Colonoscopy-related adverse events and mortality in an Italian organized colorectal cancer screening program

Abstract

Background and Aims Post-colonoscopy adverse events (AE) are a key quality indicator in population-based colorectal cancer screening programs, affecting safety and costs. Aim of this study was to assess colonoscopy-related AE and mortality in a screening setting. Methods We retrieved data from a cohort of patients undergoing colonoscopy within a screening program (Faecal Immunochemical Test every 2 years, 50 to 69 years old, or post-polypectomy surveillance) in Italy between 2002 and 2014, to assess the rate of post-colonoscopy related AE and mortality. Any admission within 30 days of a screening colonoscopy was reviewed to capture any possible AE. Mortality registries were also matched with endoscopy database to investigate 30-day post colonoscopy mortality rate. Association of each outcome with patient/procedure related variables was assessed with multivariable analysis. Results Overall, 117,881 screening colonoscopies (66,584, 56.5%, with polypectomy) were included. Overall, 497/117,881 (0.42%) post-colonoscopy AE occurred: 281 (0.24%) bleedings and 65 (0.05%) perforations (3.7‰/0.7‰, operative/diagnostic procedures, p<0.001). At multivariable analysis, bleeding was associated to polyp size (≥20mm: OR 16.29, 95%CI: 9.39-28.29), proximal location (OR 1.46, 95%CI: 1.14-1.87), and histology severity (high-risk adenoma, OR 5.6, 95%CI: 2.43-12.91), while perforation was associated to endoscopic resection (OR 2.91, 95%CI: 1.62-5.22), polyp size (OR 4.34, 95%CI: 1.46-12.92) and proximal location (OR 1.94, 95%CI: 1.12-3.37). Post-colonoscopy death occurred in 15/117,881 (1.27x10,000) cases. Conclusions In an organised screening program, post-colonoscopy AE are a rare but not negligible eventuality. The most frequent is post-polypectomy bleeding, especially after resection of large (≥20mm) and proximal lesions.

Doing our best to do no harm

“…The data of Benazzato et al [1] are in line with previous data: the bleeding and perforation rates are higher than those in screening populations [2], but very similar to the pooled estimates for a broader spectrum of indications [3,4]. Individuals with a FIT + result represent a population enriched in advanced neoplasia [5], in whom a higher rate of polypectomy, larger polyps, and endoscopic mucosal resection (EMR) would be expected.…”

“…Clipping should be performed after removal of proximal polyps ≥ 20 mm [7]. The observation by Benazzato et al [1] that perforation was more common in procedures performed after incomplete colonoscopy should remind us of the common-sense advice [8] not to push against fixed resistance, to reduce the scope, and to continuously strive to improve our technique.…”

“…It is unclear whether the ongoing randomized controlled trials of screening colonoscopy will have the power to address this question. The observation by Benazzato et al [1] that the occurrence of adverse events was strongly associated with 30-day post-colonoscopy death makes a strong case that some post-colonoscopy deaths are indeed related to the procedure. Of the 15 deaths reported, the cause of death was perforation in 3, myocardial ischemia in 7, cardiac arrest in 1, and other in 4.…”

“…The great successes of CRC screening require exposing very large numbers of people to the potential risks of screening. The study by Benazzato et al of adverse events post-colonoscopy in Veneto's CRC screening program [1] makes a valuable contribution by focusing on a population undergoing colonoscopy primarily because of an abnormal fecal immunochemical test (FIT).…”

Management of patients with early-stage colon cancer: guidelines of the Italian Medical Oncology Association

“…Pancolonoscopy has a perforation risk of 0.1%, bleeding risk of >0.3% and mortality risk of 0.01%-0.03%. [39][40][41][42] As an alternative to pancolonoscopy, RSS in combination with colon CT scan can be used, even if approximately 30% of patients should additionally undergo colonoscopy. Sensitivity and specificity of RSS are similar to colonoscopy but limited to the first 60 cm.…”