Colonoscopy Complications: Identification and Management Focus: Perforation G. S. Raju, MD

When? • Preparation

• Procedure

• Post-procedure

COLONOSCOPY

Home

Procedure

H

What is the reported frequency of major complications related to screening colonoscopy?

1. 1 per 1000 procedures

2. 3 per 1000 procedures

3. 6 per 1000 procedures

4. 9 per 1000 procedures

Serious adverse event

2.8 per 1000 screening colonoscopies U.S. Preventive Services Task Force

Home

Procedure death

bleeding

perforation ER/Clinic Visits

Whitlock EP et al. Ann Int Med 2008;149:638-58

H

You discuss implementing a quality improvement program in your colonoscopy group practice. What is an unacceptable metric for perforation related to screening colonoscopy?

1. > 1 in 100 colonoscopies

2. > 1 in 1000 colonoscopies

3. > 5 in 100 colonoscopies

4. > 5 in 1000 colonoscopies

PERFORATION Unacceptable Metrics > 1 in 500 colonoscopies

> 1 in 1000 screening colonoscopies Reason for concern

Rex DK et al. GIE 2006;63:S16-28

Preparation

Procedure

Post--op

Managing Complications

Suboptimal preparation

failure to detect lesions perforation - a disaster

Stop

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Perforation Complications

Onset of Bleeding & Perforation after

Outpatient Colonoscopy

100

Perforation

100

75

75

%

Bleeding

%

50

50

25

25

0

0

day 0

day 2

day 5

day 0

14 day reporting period

Rabeneck et al. GIE 2011;73:520-3

day 2

day 14

day 25

Could we recognize it?

Delay in Recognition 3/4

post procedure

70

Ostomy

52.5

n=180

1/4

%

1980-2006

35 17.5 0 24 hours Iqbal J Gastrointest Surg 2005 Mana et al. GIE 2001;53:258-9

>24 hrs

What caused it? Could we fix it?

CAUSES of COLON PERFORATION Frequency

Blunt Polypectomy Thermal

18%

55% 27%

Iqbal J Gastrointest Surg 2005

CAUSES of COLON PERFORATION Frequency

Blunt Polypectomy Thermal

Fecal Diversion

50

18%

37.5 25 55% 27%

12.5 0 2.0 cm

Iqbal J Gastrointest Surg 2005

0.9 cm

1.4 cm

TREATMENT of COLON PERFORATION Therapeutic

Diagnostic

Clip

Clip

2004-2011 105 cases

82% 11%

31%

Magdeburg R et al. Scand J Gastroenterol 2013

44%

What caused it? Could we prevent it?

PREVENTION OF PERFORATION PREVENT HOCKEY STICK INJURY ANGULATED SIGMOID Thin instrument REDUNDANT SIGMOID Balloon assisted endoscopy

Overtubes

Water immersion*

Left lateral 2 prone position**

Vemulapalli & Rex. Gastrointest Endosc 2012;76:812-7* Awazu S et al. Gastrointest Endosc 2012; 75:702-4**

PREVENTION OF PERFORATION PREVENT RETROFLEXION INJURY SMALL RECTUM Avoid retroflexion

Cap fitted colonoscope helps in examining the lower rectum

PREVENTION OF PERFORATION PREVENT BAROTRAUMA INJURY DIFFICULT INSERTION CLOSED LOOPS

Use CO2

Periodic decompression

Water Immersion

PREVENT THERMAL PERFORATION Colon Explosion Avoid APC in a dirty colon

Perforation Saline injection +/- Epinephrine

prior to ablation

PREVENT POLYPECTOMY PERFORATION Tension Pneumoperitoneum Use CO2

Periodic decompression Fecal Peritonitis Clean colon

Dry colon

Lesion - nondependent Perforation Submucosal fluid cushion

Snare parallel to the wall

Safe cut

Prevention of EMR Perforation Clean & dry colon

Nondependent

Snare parallel

Lift & loosen

Tight squeeze-cut

Examine base

Raju et al. Gastrointest Endosc 2011;74:1380-88

STUDY THE RESECTION BASE

sm

mp

perf.

Acute Perforation Now What Do I Do?

Is there tension pneumoperitoneum? Pulseless Electrical Activity

tension

pneumoperitoneum

Raju GS, Ikhara H, Kaltenbach T, Gotoda T, Soetikno R. Endoscopic Closure of GI Perforations. ASGE Learning Library 2010

Small perforation - clip closure

Large perforation - clip closure

Acute Perforation Clip closed What next?

Management after Clip Closure

H Therapy

Unfavorable

Close monitoring

Diagnostic

large perforation

Nil by mouth

wbc >10k

IV fluids

Fever >37

Broad spectrum IV antibiotics

Severe abdominal pain

Surgical consult

AXR: Free air > 3 cm

Limitations

Difficulty in ensuring complete closure

Repair

Clip detachment Interference with laparoscopic closure

Kim JS et al. Surg Endosc. 2013; 27: 501–4. Cho SB et al Surg. Endosc 2012; 26: 473–9.

Diversion