Diagnostic Endoscopy-Associated Perforation

Diagnostic endoscopy is widely used in diagnosing, screening, and follow-up for colorectal diseases. The direct damage to the bowel wall during the insertion process is the main cause of perforation which is the most serious complication. Early in 2006, the American Society for Gastrointestinal Endoscopy (ASGE), the American College of Gastroenterology (ACG), and the European Society of Gastrointestinal Surgery (ESGS) mandated that the perforation rate should be less than 1/1000 in screening colonoscopy. ^, The prevalence of procedure-associated bowel perforation has decreased over the years. Population-based studies reported that the overall colonoscopic perforation occurs in 0.03% to 0.07% of patients undergoing diagnostic colonoscopy. A large population study found that there were 77 perforations after 39,286 colonoscopies (incidence = 1.96/1000 procedures) and 31 perforations after 35,298 sigmoidoscopies (incidence = 0.88/1000 procedures). Adjusted odds ratio (OR) for perforation from colonoscopy relative to perforation from sigmoidoscopy was 1.8 (95% confidence interval [CI]: 1.2 to 2.8).

The rectum and sigmoid colon (53%) are the predominant sites of perforation, followed by the cecum (24%), ascending colon (9%), transverse colon (9%), and descending colon (5%). The risk of perforation from colonoscopy is approximately double that from sigmoidoscopy. Perforation is located mostly in the rectosigmoid colon with a mean diameter of 2 cm in colonoscopy or flexible sigmoidoscopy. The mechanism of the sigmoid colon prone to injury is that its transitional part is relatively narrow, and the mesentery of the sigmoid colon is redundancy leading to tortuousness of the tubular colon. It is easy to lengthen the tortuous intestine causing looping when the scope is advanced. Due to diminished collaterals between the sigmoid colon artery and branches of the superior rectal artery, perforation can occur if the luminal pressure is too high. Generally, perforations caused by diagnostic colonoscopy are larger and can be detected earlier than those caused by therapeutic colonoscopy. Almost 30% of perforations are recognized at the time of colonoscopy by endoscopists. However, delayed diagnosis of perforation is common, especially in patients with a small-sized perforation without immediate tension pneumoperitoneum. These patients are often diagnosed until symptoms including fever and abdominal pain are presented, and perforation can be confirmed by imaging examination such as plain abdominal X-ray and computer tomography (CT) scan ( Fig. 28.1 ).

Diagnostic colonoscopy-associated perforation confirmed by CT imaging in 24 hours. (A) Colonoscopy indicated Crohn’s lesions in the right colon; (B) CT imaging showed air in the abdominal cavity ( arrow ).

The risk factors for the ICPs can be classified into patient-related, disease-related, and procedure-related. Reported patient-related factors include old age, female, and malnutrition. Individuals over 65 years of age carry a higher risk for ICPs, and for every year increase in age, the risk of a perforation increased by 7%. The female patients have a twofold increase in the risk for perforation than males. Low body mass index (BMI) and low serum albumin levels are also related to the risk for ICPs. ^, In addition, colonoscopy or flexible sigmoidoscopy for inpatients or patients in the intensive care unit (ICU) is more likely to have perforation, which may result from poor bowel preparation or comorbidities. For disease-related factors, the presence of Crohn’s disease (CD) is an independent risk factor in ICPs. A retrospective population-based study of 80,118 cases indicated that perforations are more likely to occur in patients with CD than in controls with a prevalence of 4% in CD versus 0.41% in non-CD patients ( P = .018). Steroid use in patients with CD was found to be a risk factor for perforation (Or = 7.68; 95% CI: 1.48, 39.81). However, a distinct study revealed no significant difference in the incidence of ICP complications between CD and controls, with rates of 0.168% and 0.102% respectively (P = .57). This study analyzed a total of 1547 colonoscopies performed on patients with CD and 15,671 colonoscopies on non-CD patients. In addition to CD, the presence of diverticular disease is noted to be a risk factor in several studies. ^, Poor maneuvering skills of the endoscopic and visualization of the lumen are the main reported procedure-related factors. The looping of the bowel and blind pushing may lead to perforation. The skill level of endoscopists may also be related to the incidence of perforation as a higher rate of ICP has been reported by non-GI endoscopists or in low-volume endoscopy centers.

Therapeutic Endoscopy-Associated Perforation

Therapeutic endoscopy in the lower GI tract procedures includes endoscopic polypectomy (EP), endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), endoscopic balloon dilation (EBD) of stricture, endoscopic stricturotomy, and endoscopic stricturoplasty. Colorectal cancer (CRC) develops from the normal mucosa via colonic adenoma. EP, EMR, and ESD are clinically applied to remove superficial neoplasms to prevent the development of advanced malignant lesions. EP can completely remove more than 80% of colonic polyps. Similar to diagnostic colonoscopies, the most concerning complication of therapeutic endoscopy procedures is also perforation. Compared to that in diagnostic colonoscopy, perforation occurred at a higher rate in therapeutic colonoscopy, with reported frequencies ranging from 0.1% to 2.1%. ^, EP-related perforation is reported to be 1.1% after examining 3976 snare polypectomies in 2257 patients. Sessile polyps, lesions >20 mm, or polyps located in the right colon are associated with a high risk for perforation. Older age, major concurrent comorbidities, inflammatory bowel disease (IBD), and right-sided location are reported risk factors of EP-related perforation. It was noted that the risk of perforation as well as post-polypectomy bleeding is lower with cold-snare polypectomy (CSP) rather than hot-snare polypectomy (HSP). In addition, compared with HSP, CSP has a similar complete resection rate of polyps, while the procedure time is reduced. HSP approach, sessile polyps, and inexperienced endoscopists are procedure-related risk factors for high perforation rates. Therefore, CSP has become the primary therapeutic approach for small polyps. ^,

Most flat or sessile advanced adenomas can be safely removed using EMR, although the perforation rate of EMR is higher than diagnostic colonoscopies. In a study of 1858 cases undergoing EMR, 4 patients experienced perforations (0.2%). The perforations that occurred during EMR were typically small and were amenable to endoscopic closure. This is confirmed by another report indicating that the mean perforation diameters for EMR were smaller (5.8 mm vs. 19.3 mm, P = .01), and EMR-associated were less likely to require laparotomies (9% vs. 88%) than diagnostic colonoscopy-associated perforation.

Endoscopic submucosal dissection has shown advantages over EMR for the removal of larger and deeper lesions. However, ESD is more time-consuming with a higher rate of complications than EP or EMR. The reported perforation rate of ESD was up to 5% (range, 1.4–10%) in a study of 648 lesions (37% located in the right colon). Despite the high perforation rate of ESD, salvage surgery due to ESD-related complications is around 1% according to a systematic review of nearly 3000 ESD procedures. Colorectal ESD requires more additional surgical intervention for endoscopic failure or associated complications (OR = 2.16, 95% CI: 1.16–4.03) than EMR. Given the high risk of perforation and longer procedure time, ESD may only be applied in lesions with suspected superficial invasive carcinoma. Risk factors for EMR and ESD-related perforations include colonic lesion location, large tumor size, presence of submucosal fibrosis, and endoscopist inexperience (<50 cases).

Endoscopic balloon dilation, endoscopic electroincision with stricturotomy and strictureplasty, and endoscopic stenting have merged as valid treatment options for strictures in the lower GI tract. Attempts of EBD or endoscopic electroincision should be made for primary or anastomotic strictures (<4–5 cm) from CD or other benign colorectal diseases, before surgical intervention. Endoscopic stenting is mainly indicated for malignant bowel obstruction.

Endoscopic balloon dilation is the most commonly performed therapeutic procedure for strictures of the lower GI tract. Patients with underlying CD who underwent EBD had a higher perforation rate and needed more requirements for surgery than controls. However, perforation for endoscopic stricturotomy in CD is not common, in a series of 85 endoscopic stricturomies using needle-knife technology, only 1 patient (0.4% per procedure based) had perforation which required hospitalization and urgent exploratory laparotomy. Risk factors for EBD or endoscopic stricturotomy are anastomotic strictures, long strictures (>4–5 cm), and a history of smoking. , However, the size of perforation that occurred during the therapeutic colonoscopies was usually smaller than those happened during the diagnostic colonoscopies, and patients usually have subdiaphragmatic free air without signs of peritoneal irritation due to minimal fecal contamination and higher intestinal cleanliness, although perforation is demonstrated by imaging ( Fig. 28.2 ). Patients having therapeutic endoscopy-associated perforation tend to have delayed tension pneumoperitoneum, fever, and the onset of abdominal pain.

Therapeutic colonoscopy-associated perforation was confirmed by CT imaging in a patient having subdiaphragmatic free air. (A) Free air in the abdominal cavity ( arrow ) indicated by X-ray; (B) CT imaging demonstrating subdiaphragmatic free air ( arrow ).

Indications and Principles

Endoscopy-associated perforations are rare events but with severe morbidities and mortality, which are reported up to 40% and 25%, respectively. ^{, ,} With advances in minimally invasive surgery, laparoscopy is increasingly used for the treatment of endoscopy-related perforation. However, there are no convincing data to clearly define the indications for laparoscopic repair. Explorative laparoscopy should be considered for those with good physical conditions. In contrast, laparoscopic surgery is indicated in patients with persistent sepsis, diffuse peritonitis, large-sized perforations, failure of conservative or salvage endoscopic treatments, or the segment of the perforated bowels containing malignant pathology. ^, For perforations related to therapeutic endoscopy, most patients had already had bowel preparation. Therefore, fecal contamination should be able to be controlled to an acceptable degree, which makes laparoscopic repair amenable. Also, for tissue healing and cosmetic reasons, laparoscopic repair is preferred over open surgery. Primary laparoscopic repair or bowel resection with or without an ostomy is thus applied depending on intraoperative findings and the general condition of the patients. Clinically, bowel resection and ileostomy or colostomy are used in patients with extensive fecal contamination, operative delay, and comorbidities.

Techniques

No matter what surgical approach (laparoscopic vs. open) is chosen to manage the perforations, the complete exploration, and peritoneal washout and drainage, along with the restoration of the intestinal continuity are mandatory during the surgical management of endoscopy-associated perforations especially ICPs. Identifying the site of perforation is the key point of surgical management, and fecal contamination can be a sign to find the perforation site. In some cases, especially those with a small-sized perforation and limited fecal contamination; however, it may be difficult to find the site. In these cases, submucosal injection of methylene blue or indigo carmine dye during endoscopic procedures or intraoperatively helps identify the site of perforation. For the endoscopist, it is recommended to inject methylene blue, indigo carmine dye, or other tattooing agents or to put a clip at the site of perforation when perforation is identified during endoscopy.

Surgical procedures for the management of ICPs include repair, wedge resection, and colonic resection with or without primary anastomosis or stoma. If the colonic tissue appears healthy and has a good blood supply, perforation could be sutured without tension under laparoscopy ( Fig. 28.3 ). If the bowel lumen would not be narrowed after bowel resection, wedge resection is suitable. If the size of the perforation is too large or the edge of the perforation has a poor blood supply, colonic resection might be the best option. A fecal diversion with the construction of a stoma is usually applied for poor tissue viability, transmural inflammation of the bowel (such as an active CD), extensive fecal contamination, and worse general status of the patients. Based on the size of the perforation, a repair strategy is indicated when the upper size limit for sutured repair is 1 cm. Between 1 and 2.5 cm, a transverse tangential stapled resection was suggested, and for those with the size of perforation greater than 2.5 cm, a segmental resection was recommended. Single-port laparoscopy, which is associated with better cosmetic outcomes, has widely been introduced for the treatment of various abdominal diseases, and single-port laparoscopy is the promising approach in the treatment of endoscopy-related perforation.

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