Article pp.189-194 du Vol.6 n°2 (1976)

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V o u s a v e z p u I i r e

I I

R~SUMIP.S SI~LECTIONN~S

Complications of colonoscopy and polypectomy

Report of the Southern California Society for Gastrointestinal Endoscopy

G. B E R C I , M . D . , J.F. P A N I S H , M . D . , M. S C H A P I R O , M.D., a n d R. C O R L I N , M . D . Departments oJ Gastroenterology and Endoscopy, Cedars-Sinai Medical Center,

U C L A Medical Center and Wadsworth Veterans Administration Hospital, Los Angeles, Cali]ornia

Gastroentorology, 1974, 67, 5 8 4 - 5 8 5

T h e S o u t h e r n C a l i f o r n i a Society for G a s t r o - i n t e s t i n a l E n d o s c o p y , b y m e a n s of a q u e s t i o n - n a i r e sent to its m e m b r e s , has r e p o r t e d o n the c o m p l i c a t i o n s e n c o u n t e r e d in a total of 3 850 c o l o n o s c o p i e s a n d 901 p o l y p e c t o m i e s . T h e i n c i d e n c e of p e r f o r a t i o n a n d b l e e d i n g in this series is d e t e r m i n e d a n d c o m p a r e d to those available in the c u r r e n t literature. T h e m o r b i - dity a n d m o r t a l i t y of c o l o n o s c o p i c polypec- t o m y is c o m p a r e d to p o l y p e c t o m y p e r f o r m e d b y surgery.

TABLE 1. - - BLEEDING

Colonoscopies . . . Polypectomies . . . Bleeding . . .

Immediate . . . Delayed . . . Mortality . . .

3 850 901

"FABLE 2. - - PERFORATION

Colonoscopies . . . Polypectomies . . . Perforations . . .

Diagnosed immediately . . . Diagnosed late . . . Related to manipulation . . . Related to coagulation . . . Mortality . . .

3 850 901 10 7 3 7 3 1

TABLE 3

SUMMARY OF RECENT LITERATURE ON COMPLICATIONS OF COLONOSCOPY

AND POLYPECTOMY

Author

Wolff and Shinya . . . . Hedberg . . . Schrock . . . S u g a r b a k e r . . . Roseman . . . . Total . . .

Colo- nosco- pies

2 000 300 355 627 3 282 I

Poly-

pecto- Blee- Perfo-

mies ding rations

499 1 1

123 * 2

70 1 0

109 1 2

49 3 5

850 10 10

* One bleeder was due to splenic rupture.

Acta Endoscopica et Radiocinematographica Tome VI - N" 2 - 1976 189

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Les accidents de la coloscopie et de la polypectornie percoloscopique

R. C H A B A N O N (Lyon)

A c t a E n d o s c o p i c a e t R a d i o c i n e m a t o g r a p h i c a , 1975, 5 , 63

Accidents of the coloscopy and coloscopic polypectomy

Le rapport concernant les accidents de la coloscopie et la polypectomie coloscopique repose sur 11 288 examens et fait 6tat de 27 accidents (0,23 %) et de ]0 d6cbs (0,09 %).

Les causes de ces accidents se r6partissent de la fagon suivante :

- - perforations coliques : 23 cas ;

accidents cardio-vasculaires et respiratoires : 3 cas ;

accidents dus au mat6riel : 1 cas.

Tr~s instructive est l'&ude des 23 perforations coliques : 18 fois il s'agit de perforations instrumentales : 17 lois par le coloscope et une fois par la pince h biopsies ; 5 fois, il s'agit de perforations par insufflation.

Le si6ge de la perforation est sigmoi'dien dans 17 observations ; 6 fois la perforation survient sur un colon sain ; 13 fois sur un colon patho- logique (diverticules : 4 cas ; tumeur : 5 cas ; Crohn : 2 cas).

L'attitude th6rapeutique adopt6e vis-a-vis des perforations a 6t6 4 fois m6dicale, 19 lois chi- rurgicale. La gu&ison a pu &re obtenue dans

13 cas, il est d6plor6 10 d6c~s.

De mani6re ~ faire le diagnostic le plus pr6- coc6ment possible, il est envisag6 de pratiquer syst6matiquement apr~s chaque examen coloscopique, un abdomen sans pr6paration de- bout.

Les accidents de la polypectomie coloscopique sont au nombre de 25 pour 740 examens r6alis6s :

20 lois, il s'agit d'h6morragies,

- - 5 lois de perforations.

On ne d6plore aucun d6c~s dans cette s6rie.

Parmi les facteurs expliquant l'h6morragie ou la perforation, on retient essentiellement la grosseur du polype qui est toujours d'un dia- m&re sup6rieur/~ 1,5 cm.

11 288 examinations were performed and there were 27 accidents (0,23 %) and 10 deaths

(O,O9 %).

The causes of these accidents were : colic perforations : 23 cases,

cardio-respiratory accidents : 3 cases, accident due to the material : 1 case.

On 23 colic perforations, 17 were due to the colonoscope, 1 due to the biopsy forceps, 5 due to insufflation. In 17 cases the sigmoid was per- forated. In 6 cases the colon was healthy, in 13 cases it was pathologic (diverticulae 4 cases;

tumour 5 cases; Crohn 2 cases...) in 4 cases the therapy was medical, and in 19 cases it

was surgical. 13 patients were cured, and 10 patients died. To make an early diagnosis of perforation, it is recommended to perform an abdominal X-ray examination after each colonoscopy.

They were 25 accidents of the coloscopic polypectomy on 740 cases :

Hemorrhage : 20,

- - P e r f o r a t i o n : 5.

No death.

For these accidents one should notice that the polyp was always of a diameter superior to 1,5 cm.

190 T o m e V I - N ~ 2 - 1976 Acta Endoscopica et Radiocinematographica

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Major Complications of Coloscopy : Bleeding and Perforation

J.E. GEENEN, M.D., M.G. SCHMITT, Jr., M.D., W.C. Wu, M.D., B.S., and W.J. HOGAN, M.D.

A m . J. Dig. Dis., 1975, 20, 231-235 The overall frequency and types of complica-

tions associated with diagnostic coloscopy and coloscopic polypectomy are unknown. A state- wide survey of coloscopists was conducted to determine the morbidity and mortality associated with coloscopy. Twenty-eight physicians performed a total of 1,106 coloscopic procedures. 9 colonic perforations and 5 episodes of colonic bleeding resulted in a 1.3 % complication rate. Explanations for several of the complications are identified and preventive

measures proposed. 1 patient died of an un- recognized perforation of the sigmoid colon, resulting in a 0,09 % mortality rate. Of 14 complications reported in this series, 12 occurred during the early experience (less than 40 procedures) of the coloscopist. Training pro- grams in coloscopy need to be established in order to reduce the morbidity and mortality associated with a physician's early coloscopic experience.

TABLE 1

COMPLICATIONS IN 1,106 COLOSCOPIC PROCEDURES

Procedure

Diagnostic coloscopy . . . Coloscopic polypectomy ...

To:al . . .

Cases (N)

814 292 1,106

Perforations (N)

7 ( 0 , 9 % )

2 * (0,7 %) 9 (0,8 %)

Surgical intervention for perforation (N)

7

1 8

Bleeding (N)

0

5 (1,7 %) 5 (0,5 %)

Surgical intervention

for bleeding (N)

0

2 2

* Death.

Pneumatic ileal perforation : an unusual complication of colonoscopy

I.A. RAZZAK, M.R.C.P. (Uk), F.A.C.G., J. MILLAN, M.D., and M.M. SCHUSTER, M.D., F.A.C.P.

Gastroenterology Division, Department of Medicine and Pathology Department, Baltimore City Hospital, and The Johns Hopkins University School of Medicine

Gastroenterology, 1976, 70, 268-271 Pneumatic perforation of the bowel is a rare

complication of colonoscopy. Pneumatic ileal perforation complicating this procedure has not been reported. We describe a case of pneumatic ileal perforation during colonoscopy in an elder- ly lady who also had adhesions from previous abdominal surgery. A relative lack of sympto- matology, the finding of a clean ileal perforation at surgery, and a benign postoperative period characterized her course. Possible etio- logical factors are discussed with reference to

the literature dealing with intraluminal pressures in the bowel. Pressure much higher than the physiological pressure is likely to be reached during colonoscopy, with reflux of air across the ileocecal sphincter acting as a safety me- chanism. Bursting pressures differ for different layers of the bowel and from segment to segment.

This report calls attention to certain risk factors which might lead to a remote perforation during colonoscopy.

Acta Endoscopica et Radiocinematographica Tome VI - N ~ 2 - 1976 191

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Colonoscopy A Review

B . F . O V E R H O L T , M . D .

S e c t i o n o f G a s t r o e n t e r o l o g y , Saint M a r y ' s M e m o r i a l Hospital, K n o x v i l l e , T e n n e s s e e G a s t r o e n t e r o l o g y , 1 9 7 5 , 68, 1 3 0 8 - 1 3 2 0

T h e t e c h n i q u e of c o l o n o s c o p y h a s i n t r o - d u c e d a n e x c i t i n g n e w m o d a l i t y f o r t h e d i a g n o - sis a n d t r e a t m e n t o f d i s e a s e s o f t h e c o l o n . It is n o t a p a n a c e a , f o r , as w i t h a n y t e c h n i q u e , l i m i t a t i o n s a r e a l w a y s p r e s e n t ; b u t it o f f e r s t h e

s i n g l e m o s t f a r r e a c h i n g a d v a n c e f o r t h e d i a g - n o s i s a n d t r e a t m e n t of d i s e a s e s o f t h e colo~1 t h a t h a s b e e n o f f e r e d in t h e last d e c a d e . T h e n e x t 10 y e a r s s h o u l d i n d e e d p r o v e e x c i t i n g .

TABLE 3

C O M P L I C A T I O N S OF P O L Y P E C T O M Y

Author

Berci . . . Deyhle . . . Richter . . . Friend . . . Geenen (survey) . . . Goldstein . . . Grieve . . . Spencer . . . Sugarbarker . . . Williams . . . Shinya . . . Hedberg/Welch . . . Schrock/Dunphy . . . Overholt * . . . . Waye . . .

T o t ~ . . . Incidence . . .

Polyps

91 200 (7)

73 200 (7) 292

20 22 158 lO9 175 1 903 123 70 lOO 257

3 793

Bleeding

2 0

0 0

1 0

2 0

5 2

0 0

1 0

4 1

1 2

4 0

3 1 (?)

4 2

1 0

0 1

7 0

35 9

0,9 % 0,23 %

Performation Laparotomy

required

12 0 , 3 1 %

Death

0 0 0 0 1 0 0 0 0 0 0 0 0 0 0

1

< 0,03 %

* B.F. Overholt, R.L. Hargrove, and R.K. Farris, unpublished data.

192 Tome VI - N ~ 2 - 1976 Acta Endoscopica et Radiocinematographica

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Diagnostic colonoscopy

An assessment of the clinical indications

M.G. SCHMITT, Jr., M.D., W.C. Wu, M.B., J.E. GEENEN, M.D., and W.J. HOGAN, M.D.

Division of Medicine and Department of Gastroenterology, Medical College of Wisconsin, Milwaukee, Wisconsin

Gastroentorology, 1975, 69, 765-769

Fiberoptic endoscopy of the colon has been proposed for a variety of clinical situations. We have critically analyzed our experience with 276 consecutive diagnostic colonoscopic examinations to determine in which specific clinical situations colonoscopy was beneficial in the diagnosis or management of patients with colon diseases. Colonoscopy is indicated in patients

with (1) abnormalities on barium X-ray, (2) chronic gastrointestinal bleeding, (3) barium X-ray abnormalities which appear following colonic surgery and, (4) select patients with chronic inflammatory bowel disease. The value of colonoscopy in other proposed clinical situations remains to be docume'ated.

Colonoscopy in the Irritable Bowel Syndrome

A.E. STEVENS Gut, 1973, 14, 432

Thirty patients with irritable bowel syndrome were investigated by fibre-colonoscopy, rigid sigmoidoscopy, and barium studies to exclude organic disease. Barium enema was normal in 13 cases, and showed spasm in 17. Following routine preparation a long Olympus colonoscope was introduced under diazepam seda- tion with Entonox if required, until either undue complaint of pain or failure to advance readily occurred. In 21 cases the examination was terminated because of pain or spasm, in five by difficulty with a sharp bend, and in three by inadequate preparation. In all but six cases more than 40 cm was reached, in 14 cases more than 70 cm. in two cases more than 130 cm, and in one ?atient the region of the caecum. The only organic finding was single small polyps in each of three patients. Multiple

spastic areas were observed from the upper rectum to as high as 80 cm. Experience showed that the only way to negotiate these was to wait patiently for them to relax when the lumen would suddenly appear ahead. Complaints of pain often seemed to be disproportionate or even histrionic as the instrument was advancing readily. In a subsequent postal enquiry to which 23 patients replied, 22 % said the examination was not unpleasant, and 65 % said it was unpleasant but bearable; as compared with 37 patients with other conditions, 49 % of whom found the examination not unpleasant and 46 % unpleasant but bearable. An important part of the management of irritable bowel syndrome is to demonstrate to all that organic disease has been excluded.

Acre Endoscopica et Radiocinematographica Tome VI - N ~ 2 - 1976 193

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The radiological demonstraction of colorectal polyps undetected by endoscopy

I. LAUFER, M.D., N.C.W. SMITH, M.B., and J.E. MULLENS, M.D.

Departments o] Radiology and Surgery, McMaster University Medical Centre, Hamilton, Ontario, Canada

Gastroenterology, 1976, 70, 167-170

In a consecutive series of 800 routine double contrast studies of the colon, 119 polyps were diagnosed radiologically in 78 patients. Follow- up studies were available in 46 patients with 72 polyps. Ultimately, 56 of these polyps were confirmed (55 by endoscopy and 1 by repeat radiology). Six of these polyps had been missed on the initial endoscopic examination. The missed polyps are usually located in the rectum behind a valve of Houston or in any area of the colon where there is sharp angulation. Radio- logists and endoscopists should be aware of these as potential endoscopic blind spots. These cases illustrate the importance of high quality

radiological study of the colon and the comple- mentary nature of radiology and endoscopy in the detection of colorectal polyps.

TABLE I. - - C O L O N I C POLYPS D I A G N O S E D R A D I O L O G I C A L L Y

WITH N E G A T I V E E N D O S C O P Y

Repeat endoscopy . . . polyp 5 Repeat radiology . . . polyp l Repeat radiology . . . no polyp 6

No further investigation 4

Total ! 6

Figure 1 ;

Diagramatic representation of the sites of the polyps which were missed on the initial endoscopic examination. Note that most of the polyps are located behind a fold at an area of sharp angulation of the colon. These are potential endoscopic blind spots.

194 T o m e V I - N ~ 2 - 1 9 7 6 A c t a E n d o s c o p i c a e t R a d i o c i n e m a t o g r a p h i c a