Iatrogenic Perforation at Therapeutic Colonoscopy: Should the Endoscopist Attempt Closure Using Endoclips or Transfer Immediately to Surgery?

We read the important article by Heldwein et al. [1] with interest. This prospective study confirms that more than 90 % of complications encountered in colonoscopic polypectomy, including perforation, can be managed conservatively if adequate endoscopic expertise is available. Perforation is the most serious complication during endoscopic treatment, and requires rapid and appropriate management. In this study, there were 26 cases of perforation among which nonsurgical management succeeded in 12 cases, five with endoscopic clipping and seven with conservative treatment only.

Regarding perforation in the lower gastrointestinal tract, it is still controversial as to whether endoscopic clipping is the treatment of first choice. However, some reports have questioned the efficiency of clipping in patients with perforation in the lower gastrointestinal tract [2] [3]. On the other hand, Raju et al. reported that endoscopic closure with clips of small iatrogenic colon perforations, in a porcine model, results in mucosal and submucosal healing and prevents fecal soiling of the peritoneal cavity [4].

Recently, we have retrospectively reviewed the patients referred to National Cancer Centers in Japan who had perforation of the colorectum due to endoscopic treatment. We had observed 16 cases of immediate perforation with small defects (less than 10 mm) during endoscopic submucosal dissection (ESD) or endoscopic mucosal resection (EMR). In 13 of these cases, we tried closure using rotatable clips, and this was successful in nine of the 13 cases (69 %). All these cases with successful closure were managed conservatively. However, five of the remaining seven cases (71 %), with unsuccessful closure or no apposition, required surgical management. From these experiences, we believe that endoscopic clipping for perforations during therapeutic colonoscopy is a useful and an essential procedure if possible.

To facilitate these procedures, colonoscopists should focus on: (i) adequate washing of the area around the lesion, and adequate aspiration of fecal fluid at the time of resection; and (ii) changing the patient’s position so that the resected lesion is placed as high as possible, to minimize leakage due to gravity. Even when perforation has developed, such methods can easily prevent further intestinal leakage of fecal fluid and allow rapid clipping.

From our experience, the indications for endoscopic clipping for perforations are as follows: (i) the size of the defect is small (less than 10 mm); (ii) the bowel can be prepared adequately; and (iii) the patient’s condition is remaining stable after immediate perforation. However, these will need to be confirmed by prospective studies.

Competing interests: None

References

• 1 Heldwein W, Dollhopf M, Rosch T. et al . The Munich Polypectomy Study (MUPS): prospective analysis of complications and risk factors in 4000 colonic snare polypectomies.  Endoscopy.. 2005;  37 1116-1122
• 2 Mana F, De Vogelaere K, Urban D. Iatrogenic perforation of the colon during diagnostic colonoscopy: endoscopic treatment with clips.  Gastrointest Endosc. 2001;  54 258-259
• 3 YoshikaneH , Hidano H, Sakakibara A. et al . Endoscopic repair by clipping of iatrogenic colonic perforation.  Gastrointest Endosc. 1997;  46 464-466
• 4 Raju G S, Pham B, Xiao S Y. et al . A pilot study of endoscopic closure of colonic perforations with endoclips in a swine model.  Gastrointest Endosc. 2005;  62 791-795