Endoscopic Repair of Colonic Perforations

In another small step in the evolution of medical care towards less invasive diagnosis and treatment, the previously automatic operative intervention in colonic perforation after colonoscopy is being questioned by leading academic surgeons and gastroenterologists.

The topic was discussed at length at the December, 2011 meeting of the New York Society of Gastrointestinal Endoscopy and was headed by Dr. G. S. Raju of the Department of Gastroenterology, Hepatology, and Nutrition at the University of Texas MD Anderson Cancer Center in Houston.

Colonoscopy-related perforations are unusual and usually occur in the setting of a polypectomy. The incidence ranges from .1% to 5% with endoscopic mucosal and endoscopic submucosal polypectomy carrying the largest risk.

Due to the usual colon insufflation used during the procedure, perforations result in an almost immediate air leak with resultant pneumoperitoenum, allowing one-third of the perforations to be diagnosed at the time of the procedure. If left unrepaired, bowel contents tend to spill into the peritoneal cavity, causing peritonitis and eventual sepsis.
Perforations can occur up to two weeks after polypectomy.

Up until a decade ago, virtually all colonic perforations were taken to the operating room for laparotomy or laparoscopy and surgical repair. Dr. Raju and others who are advocating for a larger role in gastroenterologists treating their own complications argue that the hole is likely to be small and might be amenable to the placement of clips to effect bowel closure.

Not surprisingly, some in the surgical community are expressing some caution. Dr. George S. Chang is director of clinical operations in the Minimally Invasive and New Technologies in Oncology Program at MD Anderson acknowledges that the best approach to treating patients is always with the least invasive procedure if good outcomes can be achieved. Dr. Chang expressed his view, “I would recommend engaging surgical consultation earlier rather than later. Patients will need to be very closely monitored to ensure that a more significant complication has not occurred.”

He further explained (perhaps mindful that many gastroenterology divisions do not have inpatient services), “The closure may be attempted and may appear to be technically successful, but the patient could have a clinical deterioration. You cannot do this [repair] and then forget about the patient. This is clearly an advanced technique that only appropriately trained endoscopists should attempt. We must remember first, do no harm.”