2017 WSES guidelines for the management of iatrogenic colonoscopy perforation

Abstract

Iatrogenic colonoscopy perforation (ICP) is a severe complication that can occur during both diagnostic and therapeutic procedures. Although 45–60% of ICPs are diagnosed by the endoscopist while performing the colonoscopy, many ICPs are not immediately recognized but are instead suspected on the basis of clinical signs and symptoms that occur after the endoscopic procedure. There are three main therapeutic options for ICPs: endoscopic repair, conservative therapy, and surgery. The therapeutic approach must vary based on the setting of the diagnosis (intra- or post-colonoscopy), the type of ICP, the characteristics and general status of the patient, the operator’s level of experience, and surgical device availability.Although ICPs have been the focus of numerous publications, no guidelines have been created to standardize the management of ICPs. The aim of this article is to present the World Society of Emergency Surgery (WSES) guidelines for the management of ICP, which are intended to be used as a tool to promote global standards of care in case of ICP. These guidelines are not meant to substitute providers’ clinical judgment for individual patients, and they may need to be modified based on the medical team’s level of experience and the availability of local resources.

Intraperitoneal and Extraperitoneal Colonic Perforation Following Diagnostic and Therapeutic Colonoscopy with Crohn’s-related Stricture Dilation

“…There have been case reports of colonic perforations of lesser magnitude managed conservatively with bowel rest and antibiotics. There have also been studies supporting endoscopic repair such as endoscopic clipping or suturing closure [14]. However, in the case we present, the patient's condition was unstable, and the complications of colonic perforation were so extensive that surgical intervention was necessary.…”

“…Although iatrogenic colonic perforation due to colonoscopy has low incidence, perforation can have catastrophic consequences with up to 25% mortality [14]. The rate of colonic perforation is higher during therapeutic colonoscopy compared to diagnostic colonoscopy, with incidences estimated at 0.02%-8.0% and 0.016%-0.8%, respectively [15].…”

Delayed perforation after endoscopic resection of a colonic laterally spreading tumor: A case report and literature review

“…In the English literature, only five other reports (10 cases) of delayed perforation after EMR and ESD with non-surgical management have been reported[ 8 - 12 ] (Table 1 ). The decision to conduct an endoscopic operation also depends on the perforation size, endoscopist’s experience, and instruments available[ 2 , 15 , 20 - 23 ]. During endoscopic closure, carbon dioxide insufflation is generally preferred to prevent barotrauma because this gas is absorbed more quickly than air[ 24 ].…”

Endoscopic Management of an Iatrogenic Colonic Perforation Using Standard Hemoclips

“…[9] The 2017 World Society of Emergency Surgery guideline [ Figure 4] suggests endoscopic closure be reserved for patients with small perforations (<20 mm), good bowel preparation, and minimal peritoneal signs. [10] With growing experience, endoscopic clipping has been applied for closure of larger (>30 mm) defects as well. [9] Close hemodynamic monitoring, broad-spectrum antibiotics and nil per orally form an essential part of the management plan till bowel function returns.…”

“…[9] Close hemodynamic monitoring, broad-spectrum antibiotics and nil per orally form an essential part of the management plan till bowel function returns. [10] The superficial apposition of colon wall seems sufficient for the healing of perforation, and the reported success rate with this approach ranges from 69% to 93%. [4] The risk factors associated with the need for early surgical intervention after endoscopic clip closure includes large perforation size, leukocytosis, fever, severe abdominal pain, and a large amount of free peritoneal air.…”