33
The Endoscopic Management of Immediate Complications of Therapeutic Endoscopy

David A. Greenwald^1,2 and Martin L. Freeman³

¹ Mount Sinai Hospital, New York, NY, USA

² Icahn School of Medicine at Mount Sinai, New York, NY, USA

³ University of Minnesota, Minneapolis, MN, USA

Introduction

Endoscopy is no longer merely diagnostic; therapeutic maneuvers are integral parts of most procedures. With increasingly complex therapy possible during gastrointestinal endoscopy comes an increased risk for complications. These complications, including bleeding, perforation, pancreatitis, infection, airway issues, and hypotension, must be immediately recognized and appropriately managed. The skills to assess and manage risk pre‐procedure, to recognize and manage serious problems that occur during endoscopy, and finally the ability to manage these issues successfully are an important part of training for endoscopy today. Chapters 5–8 in this volume have looked at training in the various procedures in gastrointestinal endoscopy such as upper endoscopy, colonoscopy, endoscopic retrograde cholangiopancreatography (ERCP), and endoscopic ultrasound (EUS) as well as training in associated techniques such as electro surgery (Chapter 12). This chapter focuses solely on training to recognize and manage immediate complications of therapeutic endoscopy (Table 33.1).

Assessing risk prior to procedure

Patients being considered for therapeutic endoscopy need to be assessed pre‐procedure for risks that can be anticipated, and then steps can be taken to minimize or mitigate those risks. Issues to be addressed pre‐procedure include a number of factors related to the cardiopulmonary risk of sedation, analgesia, or anesthesia; and risks related to the specific procedure such as bleeding for polypectomy, endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), peroral endoscopic myotomy (POEM), or sphincterotomy; or pancreatic risks related to ERCP. Sometimes, the set of risk factors for these aspects overlap, but often the set of risk factors is completely different. For example, cardiopulmonary risk is generally higher in older patients and those with more co‐morbidities, while post‐ERCP pancreatitis risk is higher in younger, healthier patients; bleeding risk is generally related to parameters related to the coagulation status of the patient, and the type of procedure done.

Cardiovascular complications of endoscopy related to sedation and analgesia are common, accounting for nearly half of the reported complications in one American Society for Gastrointestinal Endoscopy (ASGE) survey [1, 2]. Cardiovascular complications may be more likely to occur in a subset of patients including those who are obese, older, have pulmonary disease such as COPD and sleep apnea, have a history of cardiac disease, have certain body features such as short necks, or have a history of substance abuse. Those who have been difficult to sedate in the past are also of concern. Cardiovascular complications range from minor, such as transient and asymptomatic rhythm changes, to more severe, such as myocardial infarction and shock/hypotension. Respiratory conditions range from subtle hypoxemia to severe respiratory depression. Adequate training in sedation and monitoring allows for such problems to be anticipated and avoided wherever possible. Training may include standard courses in basic life support (BLS) and advanced cardiac life support (ACLS), which describe common scenarios in cardiopulmonary complications, and helps to teach and train about proper management [3, 4]. Knowledge of the use of appropriate resuscitation equipment is also of paramount importance. Careful use of sedating agents along with the use of standard monitoring equipment helps to limit the number and severity of cardiopulmonary complications.

Use of mock airway drills to practice in the event of a compromised airway should be part of training for therapeutic endoscopy. Similarly, a working knowledge of the medications and techniques necessary to recognize and manage common cardiovascular complications such as brady and tachy arrhythmias, hypotension and cardiac arrest is necessary, as well as adequate training in the use of reversal agents for medications given for sedation for therapeutic endoscopy.

Table 33.1 Check list for mastery in training to recognize and manage complications.

1. Know your limits.

2. Know when to ask for assistance.

3. Team training.

4. Excellent communication between all members of team.

Assessment before the procedure may also reveal an increased risk for bleeding either because of medication use or an underlying coagulopathy. Training should include familiarity with guidelines for the management of anticoagulants and antiplatelet agents in endoscopy [5].

Intraprocedure recognition of complications

Risks of therapeutic endoscopy

Perforation of the upper gastrointestinal (GI) tract during diagnostic endoscopy is very uncommon, with rates of 0.03% in an ASGE survey [1]; risk factors include the presence of a Zenker’s diverticulum, anterior cervical osteophytes, esophageal strictures, and malignancies. Perforation is more common with therapeutic maneuvers including dilation of benign and malignant strictures, stent placement, and dilation of achalasia. Training to minimize complications in dilation includes knowledge of the different dilating options and then making appropriate decisions. In one series comparing dilating systems, perforations were substantially more common with blind passage of Maloney‐type dilators than with the use of balloon‐based systems or wire‐guided dilators. In achalasia, avoiding higher inflation pressures (greater than 11 psi) or by limiting the initial dilation to a 30 mm diameter may be associated with a decreased likelihood of perforation [6, 7]. In malignant strictures, dilation of a stricture with or without previous radiation treatment to that area did not influence perforation rates [8]. Perforations may occur after dilation for gastric outlet obstruction as well (See also Chapter 17).

Training in the recognition and management of perforations includes understanding that the most common sign of perforation is pain; other symptoms of note are fever, crepitus, chest pain (often pleuritic), and pleural effusion. Diagnosis may be seen with air radiographs of the neck. If a perforation is suspected, recognition may be confirmed by the use of a water‐soluble contrast media initially, or computed tomography (CT) scan, depending on the site and extent of perforation.

Bleeding may occur during therapeutic endoscopy in many situations, including during the treatment of ulcers, dilation of strictures, stent placements, and management of variceal hemorrhage. Induction of bleeding during nonvariceal hemostasis is reasonably common, occurring in up to 5% of procedures [9]. Fortunately, it is usually easy to control during the procedure. Bleeding has also been reported in up to 6% of patients after endoscopic variceal sclerotherapy and band ligation, as a consequence of the resultant ulcers [10]. Practice in the management of acutely bleeding lesions, whether on porcine models or via the use of simulators, may be useful in training to manage bleeding complications in the upper GI tract.

c33i001 Other risks of therapeutic upper endoscopy that may be seen immediately following the procedure include aspiration, stent migration, and mucosal injury following foreign body removal. Proper training in the equipment used for foreign body removal, including use of overtubes, latex hoods, and a variety of graspers is crucial to minimizing complications, which have been reported in about 8% of foreign body removals [11]. Esophageal overtube placement and use have been associated with bleeding and perforation, often due to pinching of the overtube into the esophageal mucosa. Latex hoods fitted over the end of the endoscope may protect the GI mucosa from trauma as the foreign body is retrieved. In the case of foreign body removal, training should include extracorporeal simulation of the removal of the foreign body to assess for efficacy and safety of the planned technique prior to its attempt inside the GI tract (Video 33.5; See also Chapter 18).

Risks of therapeutic colonoscopy

Complications as a result of diagnostic colonoscopy are very rare, with perforation rates estimated to be 0.35% [1, 12]. Therapeutic colonoscopy, however, has an increased rate of complications, with major complications reported to occur 0.2–0.3% of the time. Complications include bleeding, perforation, and cardiovascular and cerebrovascular events [13]. Risk factors for developing complications during therapeutic colonoscopy include the concomitant use of antiplatelet agents or anticoagulants. Post‐polypectomy bleeding rates decrease with increased experience of the endoscopist [14]. While the rate of perforation does not clearly seem to be related to the size of the polyp being removed, right colon polyps seem to be associated with the highest risk of perforation due to the thinness of the wall in that section of the colon [15].

Training should include learning techniques to help avoid complications. For example, proper technique in closing the snare during polypectomy is important to prevent entrapment of normal mucosa along with the polyp. Too rapid closure of the snare and guillotining of a polyp before cautery effect has occurred can be associated with increased bleeding. Use of saline or epinephrine injected under flat polyps, particularly in the right colon, seems to be effective in decreasing perforation associated with polypectomy in that area.

Perforation during colonoscopy can occur for a variety of reasons, including barotrauma, direct bowing, and force against the colon wall, or as a result of therapeutic procedures [16]. Management of perforation begins with immediate recognition, and early recognition and prompt intervention may decrease patient morbidity and mortality. Because many perforations can now be closed during the index endoscopy, careful inspection for visual and or radiographic signs (if under fluoroscopy) is paramount, before or very shortly after withdrawing the endoscope. The so‐called “target sign” is often an indication of a perforation that the endoscopist should be prepared to recognize as a perforation, and possibly repair immediately (Figure 33.1).