Endoclipping of iatrogenic colonic perforation to avoid surgery

Abstract

Background Colonoscopy is an established tool for the diagnosis and management of colonic and rectal pathology. Even though colonic perforation is rare after colonoscopy, it is a serious and typical complication. The definitive management remains controversial. Both operative and nonoperative techniques have been described in the literature, though the standard treatment for these patients is still an operative repair of the perforation site. Recently, endoscopic clip application was recommended, particularly for iatrogenic perforations, but less is known about the effectiveness of endoluminal repair of colonic perforations with clips. Methods In this series, 7589 colonoscopies were performed over a 34-month period in a tertiary-level referral center. Three perforations occurred during 5413 diagnostic colonoscopies. Therapeutic colonoscopy was under taken in 2176 patients, resulting in a total of 27 perforations. Out of 30 patients with colonic perforation, five patients underwent operative management and 25 patients were subsequently treated nonoperatively. Results In 27 patients, endoscopic application of inert metallic clips was used for closure of iatrogenic perforation. Twenty-five of these patients were treated nonoperatively, while two patients underwent surgery. The mean postoperative length of hospitalization for patients was 12.2 days, compared to 3.5 days for patients treated conservatively.Conclusions Endoluminal repair of colonic perforations with clips and further conservative treatment seems to provide a tool that avoids the major additional trauma associated with laparotomy or laparoscopy and minimizes the length of hospitalization.

Endoscopic closure of iatrogenic perforation

“…4) provided successful closure rate at 75.86% to 95.65% in retrospective series. 33,[92][93][94][95] Predictors for the need of surgery within 24 hours after clipping are perforation size 10 mm or more, leukocytosis, fever, severe abdominal pain, and large amount of peritoneal free air indicated by a distance between right diaphragm and upper border of liver of 3 cm or more.…”

Emergencies after endoscopic procedures

“…In colon perforations, endoscopic closure in association with conservative management is successful in 60-100% of patients, avoiding the morbidity of surgery and shortening the length of hospital stay, provided that perforation is immediately recognized and closed. Initial series showed success with endoclips for small perforations [111,112], in the absence of peritoneal irritation. Subsequently also diagnostic, large perforations, in the presence of free air or moderately inflammatory signs, were also successfully treated with multiple clipping, OTSC or even band ligation [90].…”

Traitement endoscopique des perforations iatrogènes

“…Il n'existe pas de grande série publiée concernant cette technique. Globalement, la fermeture par endoclips est un succès technique et clinique dans 69 à 100 % des cas [18,28]. La technique consiste à ouvrir le clip juste à la sortie de l'endoscope, ce qui permet de manoeuvrer l'ensemble endoscope-clip comme un bloc unique ; ensuite, il faut essayer de positionner les mâchoires du clip à 90° par rapport à la perforation, appuyer une mâchoire sur l'une des berges, pousser légèrement l'ensemble clip-endoscope et effectuer une aspiration qui permettra de ramener un maximum de tissu entre les 2 mâchoires du clip qui sera largué immédiatement.…”