Perforation Following Colorectal Endoscopy: What Happens Beyond the Endoscopy Suite?

Transcription

1 credits vilble for this rticle see pge 88. Originl RESEARCH & CONTRIBUTIONS Perfortion Following Colorectl Endoscopy: Wht Hppens Beyond the Endoscopy Suite? Michel S Tm, MD; Mher A Abbs, MD, FACS, FASCRS Perm J 2013 Spring;17(2): Abstrct Bckground: The risk fctors for from colorectl endoscopy hve been well studied, but little is known bout clinicl outcomes beyond the immedite event. Objective: To evlute short- nd long-term outcomes of itrogenic colorectl following colorectl endoscopy. Design: Retrospective review over 16 yers t single tertiry cre institution. Min Outcome Mesures: Tretment interventions, morbidity nd mortlity rtes, hospitl length of sty, stom closure rte, nd long-term complictions. Results: Of 132,259 colorectl endoscopies, 26 ptients (0.02%) hd (54% mles; men ge, 67 yers). The rectosigmoid colon ws the most common site of (65%). Thirty-eight percent of the s were recognized t the time of procedure, 31% presented within 24 hours, nd 31% presented beyond 24 hours. Opertive repir ws undertken in 85% of the ptients, nd 15% were mnged with inptient hospitl observtion. Primry repir ws performed in 68% (defunctioning stom in 18%). Men hospitl length of sty ws 10.1 dys. The overll postopertive complictions rte ws 55%, nd wound complictions were noted in 45%. The 30-dy mortlity rte ws 19%. No deth ws observed beyond the first month. Americn Society of Anesthesiologists physicl sttus Clsses 3 nd 4 were ssocited with mortlity (p = 0.004). Of 7 ptients who received stom, only 2 ptients (29%) hd stom reversl. Long-term complictions included incisionl herni (10%) nd smll-bowel obstruction (5%). Conclusions: Perfortion following colorectl endoscopy ws uncommon in this study but ws ssocited with significnt morbidity nd mortlity. An incresed risk of deth ws noted with higher Americn Society of Anesthesiologists physicl sttus clss. Introduction Perfortion is widely recognized s one of the most serious complictions of endoscopy of the lower gstrointestinl trct Colonoscopy remins the gold stndrd for screening of colorectl cncer nd is useful in the workup of mny gstrointestinl conditions. The risk of rnges from 0.027% to 0.088% for flexible sigmoidoscopy, from 0.016% to 0.2% for dignostic colonoscopy, nd up to 5% for therpeutic endoscopy. 1,11 As the volume of both dignostic nd therpeutic endoscopic procedures increses, the bsolute number of s will undoubtedly increse even with reltively constnt rte. 12 The risk fctors contributing to re well estblished in the literture. They include ptient-relted fctors such s dvnced ge, femle sex, diverticulr disese, previous bdominl surgery, nd colonic stricture in ddition to therpeutic procedures such s endoscopic resection nd diltion. 1-4,11 Tretment options for endoscopic include conservtive mesures such s bowel rest with brod-spectrum ntibiotic therpy nd opertive interventions such s primry surgicl repir with or without diversion, segmentl colectomy with primry nstomosis, or resection with Hrtmnn pouch. Despite severl published reports on the vrious vilble surgicl nd mngement options, little is known regrding the clinicl outcomes of ptients who sustin during or following colorectl endoscopy The im of this study ws to review the short- nd long-term outcomes of such ptients. Methods Ptients The study ws pproved by the institutionl review bord of Kiser Permnente (KP) Southern Cliforni. A retrospective review ws conducted of ll ptients who sustined during or following colorectl endoscopy over nerly 16-yer period from Jnury 1995 to October All procedures were performed by group of gstroenterologists nd colorectl surgeon t the KP Los Angeles Medicl Center, regionl tertiry cre institution in Southern Cliforni tht serves popultion of pproximtely 3.4 million ptients. All elective ptients prepred with polyethylene glycol-electrolyte solution the dy before their procedure. The cohort of ptients with ws identified by reviewing the endoscopy suite dtbse in ddition to the morbidity nd mortlity registry of the Deprtments of Surgery nd Gstroenterology. Individul ptient dt were bstrcted using both the outptient nd inptient records. Dt nlyzed included demogrphics, Americn Society of Anesthesiologists (ASA) physicl sttus clss, medicl comorbidities, indiction for the procedure, loction of the, the cuse ttributed to the, nd when the ws recognized. Michel S Tm, MD, is Surgeon t the Los Angeles Medicl Center in CA. E-mil: michel.s.tm@kp.org. Mher A Abbs, MD, FACS, FASCRS, is n Associte Professor of Surgery t the University of Cliforni Los Angeles, Chir of the Center for Minimlly Invsive nd Robotic Surgery for Kiser Permnente Los Angeles, Regionl Chief of Colorectl Surgery for the Southern Cliforni Permnente Medicl Group, nd Director of the Permnente Ntionl Center of Excellence for Colon nd Rectl Surgery. E-mil: mher..bbs@kp.org. The Permnente Journl/ Spring 2013/ Volume 17 No. 2 17

2 Originl RESEARCH & CONTRIBUTIONS Perfortion Following Colorectl Endoscopy: Wht Hppens Beyond the Endoscopy Suite? Outcome mesures included type of tretment interventions, length of hospitl sty, nd short-term (within 30 dys) nd long-term postopertive morbidity nd mortlity rte. Sttisticl Anlysis To nlyze the significnce of ssocition between ptients relted vribles nd mortlity s well s between disese nd tretment fctors nd mortlity, 2-tiled p vlues were clculted using Fisher exct test. P < 0.05 ws the criterion for sttisticl significnce. All sttisticl nlyses were performed using sttisticl nlysis softwre (SPSS version 16.0, SPSS Inc, Chicgo, IL). Results A totl of 132,259 colorectl endoscopies (86,101 colonoscopies nd 46,158 flexible sigmoidoscopies) were performed during the study period. Twenty-six ptients (0.02%) with were identified. Only 1 of the 26 s ws secondry to flexible sigmoidoscopy, nd the reminder of the s were becuse of colonoscopies. Tble 1 outlines the chrcteristics of the ptients. There were 14 mle ptients (54%) nd 12 femle ptients (46%). Men ge ws 67 yers (medin, 70 yers; rnge, 4 to 91 yers). Of the ptients, 46% were ASA Clss 2 nd 39% were ASA Clss 3 or 4. The most common indictions for the procedure were screening (42%) nd bleeding (31%). Tble 2 summrizes the chrcteristics of the s. Most of the s (65%) involved the sigmoid nd rectosigmoid res. Vrious cuses were ttributed to the s, including tortuosity of the colon (27%), diverticulosis (23%), nd polypectomy or biopsy (23%). The ws dignosed t the time of the procedure in 38% of the ptients, within 24 hours in 31% of the ptients, nd beyond 24 hours in the remining 31%. Tble 3 highlights the mngement of the perforted ptients. Most ptients (85%) underwent opertive intervention. Primry repir ws performed in 68% of the opertive cses. Seven ptients (32%) received stom. Five ptients (23%) were initilly pproched lproscopiclly, nd 2 ptients were converted to n open procedure. The men hospitl length of sty ws 10.1 dys (medin, 6 dys; rnge, 1 to 60 dys; Tble 4). Nine ptients (35%) required cre in the intensive cre unit during their hospitliztion, with men sty in intensive cre of 8.2 dys (medin, 5 dys; rnge, 1 to 22 dys). The rte of postopertive complictions ws 55%, nd they were often wound relted (45%). In ll 22 ptients who underwent n opertion, the wounds were closed primrily t the time of the opertion. The redmission rte ws 14%. The 30-dy mortlity ws 19%. An ASA clss of 3 or 4 nd history of hert disese were significntly ssocited with n incresed risk of 30-dy mortlity (p = nd p = 0.010, respectively; Tble 5). All deths occurred in ptients ge 65 yers or older (p = 0.281). None of the 4 ptients mnged nonopertively died. Among the nonopertive group, 2 of these ptients hd their s discovered t the time of the endoscopy nd the other 2 s were dignosed beyond 24 hours. During men follow-up of 79 months (medin, 63 months; rnge, 0 to 192 months), 4 of the 21 live ptients (19%) developed long-term complictions, which included ventrl herni (10%), smll-bowel obstruction (5%), nd bleeding of the lower gstrointestinl trct (5%) (see Tble 4). No mortlity ws observed beyond 30 dys. Of the 7 ptients who received stom t the time of opertive intervention, only 2 ptients (29%) hd stom reversl. Tble 1. Chrcteristics of 26 ptients with fter colorectl endoscopy Chrcteristic No. (%) Comorbidities Hypertension 14 (54) Hert disese 7 (27) Dibetes 5 (19) Renl disese 4 (15) Lung disese 4 (15) ASA clss Clss 1 4 (15) Clss 2 12 (46) Clss 3 8 (31) Clss 4 2 (8) Indiction for endoscopy Screening 11 (42) Bleeding 8 (31) Anemi 2 (8) Stenting of lrge bowl obstruction 2 (8) Other 3 (12) Some ptients hd more thn 1 comorbidity. ASA = Americn Society of Anesthesiologists. Tble 2. Chrcteristics of the 26 s Chrcteristic No. (%) Loction Sigmoid/rectosigmoid colon 17 (65) Descending colon 4 (15) Ascending colon 2 (8) Rectum 1 (4) Trnsverse colon 1 (4) Cecum 1 (4) Cuse Tortuosity 7 (27) Diverticulosis 6 (23) Polypectomy/biopsy 6 (23) Stent deployment b 2 (8) Retroflexion 1 (4) Unknown 8 (31) Recognition of During the procedure 10 (38) < 24 hours 8 (31) 24 hours 8 (31) Numbers do not totl to 26 becuse some ptients hd more thn 1 contributing cuse. b The cuse of obstruction requiring stent plcement for both cses ws mlignncy. 18 The Permnente Journl/ Spring 2013/ Volume 17 No. 2

3 Perfortion Following Colorectl Endoscopy: Wht Hppens Beyond the Endoscopy Suite? Originl RESEARCH & CONTRIBUTIONS Tble 3. Mngement of 26 ptients with colorectl Type of repir No. (%) Opertive repir 22 (85) Primry repir, no diversion 11 (50) Primry repir, proximl diversion 4 (18) Resection, primry nstomosis 4 (18) Resection, Hrtmnn pouch 3 (14) Nonopertive repir 4 (15) Bowel rest, brod-spectrum ntibiotics 4 (100) Endoscopic clipping 1 (25) Performed during the index endoscopy fter immedite recognition of. Tble 4. Outcome of 26 ptients with Outcome No. (%) Postopertive complictions 12/22 (55) Wound-relted 10 (45) Surgicl-site infection 8 (36) Serom or dehiscence 2 (9) Postopertive ileus 5 (23) Cerebrovsculr ccident 2 (9) Myocrdil infrction/congestive 2 (9) hert filure Respirtory filure 1 (5) Cogulopthy/bleeding 1 (5) Redmission rte 3/22 (14) 30-dy mortlity 5/26 (19) b Long-term complictions 4/21 (19) Incisionl ventrl herni 2 (10) Smll-bowel obstruction 1 (5) Anstomotic bleeding 1 (5) Some ptients hd more thn 1 compliction. b No mortlity ws noted beyond 30 dys. Discussion The incidence of ws very low, nd most cses involved the sigmoid nd rectosigmoid res of the colon. All s were dignosed by history nd physicl exmintion findings in conjunction with rdiogrphic evidence of free ir or by direct endoscopic visuliztion during the index endoscopic procedure. Most ptients presented with the fter leving the endoscopy suite, nd they were commonly mnged surgiclly t the discretion of the treting surgeon. A primry repir ws fesible in most ptients. Those who were treted nonopertively did not require n eventul opertion, lthough one required percutneous drin for n bscess. The time to recognition of the did not ffect mortlity, nor did it singlehndedly dictte the mngement of the ptient. The morbidity nd mortlity following were significnt, nd higher ASA clss ws ssocited with n incresed risk of deth within 30 dys of the event. All ptients who died were elderly (65 yers or older) nd succumbed to either crdiopulmonry or cerebrovsculr event. Wound-relted complictions were common postopertively. There were severl limittions to this study. Despite lrge volume of endoscopic procedures during the 16-yer period, the number of ptients who sustined ws reltively smll. This smll smple size might hve ffected the findings. Furthermore, the study ws retrospective in nture, nd diverse group of surgeons contributed to the mngement of the ptients. No stndrd lgorithm hd been estblished to guide the decision mking of when to mnge nonopertively vs opertively nd wht type of opertion to perform. Indeed, the mngement of ech ptient ws left to the discretion of the individul surgeon. Furthermore, the setting of this study ws tertiry cre institution with lrge popultion of elderly ptients with substntil crdiopulmonry disese, which might hve skewed the morbidity nd mortlity findings. Despite the cknowledged shortcomings, this study provided vluble dt on the entire spectrum of cre nd described the outcomes of ptients beyond the endoscopy suite. Most of the existing literture on endoscopic describes the incidence, mechnism, nd loction of the 1-7,9,11 or focuses on the vrious tretment options, including new evolving techniques such s endoscopic clipping or lproscopic repir. 10,13-18,20 There is pucity of dt on the outcome of ptients who sustin during colorectl endoscopy nd on fctors tht hve n impct on morbidity nd mortlity. 8,12,19 Some of the findings of the current study confirmed the observtions of prior studies. We documented 0.02% rte, which is within the previously reported rnge of 0.005% nd 1.2% in most studies. 1,11 Therpeutic endoscopy hs been ssocited with higher incidence of, rnging from 0.06% to 5%. 1,2,4,6,9,11 The most common site of in the present study ws the rectosigmoid nd sigmoid colon, which is consistent with other published studies. 1-3,6,12,20 The reltive mobility, ngultion, nd tortuosity of this portion of the lrge bowel, disese processes such s diverticulosis, nd older ge hve been implicted s contributing fctors to the development of. 1,2 Most ptients in our study underwent opertive intervention, nd nonopertive mngement ws selectively used in few ptients. Surgicl mngement hs been dvocted for most ptients with colorectl, nd more recently the lproscopic pproch hs been introduced s n lterntive to the open pproch to minimize the postopertive morbidity. 12,14-16 In our study, the number of ptients who were pproched lproscopiclly ws smll nd none died, but we cnnot drw ny conclusion becuse of the limited number. However, two recent studies hve reported shorter hospitliztion nd fewer complictions in ptients treted lproscopiclly compred with ptients mnged with n open pproch. 15,16 We suspect tht lproscopy will ply n incresing role in the mngement of this condition in the future. Severl recent studies hve reported on nonopertive mngement. 10,17-20 Depending on the time of recognition of Therpeutic endoscopy hs been ssocited with higher incidence of Most ptients presented with the fter leving the endoscopy suite The Permnente Journl/ Spring 2013/ Volume 17 No. 2 19

4 Originl RESEARCH & CONTRIBUTIONS Perfortion Following Colorectl Endoscopy: Wht Hppens Beyond the Endoscopy Suite? the, endoscopic clipping, bowel rest, nd brodspectrum ntibiotics re vible lterntive in select group of ptients. In our study, 15% of the ptients were successfully treted nonopertively, with no morbidity or mortlity. Smll s tht re recognized t time of the procedure cn be mnged with endoscopic clip closure Jovnovic nd collegues 18 ttempted endoscopic clip closure in 6 of 12 s over 6.5-yer period. 18 A successful outcome ws noted in ptients with defect less thn 10 mm, nd the only observed filure ws in ptient with 20-mm defect. Ptients who undergo endoscopic closure need close observtion. Cho nd collegues 19 closed 29 s with endoscopic clipping. Seven ptients required dditionl surgicl intervention, nd in 3 ptients n intr-bdominl bscess developed. Ptients who present with delyed loclized cn be cndidtes for conservtive mngement with bowel rest nd ntimicrobil therpy. 1,2,10,13 In our study, 32% of the ptients who underwent surgicl intervention hd fecl diversion. This is similr to the Myo Clinic study, which reported stom formtion rte of 38%. 12 Most stoms in our study were never closed becuse of either ptient s deth or mjor medicl comorbidities tht precluded ny dditionl elective surgery. A significnt rte of morbidity nd mortlity ws noted in our study. The Myo Clinic study reported postopertive compliction rte of 36% nd 7% mortlity rte. Teoh nd collegues 8 reviewed 37,971 colonoscopies over n 8-yer period nd reported 43 s Tble 5. Predictors of mortlity in 26 ptients with colorectl Number Vrible Ctegory of ptients Mortlity p vlue Age < 65 yers yers 18 5 Sex Mle Femle 12 1 Comorbidities Hypertension None 12 1 Hert disese None 19 1 Dibetes None 21 2 ASA clss Clss 1 or Clss 3 or Intervention Opertive Nonopertive 4 0 Type of opertion Primry repir Resection 7 3 Cuse of Recognition of Boldfce vlues indicte sttisticlly significnt. ASA = Americn Society of Anesthesiologists Biopsy/stent Nontherpeutic 18 4 Procedure < 24 hours hours 8 2 with n overll morbidity nd mortlity rte of 48.7% nd 5.6%, respectively. Their study found tht n ASA Clss 3 or higher nd ntipltelet therpy were independent predictors of mortlity. We documented similr finding in ptients with ASA Clss 3 or higher. Conclusions The risk of during or following colorectl endoscopy ws low in this study. However, the morbidity nd mortlity ssocited with such events were significnt. A higher ASA clss ws ssocited with n incresed risk of mortlity. Although most cses in this study underwent surgicl intervention, endoscopic nd medicl mngement my ply n incresing future role in the mngement of ptients with colorectl. Although we nticipte tht such interventions my led to less morbidity nd mortlity, further reserch is needed to delinete stndrd lgorithm of cre nd to identify ptients who re suitble for nonopertive mngement. v Disclosure sttement This mnuscript ws presented t the Americn Society of Colon nd Rectl Surgeons 2012 Annul Scientific Meeting in Sn Antonio, Texs, June 2-6, The uthor(s) hve no conflicts of interest to disclose. Acknowledgment Kthleen Louden, ELS, of Louden Helth Communictions provided editoril ssistnce. References 1. Lohsiriwt V. Colonoscopic : incidence, risk fctors, mngement nd outcome. World J Gstroenterol 2010 Jn 28;16(4): DOI: dx.doi.org/ /wjg.v16.i Tiwri A, Melegros L. Colonoscopic. Br J Hosp Med (Lond) 2007 Aug;68(8): Anderson ML, Psh TM, Leighton JA. Endoscopic of the colon: lessons from 10-yer study. Am J Gstroenterol 2000 Dec;95(12): DOI: 4. Levin TR, Zho W, Conell C, et l. Complictions of colonoscopy in n integrted helth cre delivery system. Ann Intern Med 2006 Dec 19;145(12): Aror G, Mnnlithr A, Singh G, Gerson LB, Tridfilopoulos G. Risk of from colonoscopy in dults: lrge popultion-bsed study. Gstrointest Endosc 2009 Mr;69(3 Pt 2): DOI: org/ /j.gie Pnteris V, Hringsm J, Kuipers EJ. Colonoscopy rte, mechnisms nd outcome: from dignostic to therpeutic colonoscopy. Endoscopy 2009 Nov;41(11): DOI: 7. Lüning TH, Keemers-Gels ME, Brendregt WB, Tn AC, Rosmn C. Colonoscopic s: review of 30,366 ptients. Surg Endosc 2007 Jun;21(6): DOI: 8. Teoh AY, Poon CM, Lee JF, et l. Outcomes nd predictors of mortlity nd stom formtion in surgicl mngement of colonoscopic s: multicenter review. Arch Surg 2009 Jn;144(1):9-13. DOI: org/ /rchsurg Sry T, Ikemtsu H, Fu KI, et l. Evlution of complictions relted to therpeutic colonoscopy using the bipolr snre. Surg Endosc 2012 Feb;26(2): DOI: Avgerinos DV, Llgun OH, Lo AY, Leitmn IM. Evolving mngement of colonoscopic s. J Gstrointest Surg 2008 Oct;12(10): DOI: Ko K, Gip AQ, Abbs MA. Endoscopic excision of lrge colorectl polyps s vible lterntive to surgicl resection. Arch Surg 2011 Jum;146(6): DOI: 20 The Permnente Journl/ Spring 2013/ Volume 17 No. 2

5 Perfortion Following Colorectl Endoscopy: Wht Hppens Beyond the Endoscopy Suite? Originl RESEARCH & CONTRIBUTIONS 12. Iqbl CW, Cullinne DC, Schiller HJ, Swyer MD, Zietlow SP, Frley DR. Surgicl mngement nd outcomes of 165 colonoscopic s from single institution. Arch Surg 2008 Jul;143(7): DOI: org/ /rchsurg Frley DR, Bnnon MP, Zietlow SP, Pemberton JH, Ilstrup DM, Lrson DR. Mngement of colonoscopic s. Myo Clin Proc 1997 Aug;72(8): DOI: Hnsen AJ, Tessier DJ, Anderson ML, Schlinkert RT. Lproscopic repir of colonoscopic s: indictions nd guidelines. J Gstrointest Surg 2007 My;11(5): DOI: Rotholtz NA, Lporte M, Lencins S, Bun M, Cnels A, Mezzdri N. Lproscopic pproch to colonic due to colonoscopy. World J Surg 2010 Aug;34(8): DOI: Coimbr C, Bouffioux L, Kohnen L, et l. Lproscopic repir of colonoscopic : new stndrd? Surg Endosc 2011 My;25(5): DOI: Trecc A, Gj F, Gglirdi G. Our experience with endoscopic repir of lrge colonoscopic s nd review of the literture. Tech Coloproctol 2008 Dec;12(4): DOI: Jovnovic I, Zimmermnn L, Fry LC, Mönkemüller K. Fesibility of endoscopic closure of n itrogenic colon occurring during colonoscopy. Gstrointest Endosc 2011 Mr;73(3): DOI: org/ /j.gie Cho SB, Lee WS, Joo YE, et l. Therpeutic options for itrogenic colon : fesibility of endoscopic clip closure nd predictors of the need for erly surgery. Surg Endosc 2012 Feb;26(2): DOI: org/ /s y 20. Won DY, Lee IK, Lee YS, et l. The indictions for nonsurgicl mngement in ptients with colorectl fter colonoscopy. Am Surg 2012 My;78(5): The Belly nd The Members The members of the Body rebelled ginst the Belly, nd sid, Why should we be perpetully engged in dministering to your wnts, while you do nothing but tke your rest, nd enjoy yourself in luxury nd self-indulgence? The members crried out their resolve, nd refused their ssistnce to the Belly. The whole Body quickly becme debilitted, nd the hnds, feet, mouth, nd eyes, when too lte, repented of their folly. Fbles, Aesop, c BC, fbulist nd story teller The Permnente Journl/ Spring 2013/ Volume 17 No. 2 21