but also the patient.

Next, it is important for the endoscopist to be prepared for the task at hand, whether that be resecting a polyp, dilating a stricture, or performing a sphincterotomy. Preparation includes several factors: (1) know the patient’s history, in addition to any underlying comorbidities and medications that increase the risk for perforation (eg, connective tissue disorder, chronic steroid use); (2) schedule the procedure for the appropriate amount of time (eg, 30 minutes may not be reasonable for endoscopic mucosal resection of a large colon adenoma); (3) have expert mastery of the endoscopic equipment and devices that will be used, including their Food and Drug Administration–approved uses, how they work, and troubleshooting them when they malfunction. It is equally important that the staff (eg, nurses, technicians) in the room also have proficiency using the equipment and devices including, but is not limited to, operation of electrosurgical generators and their different settings, the characteristics of different snares, the differences in deploying different brands of endoclips, setting up band ligators, and use of devices or equipment that may be used infrequently such as polyvinyl endoloops or mechanical lithotripters. Some suggestions for ensuring that physicians and staff remain up to date and proficient in handling endoscopic equipment include working with representatives of the various device manufacturers to arrange for regular, periodic “in-services” where hands-on demonstrations and instructions are provided in detail; encouraging staff to attend conferences or hands-on workshops geared toward GI nurses and technicians; and creating specialized nurse/technician teams to regularly staff the more advanced cases that use unique equipment (eg, endoscopic retrograde cholangiopancreatography [ERCP], endoscopic ultrasonography [EUS], luminal stenting, GI bleeding).

Even the best-prepared endoscopists, however, should know their capabilities and their limitations. Such knowledge will minimize the risk of perforation from maneuvers for which the endoscopist is inadequately trained or skilled in performing. For example, the decision may be made to refer a large, complicated colon polyp to a therapeutic endoscopist at a tertiary center. By doing so, the risk of perforation by both the referring physician and the endoscopist who will eventually perform the endoscopic mucosal resection can be reduced. Directors of endoscopy units can refer to published guidelines suggesting appropriate credentialing criteria.

Finally, GI endoscopists and endoscopic units as a whole should participate in 1 or more programs focusing on ongoing practice performance (quality) improvement. For example, this may take the form of tracking adverse events and presenting them in hospital morbidity and mortality conferences, or comparing them with peers across the country via a database system such as the GI Quality Improvement Consortium (GiQuIC), attending hospital morbidity and mortality conferences, and/or enrolling in the American Society for Gastrointestinal Endoscopy (ASGE) Endoscopic Unit Recognition Program. By focusing on metrics of quality, including adverse events such as perforation, patterns and trends can be identified early so that a process to identify the etiology of a high perforation rate, for example, can be initiated, and a means to remediate the problem implemented.

General principles: assessment of acute endoscopic perforations

Despite the best intentions and efforts, iatrogenic endoscopic perforations will occur. When they do occur, it is essential that the endoscopist knows how to assess and confirm the presence and location of a perforation, in addition to its severity. By doing so, the appropriate measures can be promptly taken, whether by attempting endoscopic closure, choosing to manage it conservatively with antibiotics, or calling a surgical colleague.

Early recognition of acute perforations is essential in improving the patient’s outcome. This recognition typically begins during the endoscopy by maintaining a high index of suspicion ( Fig. 1 ). Perforation may be obvious, as when serosal fat is seen after resecting a large polyp in the colon. Other times, however, only subtle clues may be present such as difficulty in maintaining air insufflation, manifested by inability to keep the lumen of the bowel distended. Prompt recognition can allow for attempts at endoscopic closure and avoid potential sepsis, peritonitis, and the need for surgery.

General principles for the assessment of acute, iatrogenic perforations during endoscopy.

Many times, however, a perforation is not appreciated at the time of endoscopy, and the patient may present with obvious symptoms such as abdominal pain and peritoneal abdominal signs on examination, or with vague, nonspecific symptoms or signs such as respiratory distress, confusion, or tachycardia ( Fig. 2 ). In these situations, it is critical that the endoscopist has a low threshold for additional testing to evaluate for a possible perforation.

General principles for assessment of acute, iatrogenic perforation following completion of endoscopy.

Imaging plays an important role in the postprocedure assessment of a perforation. Often the quickest and least expensive option is a plain radiograph of the chest and abdomen to evaluate for pneumothorax, pneumomediastinum, and free air under the diaphragm. Although retroperitoneal air can sometimes be seen, a computed tomography (CT) scan is a much more sensitive test if a retroperitoneal perforation is suspected (eg, after endoscopic biliary sphincterotomy). CT is also more sensitive for smaller perforations or microperforations and leaks; the approximate sensitivity and specificity of CT for perforation of the GI tract is 80% to 100%. It is important to recognize, however, that extraluminal air on imaging is not always an indication for surgery. The location, size, fluid collections, and clinical status of the patient all play a role in deciding whether a patient should be brought to the operating room, although a surgical consultation should almost always be obtained in these situations. Two important principles to remember when extraluminal air is seen are: (1) air itself does not necessarily imply infection; and (2) the volume of free air is does not indicate the size of perforation, and is due in large part to the duration of the procedure and the volume of air insufflated after the perforation has occurred. Location-specific approaches to assessing perforations are described in the following sections.

Esophageal perforations

Etiology

The overall reported rate of esophageal perforations during standard upper endoscopy is less than 0.1%. Perforation may rarely occur at the level of the hypopharynx or proximal esophagus from blind passage of the endoscope. This occurrence is more frequent with scopes that do not have a forward-viewing lens such as a duodenoscope (side-viewing) or echoendoscope (oblique-viewing). Patients who are at higher risk for perforations in this location from scope passage, even with a forward-viewing endoscope, include those with Zenker diverticulum, head and neck cancer, and prior external beam radiation therapy.

Therapeutic interventions carry a slightly higher risk of perforation even in experienced hands. Dilation of esophageal strictures with either a tapered-tip bougie or Savary dilator or a balloon catheter carries a risk of perforation of approximately 0.4%. This rate may be higher in radiation-induced strictures, and is higher in complicated (long and/or tortuous) strictures. Passage of a scope through a stricture, even without dilation, may also result in perforation, particularly if the scope is an echoendoscope or duodenoscope whereby the stricture may be unknown (if a standard esophagogastroduodenoscopy [EGD] was not performed first) or poorly visualized. In patients with foreign bodies or food impactions, there may be underlying strictures that can lead to perforations when endoscopy is performed. Pneumatic dilation of patients with achalasia carries a reported median risk of perforation of 2% to 4%. Endoscopic mucosal resection (EMR) of mucosal lesions (nodules in Barrett esophagus) and subepithelial lesions are other causes of acute perforation. Esophageal stents can cause perforation at the time of stent insertion, or can occur much later if pressure necrosis occurs at the site of the stricture, or either end of a large stent; this can result in frank pneumomediastinum, or in the creation of respiratory esophageal fistulas.

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  Causes of Endoscopic Esophageal Perforations

  
  
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  Blind passage of endoscope (hypopharynx, proximal esophagus)

  
  
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  Dilation of stricture

  
  
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  Achalasia dilation

  
  
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  Passage of non–forward-viewing endoscope through stricture

  
  
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  Foreign body removal

  
  
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  EMR of Barrett esophagus, intramucosal carcinoma, subepithelial lesions

  
  
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  Long-standing esophageal stent

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