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Endoluminal Repair of Iatrogenic Colonic Perforation

      Abstract

      Colonic perforation is a serious accidental complication that occurs with polypectomy of colorectal polyps. In selected cases, endoluminal repair of colonic perforations with clips and further conservative treatment provides a tool that avoids the major additional trauma associated with laparotomy. This case illustrates the closure of a postpolypectomy perforation in the transverse colon with metal clips. This article is part of an expert video encyclopedia.

      Keywords

      Video Related to this Article

      Technique

      Colonoscopy.

      Materials

      • Endoscope: EC530WI; Fujifilm, Tokyo, Japan.
      • Metal clips: Resolution™ clip device, Boston Scientific Corporation, Natick, MA, USA.

      Background and Endoscopic Procedure

      At resection of colorectal polyps, perforation occurs in 00.5–2.0% of cases, depending on the size and location of the polyp.
      • Loffeld R.J.
      • Engel A.
      • Dekkers P.E.
      Incidence and Causes of Colonic Perforations: A Single-Center Case Series.
      There are two major mechanisms for perforation: (1) immediate perforation due to mechanical slicing across the wall; and (2) perforation due to thermal necrosis of the wall that leads to ‘delayed’ perforation within a few hours after polypectomy.
      Immediate perforation during the procedure may be witnessed by the endoscopist and offers the option for endoscopic management. Successful endoscopic management critically depends on the visualization of the perforation and the location and size of the wall defect.
      In the present case, a 25 mm flat lesion on top of a haustral fold was resected en bloc with a snare. Immediately after the cut, a perforation with a defect extending through the muscle layer was identified. The different layers of the colonic wall can be seen and at the bottom of the perforation, the visceral serosa and peritoneal fat are identified. However, there is no visible access to the peritoneal cavity and the lesion might still be covered by some visceral serosa. In this case, there are excellent options for endoluminal repair by endoscopic closure using metal clips. In most cases, it is advisable not to start clip application in the middle of the hole, but to start on one site and then place one metal clip next to the other to adapt the edges of the perforation and finally close the hole.
      During the procedure, the patient reported no pain and there was no presence of free air after colonoscopy. The patient was treated with intravenous fluids, nothing by mouth, and prophylactic antibiotics for 2 days. No signs of acute inflammation occurred and the patient was discharged 2 days after the procedure.
      Endoscopic management in this case was sucessful. However, if patients with iatrogenic perforations develop signs of peritoneal contamination or abdominal sepsis, endoluminal clipping is not enough and surgical therapy must be considered.

      Key Learning Points/Tips and Tricks

      • The most important issue is to prevent perforations. In the present case, it is likely that due to the location of the lesion, the snare engaged a piece of the haustral fold and then just sliced through the wall. The complication might have been prevented by piecemeal resection.
      • In case a perforation occurs, it might be helpful to apply carbon dioxide instead of air during endoscopic management, because carbon dioxide is easily absorbed in the peritoneal cavity.

      Scripted Voiceover

      This is a perforation after en bloc polypectomy of a 25 mm flat lesion that extended over a haustral fold. We see the defect within the muscle layer and look directly down to the visceral serosa and peritoneal fat. In this case we have excellent options for endoluminal repair with metal clips.
      When closing a perforation in most cases it is advisable not to start clipping the center of the perforation but to start on one site and then place one metal clip next to the other to adapt the edges of the perforation and finally close the hole.

      Reference

        • Loffeld R.J.
        • Engel A.
        • Dekkers P.E.
        Incidence and Causes of Colonic Perforations: A Single-Center Case Series.
        Endoscopy. 2011; 43: 240-242