Colonoscopic Perforation

Jared Torkington, MS FRCS(Gen Surg) Cardiff Colorectal Unit 

Powerpoint File

The role of the colorectal surgeon in performing colonoscopy is under the microscope. Various regulatory bodies are taking a view on the delivery of training and criteria for accreditation of units and individual colonoscopists. It is likely that these factors, along with the advent of screening, will lead to a change in the way that colonoscopy services are delivered in the UK. Regardless of the outcome of any reorganisation, the Colorectal Surgeon will still have to be on hand to deal with the rare complication of colonoscopy perforation.

Incidence

The overall risk appears low. Rates in reported series vary from 1in 200 to 1in 5000. These are often personal series, single centres or small sample sizes. Good evidence from a large US population-based series looking at over 35,000 colonoscopies and a similar number of flexible sigmoidoscopies suggest a rate of perforation of 1.96/1000 for colonoscopy and 0.88/1000 for flexible sigmoidoscopy.1

Risk Factors

Risk appears to increase with age (of the patient!), increasing co-morbidity and in particular polypectomy.

Mechanism2

1) Direct injury by colonoscope or biopsy forceps

2) Indirect from barotrauma

3) Secondary to therapeutic procedures

Management

Firstly the diagnosis must be made. Up to 50% of perforations may be recognised at the time of the procedure but the rest present later, usually within 48 hrs.3,4

This can be operative or non operative. There are some absolute indications for a surgical approach such as a large tear or injury, generalized peritonitis and underlying bowel conditions such as acute colitis or if the perforation has occurred at the site of a cancer. However, there is another set of patients where a carefully managed conservative approach is appropriate. These patients may be asymptomatic or have localised but improving peritonism. Some may fall into the group known as “post polypectomy syndrome”. These patients require systemic antibiotics and regular review.

Surgical options include resection, diversion or simple closure.

One suggested algorithm is referenced below. (From Kavic et al5)

Gatto NM et al. Risk of perforation after colonoscopy and sigmoidoscopy: a population based study. J Natl Cancer Inst 2003;95(3):230-6

Dalmore LJ2nd et al. Colonoscopic perforations. Etiology, diagnosis and management. Dis Colon Rectum 1996;39(11):1308-14

Cobb WS et al. Colonoscopic perforations: incidence, management and outcomes. Am Surg. 2004;70(9):750-7

Anderson ML et al. Endoscopic perforation of the colon:lessons from a 10-year study. Am J Gastroenterol 2000;95(12):3418-22

Kavic SM et al. Complications of endoscopy. Am J Surg 2001;181:319-32