Serious Complication Of Colonoscopy Research Articles

Clinical characteristics and outcome of iatrogenic colonic perforation related to diagnostic vs. therapeutic colonoscopy

AimIatrogenic colonic perforation (ICP) is a rare serious complication of colonoscopy, where standard treatment is controversial. This study aimed to characterize diagnostic ICP (DICP) compared to therapeutic ICP (TICP) and determine the possible indication of endoscopic repair.MethodsWe studied patients with ICP over 7 years starting in 2011. Their demographics and data regarding perforation, treatment, and outcome were investigated by retrospective review of medical records, and the diagnostic and therapeutic groups were compared.ResultsAmong 29,882 patients who underwent colonoscopy, ICP was identified in 28 (0.09%: diagnostic, 15/24,758, 0.06%; therapeutic, 13/5124, 0.25%). A total of 56 patients (33 DICP and 23 TICP) including 28 referred cases were analyzed. Mean age was 62.3 ± 11.4 years, and 24 were men. Perforations occurred mostly in the rectosigmoid region and half were detected during or immediately after colonoscopy. Endoscopic treatment was successful in 22 cases and 34 required surgery. Mortality occurred in 4 (7.1%).Compared to TICP, DICP was more prevalent in females and rectosigmoid region and more frequently detected immediately (all p < 0.05); DICP tended to occur in older patients, be larger and have better chance of endoscopic repair.Regardless of type of ICP, female predominance, smaller perforation, more frequent immediate detection, and shorter hospital stay (all p = 0.01) were found in the endoscopic repair group.ConclusionDICP was more frequent in the rectosigmoid area in older women and could be detected immediately. Immediate detection and small perforation size could be important factors for endoscopic repair. Careful attention and gentle manipulation should be required.

Risk factors for post-polypectomy bleeding; a retrospective case-control study of a high-volume colonoscopy center.

Post-polypectomy bleeding (PPB) remains an uncommon although serious complication of colonoscopy. The aim of this study is to determine the PPB-prevalence in a secondary care hospital and its associated risk factors. We collected data from 581 patients, with the removal of 1593 polyps between August 2017 and August 2019. A univariate binary logistic regression analysis was conducted retrospectively. PPB occurred in only 10 cases, representing 1.7% of patients: immediate in 1.2% and delayed in 0.5%. The number of removed polyps per patient [4.5 (SD 2.59) for hemorrhagic vs. 2.74 (SD 1.98) for non-hemorrhagic group] and the propofol dose [232 mg (SD 93.07) for hemorrhagic vs. 133 mg (SD 57.28) for non-hemorrhagic group] were relevant patient-related risk factors. The polyp-based analysis showed the polyp size [18.4 mm (SD 10.44) for hemorrhagic vs. 4.42 mm (SD 4.29) for non-hemorrhagic group], the morphology [wide-based: OR 24.83 (95 % CI 2.76 - 223.44), pedunculated: OR 56.67 (95 % CI 5.03 - 638.29)], the location at ileocecal valve [OR 20.48, 95 % CI 1.81 - 231.97)], and the polypectomy method [hot snare piecemeal with epinephrine injection: OR 75.38 (95 % CI 7.67 - 741.21)] as significant risk factors for PPB, too. The low rate of PPB confirms the safety of the procedure in non-tertiary, high-volume colonoscopy centers. The number of polyps removed per patient, the polyp size, morphology and location, as well as the sedation dose and the method of polypectomy were shown as relevant risk factors.

Medico-legal implications for the colon perforation during colonoscopy

Colon perforation is the most serious complication of colonoscopy, and tends to be considered as malpractice. The aim of this study was to identify the characteristics and causes of medical accidents by analyzing lawsuit cases on colon perforation during colonoscopy. We collected judgment results that were ruled from 2005 to 2015 using the keyword ‘colonoscopy’ in the ‘Korea's Written Judgment Public Reading System’ of the Supreme Court, and extracted the cases of colon perforation. Characteristics of medical accidents and the decisions of courts were analyzed from written judgments. Twenty-two lawsuits were analyzed. Most cases were ruled in favor of the plaintiff (n = 20). The allegations against defendants, as filed by the plaintiffs, were performance error (n = 22), improper monitoring after colonoscopy (n = 7), and a lack of informed consent (n = 8). The median compensation was 9335.47 US dollars; this is about 130 times the cost of a single colonoscopy in Korea. The greater the intestinal damage, the greater the amount of compensation (p = 0.016). The time interval from procedure to diagnosis of perforation was most frequently 24 h later (n = 9). It is important to educate patients completely about the symptoms of colon perforation and to guide them to contact medical institutions immediately when symptoms occur. In addition, doctors should explain sufficiently the possibility of perforation before colonoscopy to the patient, and not the caregiver, and get informed consent.

S3440 A Rare but Serious Complication of Colonoscopy

INTRODUCTION: Reading View. Press Alt Shift A for accessibility help. Colonoscopy is the most widely used procedure for many colonic diseases. Hemorrhage and perforation are the most common complications. Splenic injury after colonoscopy is a very rare yet serious complication. Here we present a case followed by the review of literature. CASE DESCRIPTION/METHODS: Reading View. Press Alt Shift A for accessibility help. A 71-year-old woman presented with left lower abdominal pain after undergoing routine colonoscopy three days prior. She had history of right hemicolectomy for colonic carcinoma. Her exam showed tenderness in the left lower quadrant and epigastric area. Labs were significant for hemoglobin 10.7 g/dL (baseline 11 g/dL). CT abdomen revealed a 6.2 × 2.3 × 5.1 cm hematoma surrounding the lower pole of the spleen (Figure 1). She was managed conservatively with fluid resuscitation. CT angiography showed no active bleeding. Her hemoglobin remained stable and she did not require any surgical intervention. DISCUSSION: Reading View. Press Alt Shift A for accessibility help. Splenic injury is an under-reported complication of colonoscopy, with only 103 cases reported until 2012. The first ever case of splenic injury was reported in 1974 by Wherry and Zehner with the incidence of around 0.00005-0.017% and a mortality rate of 5%. Risk factors for splenic injury post-colonoscopy are previous surgical adhesions, as in our patient, IBD, difficult colonoscopy, rushing during the procedure and insufficient visualization due to poor bowel preparation. Splenic capsular avulsions and lacerations are caused either by direct injury during manipulation through the splenic flexure or during a difficult colonoscopy owing to transcolic pressure or looping of the instrument. Technical maneuvers during colonoscopy such as the alpha maneuver, straightening of the sigmoid loop, external pressure on the left hypochondrium also increase the risk. The most common symptom is left upper quadrant pain, with referred pain to the left shoulder known as the Kehr sign. Symptoms usually present within 24 hours. CT abdomen is the best imaging modality. Splenic injury post colonoscopy is treated either conservatively or through surgical intervention depending upon the hemodynamic status of patient and size of hematoma. Conservative management includes fluid resuscitation or blood product replacement. Surgical intervention is recommended for hemodynamic instability or Grades IV-V splenic lacerations.Figure 1.: CT scan abdomen and pelvis with intravenous contrast (Coronal view – right panel & Transverse view – left panel) showing spleen (blue arrows) and a 6.2 × 2.3 × 5.1 cm hematoma (green arrows).Figure 2.: CT scan abdomen and pelvis with intravenous contrast (Coronal view – right panel & Transverse view – left panel) showing spleen (blue arrows) and a 6.2 × 2.3 × 5.1 cm hematoma (green arrows).

Colon perforation during colonoscopy – the role of an anaesthesiologist in patient management. A case report

Colon perforation is a serious complication of colonoscopy. Clinical signs and symptoms depend on the specific characteristics of the perforation (e.g., size, location, and aetiology) and patient’s general status. The paper presents a case of an 81-year-old man who underwent diagnostic colonoscopy with perforation of the sigmoid diverticulum. The endoscopist was unsuccessful in ceiling the sigmoid perforation by clipping. Therefore, emergency laparotomy was performed, during which the perforation was repaired. Postoperatively, the patient was cared for in an intensive care unit. He was discharged from the intensive care unit to general surgery on day 3 postoperatively in a good general condition. Colon perforation at colonoscopy is one of the most serious complications, with early diagnosis and surgical repair being the key to successful outcome. Proper anaesthetic management is centred around correction of metabolic, cardiovascular and respiratory derangements, which is also crucial for patient outcomes.

Tu1083 CLINICAL CHARACTERISTICS AND OUTCOME OF IATROGENIC COLONIC PERFORATION RELATED TO DIAGNOSITC VS. THERAPEUTIC COLONOSCOPY

Iatrogenic colonic perforation (ICP) is a rare serious complication of colonoscopy, where standard treatment is controversial. This study aimed to characterize diagnostic ICP (DICP) compared to therapeutic ICP (TICP) and determine the possible indication of endoscopic repair. We studied patients with ICP treated during 7 years starting in 2011. Their demographics and data regarding perforation, treatment and outcome were investigated by retrospective review of medical records, and the diagnostic and therapeutic groups were compared. Among 29,882 patients who underwent colonoscopy, ICP was identified in 28 (0.09%: diagnostic, 15/24,758, 0.06%; therapeutic, 13/5124, 0.25%). A total of 56 patients (33 DICP and 23 TICP) including 28 referred cases were analyzed. Mean age was 62.3±11.4 years, and 24 were men. Perforations occurred mostly in the rectosigmoid region (n=36, 64.3%) and half were detected during or immediately after colonoscopy. Endoscopic treatment was successful in 22 cases (39.3%) and 34 (60.7%) required surgery. Mortality occurred in 4 (7.1%). Compared to TICP, DICP was more prevalent in females (p=0.045) and rectosigmoid region (p=0.000) and more frequently detected immediately (p=0.000); DICP tended to occur in older patients (p=0.080), be larger (p=0.080) and have better chance of endoscopic repair (p=0.080). Regardless of type of ICP, female predominance (p=0.009), smaller perforation (p=0.001), more frequent immediate detection (p=0.000), and shorter hospital stay (p=0.007) were found in the endoscopic repair group. DICP was more frequent in the rectosigmoid area in older women and could be detected immediately. Immediate detection and small perforation size could be important factors for endoscopic repair. Careful attention and gentle manipulation should be required, especially at the time of passing through rectosigmoid area of older women.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

1466 Diverticulitis: The Rare and Unanticipated Complication of Colonoscopy

INTRODUCTION: Colonoscopy is a common therapeutic and diagnostic tool used for colon cancer screening and surveillance. Although considered low risk, the most common complications include hemorrhage, bowel perforation and infection with rates of 1%, 0.1% and 1.1% respectively. Other uncommon complications include splenic injury and bowel obstruction. Diverticulitis is defined as inflammation of a diverticulum and is the result of a small tears in the diverticular wall. The reported incidence of colonoscopy induced diverticulitis differs between 0.08 and 1.9 per 1000 colonoscopies. CASE DESCRIPTION/METHODS: 64-year-old male with past history of CAD, HLD and diverticulitis presented with severe abdominal pain. 6 hours before presentation, patient had undergone a screening colonoscopy with polypectomy. Patient's abdominal pain was sharp and non-radiating. He denied any associated fevers, diarrhea, nausea or vomiting. Patient however did complain of chills. Upon presentation, patient had a temperature of 102.3 °F and HR of 109. Physical exam revealed diffuse abdominal tenderness. Labs were significant for lactic acid of 3.7. WBC count was 7,900. CT scan findings suggested diverticulitis. Repeat CBC few hours later showed an up-trending WBC count (10,800). Patient was managed with IV fluids and antibiotics. He was initially kept n.p.o. and then diet was gradually advanced which he tolerated well. A day after admission, patient was tolerating oral intake well and pain had resolved. He was discharged in stable condition. DISCUSSION: A retrospective cohort studied 236,377 colonoscopies with development of acute colonic diverticulitis in 68 patients within 30 days after colonoscopy. The rate of colonoscopy induced diverticulitis in the cohort was estimated to be 10 times less than the reported rates of other complication. Past history of diverticulitis is considered to be a risk factor for development of diverticulitis. No evidence of diverticulitis specifically after polypectomy was found on literature review. In our patient, we suspect that the micro and/or macro perforations induced by polypectomy led to introduction of bacteria into the diverticular wall and subsequently to the blood stream resulting in both local and systemic manifestations. Moreover, our patient's past history of diverticulitis also increased his risk. Our case is intended to shed light on this rare but potentially serious complication of colonoscopy in patients who develop severe abdominal pain and/or fever following colonoscopy.

Pneumoretroperitoneum, Pneumomediastinum, and Subcutaneous Emphysema Due to Retroperitoneal Penetration After Endoscopic Mucosal Resection of the Ascending Colon Where Only Right Cervical Pain Was the Initial Symptom

INTRODUCTION: Intestinal perforation is one of the most serious complications of colonoscopy. Its diagnosis and treatment may be delayed by the presence of unexpected symptoms. We present a case of pneumoretroperitoneum, pneumomediastinum, and subcutaneous emphysema that occurred due to retroperitoneal penetration by EMR at the ascending colon with the initial symptom as right cervical pain alone. CASE PRESENTATION: The patient is a 51-year-old man. Colonoscopy revealed LST of about 15 mm in diameter at the lower ascending colon (Figure. 1). Then, EMR was performed. After EMR, the patient complained of mild right cervical pain. We thought that the pain would be due to changes in posture, so we did not pay particular attention to it.2154_A Figure 1. Colonoscopic findings. Approximately 15mm lateral spreading tumor is located on the lower-ascending colon.Four hours later, the patient developed a fever of 37?, complained about exacerbation of the right cervical pain, and started to complain of right-sided abdominal pain. There was tenderness on the right flank to the back, and on the right neck, with no definite signs of peritoneal irritation. Clear crepitus was palpated around the neck, the right side of the chest, and the right back. A computed tomography (CT) scan revealed massive pneumoretroperitoneum around the dorsal side of the ascending colon to the back side of the lumen, pneumomediastinum, and extensive subcutaneous emphysema around neck, right side of the chest, and right flank to the back of the abdomen, consistent with palpation (Figure 2). We decided on conservative treatment because his condition was stable and there were no signs of peritonitis. Under conservative treatment, his symptoms gradually improved without the need for surgical intervention.2154_B Figure 2. Computed tomography (CT) findings. (a) Subcutaneous emphysema of the neck. (b) Pneumomediastinum. (c) Right pneumoretroperitoneum and subcutaneous emphysema at right renal level. (d) Pneumoretroperitoneum around the dorsal side of the ascending colon just with clips after EMR back side of the lumen.DISCUSSION: The majority of the signs of colorectal perforation are abdominal symptoms, such as acute peritonitis. However, in this case, the patient complained of right cervical pain after EMR was performed. It seemed to penetrate the retroperitoneum and was the only initial symptom. Initially we had no doubts about perforation. It seems that the penetrating air reached to the neck in a very short time. Perforation by colonoscopy usually causes symptoms of peritonitis due to intraperitoneal perforation, but in the case of retroperitoneal penetration, emphysema develops outside the peritoneum, causing various symptoms located in parts other than the abdomen, such as the neck. Since cervical pain alone can manifest as a sign of perforation, we should try to find the perforation earlier based on a few symptoms.

Laparoscopy in iatrogenic colonoscopic perforation: A case report and literature review

Bowel cancer incidence has been increasing worldwide. It is the fourth most common cancer among men and the third most common among women. Screening test like Faecal Occult Blood Test (FOBT) and Colonoscopy are particularly important for early detection of asymptomatic bowel cancer. Although colonoscopy is almost always safe but complications may occur. Most complications are mild and self-resolving, such as abdominal and anal pain, flatulence, and diarrhoea. The most serious complication of colonoscopy is iatrogenic colonoscopic perforation. The overall reported incidence of perforation ranges from 0.1–0.3% for diagnostic colonoscopy and from 0.4–1.0% for therapeutic colonoscopy. Since its first introduction in 1969, colonoscopy is considered the gold standard method for the diagnosis, treatment, and follow-up of colorectal cancer. Hereby, presenting a case study of an 83-year-old man, who had iatrogenic colonoscopic perforation post elective colonoscopy, which was successfully managed laparoscopically. Laparoscopic treatment seems to reduce the invasiveness and morbidity of major surgery. At the same time, it is more definitive than conservative treatment. Therefore, use of laparoscopic techniques have become the preferred method to treat colonoscopy related colonic perforations. Since colonoscopic perforations are rare, the management of this complication by laparoscopic procedure is poorly defined. By presenting this case study and review of literatures we would like to demonstrate that laparoscopic approach is a safe option for treatment and diagnosis of selected colonoscopic perforations.

Colonoscopic perforations: Single center experience and review of the literature.

Iatrogenic colonic perforation is a well-known complication that can increase mortality and morbidity in patients undergoing colonoscopy. Closer follow-up and a well-planned treatment strategy are required when perforation arises as a complication. The aims of this study are to (1) report our experience with a large colonoscopy series; (2) evaluate the underlying mechanisms of iatrogenic colonic perforation; (3) discuss the ideal period between onset and treatment; and (4) review the current literature regarding the management of iatrogenic colonic perforations. Patients who underwent colonoscopy between January 2005 and May 2015 at a single center were reviewed retrospectively. Procedures during which colonic perforations occurred were documented and analyzed. Between January 2005 and May 2015, 31,655 patients underwent colonoscopy and 5,214 patients underwent recto-sigmoidoscopy at our center. Thirteen of these procedures were associated with perforation. The perforation rate was found to be 0.041%. The most frequent locations of perforation were (a) the rectosigmoid junction, (b) the proximal rectum, and (c) the sigmoid colon. Management included surgical treatment in 11 patients and conservative management in 2 patients. Twelve patients (92.31%) were discharged uneventfully, and death occurred in one (7.69%) patient. Although they are rarely encountered, colonic perforations are serious complications of colonoscopy. A high index of clinical suspicion is required for early diagnosis and appropriate treatment. Age, co-morbidities, the location and size of the perforation, and the time interval between onset and diagnosis should be evaluated, and the treatment approach should be planned accordingly.

Spelenic Hematoma: An Uncommon Complication of Routine Colonoscopy

Introduction: Colonoscopy is the vital diagnostic and therapeutic tool in the management of patients with bleeding polyps and lesions of the lower gastrointestinal tract. While it is a minimally invasive procedure, it is not exempt from complications. We describe a case of splenic laceration with subscapular hematoma as a serious complication of colonoscopy. Case: A 59-year-old male with a history of anemia and COPD presented to the emergency department with abdominal pain for the past 24 hours. He had undergone colonoscopy two days prior for evaluation of chronic anemia which did not identify any cause for his anemia. He denies fever, hematochezia, vomiting and has been able to tolerate his diet. In the ED. he was noted have blood pressure 95/58,heart rate 61.His abdomen was soft - but tender to palpation in epigastrium and LUQ with no rebound. Blood count showed a decrease in hemoglobin (10.9 to 8.5 g/dL), with platelet count of 177 10(3)/mcl, INR (1.1) and Liver enzymes (AST U/L 24; ALT U/L 43; Total Bilirubin 0.7 mg/dl). CT abdomen with contrast exhibited splenic hematoma measuring 14 x 9.5x11.6cm (Image 1, 2) while a follow up CT two day later showed slightly increased hematoma measuring 14 x 10 x 13 (Image 3) Patient refused invasive intervention including laparotomy and angiography. He was treated conservatively with close clinical and laboratory monitoring. Conclusion: Splenic laceration was first described by Zehner in 1974 as complication of colonoscopy. While the reported incidence ranges between 0.00005% and 0.017%, it carries mortality rate of 5%. Most patient present within 48 hours after the procedure with hypotension, anemia, leukocytosis, abdominal pain/distension, and Kehr's sign. External force or pressure on the splenocolic ligament during passage through the splenic flexure is the most likely cause of splenic injury. Previous surgeries leading to intra-abdominal adhesions is also thought to be a contributing factor. In an effort to prevent such trauma, positioning the patient in a left lateral position allows the spleen to fall to the left and prevents opposing splenic and colonic tension. However, with increasing number of colonoscopies as a result of our aging population, the incidence of splenic complication are expected to rise. This case highlights the importance of early recognition, diagnosis and prompt treatment in an effort improve outcome.Figure 1Figure 2Figure 3

PWE-316 Incidence and management of iatrogenic perforations in the welsh bowel screening programme

Introduction Iatrogenic perforation is a rare but serious complication of colonoscopy. Reported incidence varies between 0.005% and 0.629%, and is mostly based on diagnostic and therapeutic rather than screening colonoscopies. The British Society of Gastroenterology (BSG) has set a target of no more than one perforation in every 1000 screening colonoscopies. Method All cases of iatrogenic perforations within the Bowel Screening Wales programme between January 2009 and December 2014 were identified. As part of a robust Quality Assurance programme, a policy of detailed root cause analysis was introduced in 2011; this was subsequently performed for all cases and outcomes recorded. Results 17,699 screening colonoscopies were performed within the specified time period, of which 10,688 proceeded to polypectomy (60.4%). There were 13 perforations (0.073%), of which 11 underwent root cause analysis. Of these, nine cases were following polypectomy, one was following negotiation around a splenic flexure malignant tumour and one was during a difficult colonoscopy in the context of multiple adhesions and diverticular disease. Almost all were managed with emergency surgery (n = 10). There was one fatality as a result of colonoscopy (0.006%). Conclusion Our perforation rate falls well below the BSG target and is lower than most of the previously published rates for therapeutic and diagnostic colonoscopies. Management of perforations tends to be less conservative than expected, and this was addressed with individual feedback, education and training. Bowel screening is a safe procedure with a low rate of perforation and a low risk of morbidity and mortality. Disclosure of interest None Declared.

Post Colonoscopy Splenic Injuries: Case Series and Recommendations

Splenic injury is an uncommon, but serious complication of colonoscopy. Any cause of excessive spleno-colic adhesions, splenomegaly, or underlying splenic disease would be a predisposing factor for splenic injury during colonoscopy. A delay in diagnosis has been noted as many physicians are not aware of this complication of colonoscopy. We report two cases of splenic injury secondary to screening colonoscopy. The first refers to a 61-year-old male, who was involved in a motor vehicle accident a month prior to the procedure; with the second case that of a 46-year-old healthy female. Clinical, biochemical and radiological findings were suggestive of a splenic rupture and hemoperitoneum. Both patients had grade III splenic ruptures with hemodynamic instability, which warranted urgent splenectomy. Both patients had an uneventful recovery. Proposed mechanisms are traction on the spleno-colic ligament leading to splenic capsule avulsion or direct splenic trauma due to colonoscopic manipulation. So-called “ looping of the colonoscope ” in the bowel, followed by aggressive straightening can cause strain on the spleno-colic ligament and tearing of blood vessels. The presence of Kehr ’ s sign in an hemodynamically unstable patient is a very sensitive pointer towards splenic rupture. Patients with recent abdominal trauma should be properly screened with appropriate history and investigations prior to colonoscopy. CT scan of the abdomen is the test of choice for the evaluation of splenic injury. Splenectomy is the most commonly performed procedure for post-colonoscopy injuries of the spleen. doi: http://dx.doi.org/10.4021/jmc1498w

Risk Factors for Early Colonoscopic Perforation Include Non-Gastroenterologist Endoscopists: A Multivariable Analysis

Bowel perforation is a rare but serious complication of colonoscopy. Its prevalence is increasing with the rapidly growing volume of procedures performed. Although colonoscopies have been performed for decades, the risk factors for perforation are not completely understood. We investigated risk factors for perforation during colonoscopy by assessing variables that included sedation type and endoscopist specialty and level of training. We performed a retrospective multivariate analysis of risk factors for early perforation (occurring at any point during the colonoscopy but recognized during or immediately after the procedure) in adult patients by using the Clinical Outcomes Research Initiative National Endoscopic Database. Risk factors were determined from published articles. Additional variables assessed included endoscopist specialty and years of experience, trainee involvement, and sedation with propofol. We identified 192 perforation events during 1,144,900 colonoscopies from 85 centers entered into the database from January 2000-March 2011. On multivariate analysis, increasing age, American Society of Anesthesia class, female sex, hospital setting, any therapy, and polyps >10 mm were significantly associated with increased risk of early perforation. Colonoscopies performed by surgeons and endoscopists of unknown specialty had higher rates of perforation than those performed by gastroenterologists (odds ratio, 2.00; 95% confidence interval, 1.30-3.08). Propofol sedation did not significantly affect risk for perforation. In addition to previously established risk factors, non-gastroenterologist specialty was found to affect risk for perforations detected during or immediately after colonoscopy. This finding could result from differences in volume and style of endoscopy training. Further investigation into these observed associations is warranted.

Rate of Serious Complications of Colonoscopy in Quebec

The rate of serious complications is one marker of the quality of colonoscopy services. To estimate the rate of serious complications of colonoscopy according to colonoscopy indication and polypectomy status. A prospective cohort study of patients scheduled for colonoscopy who were recruited from seven endoscopy facilities across Montreal (Quebec) was conducted. Before colonoscopy, patients completed a brief questionnaire and provided their health insurance numbers. Colonoscopy indication was based on patient-reported medical history. Polypectomy status was obtained from provincial physician billing records (Régie de l'assurance maladie du Québec). Diagnoses and procedures associated with hospitalization in the 30 days following colonoscopy were obtained from the provincial hospitalization database (MedEcho). Of the 2134 patients enrolled (mean age 60.9 years, 50.1% male), 33 (1.55% [95% CI 1.06% to 2.16%]) were hospitalized within 30 days. One patient experienced bleeding following a colonoscopy that involved polypectomy and was diagnosed with carcinoma in situ of the rectum. Based on self-reported rectal bleeding in the previous six months, the colonoscopy was nonscreening. The provincial hospitalization data showed no occurrences of perforation, diverticulitis, myocardial infarction⁄stroke or death; thus, the rate of serious colonoscopy complications was 0.05% (95% CI 0.00% to 0.26%). The rate of serious colonoscopy complications requiring hospitalization was low and comparable with what is reported in the literature. The serious complication occurred subsequent to polypectomy and in a nonscreening colonoscopy. The findings support the relative safety of screening colonoscopy in persons without large bowel diseases and symptoms. However, future research to determine the rate of serious complications not requiring hospitalization is warranted to reassure decision makers of the safety of colonoscopy for colorectal cancer screening.

Colonoscopic perforation leading to a diagnosis of Ehlers Danlos syndrome type IV: a case report and review of the literature

IntroductionColonoscopic perforation is a rare but serious complication of colonoscopy. Factors known to increase the risk of perforation include colonic strictures, extensive diverticulosis, and friable tissues. We describe the case of a man who was found to have perforation of the sigmoid colon secondary to an undiagnosed connective tissue disorder (Ehlers-Danlos syndrome type IV) while undergoing surveillance for hereditary non-polyposis colorectal cancer.Case presentationA 33-year-old Caucasian man presented to our hospital with an acute abdomen following a colonoscopy five days earlier as part of hereditary non-polyposis colorectal cancer screening. His medical history included bilateral clubfoot. His physical examination findings suggested left iliac fossa peritonitis. A computed tomographic scan revealed perforation of the sigmoid colon and incidentally a right common iliac artery aneurysm as well. Hartmann's procedure was performed during laparotomy. The patient recovered well post-operatively and was discharged. Reversal of the Hartmann's procedure was performed six months later. This procedure was challenging because of dense adhesions and friable bowel. The histology of bowel specimens from this surgery revealed thinning and fibrosis of the muscularis externa. The patient was subsequently noted to have transparency of truncal skin with easily visible vessels. An underlying collagen vascular disorder was suspected, and genetic testing revealed a mutation in the collagen type III, α1 (COL3A1) gene, which is consistent with a diagnosis of Ehlers-Danlos syndrome type IV.ConclusionsEhlers-Danlos syndrome type IV, the vascular type, is a rare disorder caused by mutations in the COL3A1 gene on chromosome 2q31. It is characterized by translucent skin, clubfoot, and the potentially fatal complications of spontaneous large vessel rupture, although spontaneous uterine and colonic perforations have also been reported in the literature. The present case presentation describes the identification of Ehlers-Danlos syndrome type IV in a patient with a non-spontaneous colonic perforation secondary to an invasive investigation for another hereditary disorder pre-disposing him to colorectal cancer. Invasive procedures such as arteriograms and endoscopies are relatively contra-indicated in Ehlers-Danlos syndrome type IV. Alternatives with a lower risk of perforation, such as computed tomographic colonography, need to be considered for patients requiring ongoing colorectal cancer surveillance. Furthermore, management of vascular aneurysms in patients with Ehlers-Danlos syndrome type IV requires consideration of the risks of endovascular stenting, as opposed to open surgical intervention, because of tissue friability. Genetic and reproductive counseling should be offered to affected individuals and their families.

Comparison of endoscopic closure modalities for standardized colonic perforations in a porcine colon model

Colonic perforation is a serious complication of colonoscopy, with surgical repair usually indicated. The aim was to compare acute strength of various endoscopic colonic closure techniques by assessing air leak pressures in a previously described ex vivo experimental apparatus. Standardized colonic perforations were created using fresh porcine colon and subsequently closed on a bench. Six techniques included surgical suture (gold standard), QuickClips, T-tags, over-the-scope-clip (OTSC) system, and two types of flexible stapler (Covidien). After closure, each specimen was fixed in the apparatus and pressure was gradually increased until air bubbles were seen. Leak pressure was the primary outcome parameter. Closure using the gold standard (first 15 experiments) resulted in a mean leak pressure of 86.9 mmHg (SD 7). Using a noninferiority design a sample size of 12 specimens for each closure technique was determined. Mean colotomy leak pressures in millimeters of mercury (mmHg) and difference (with 95% confidence intervals [CI]) between each technique and the gold standard were: QuickClips 85.1 (difference -1.8; 95% CI -7.0 to 3.9); T-tags 53.9 (difference -33.0; -39.0 to -27.0); OTSC 90.3 mmHg (difference 3.4; -6.1 to 12.9); 15-mm shaft stapler 98.5 mmHg (difference 9.7; 0.8 to 18.5) and 8-mm shaft stapler 96.6 mmHg (difference 11.6; 1.5 to 21.7). OTSCs, QuickClips, and both flexible staplers produced results comparable to hand-sewn colotomy closure in this ex vivo porcine colonic model. These devices seem to be prime candidates for further evaluation in survival animal studies.

624 Factors Associated with Risk of Serious Complications of Colonoscopy: A Population-Based Study

624 Factors Associated with Risk of Serious Complications of Colonoscopy: A Population-Based Study

Splenic injury after colonoscopy

Splenic injury is a rare and serious complication of colonoscopy. The most likely mechanism is tension on the splenocolic ligament and adhesions. Eight cases were identified among claims for compensation submitted to the Danish Patient Insurance Association during the period 1992-2006, seven of which were reported after 2000. The total number of colonoscopies in Denmark in 2004 was 39 067. Seven of the eight patients were aged 65 years or over. Loops causing difficulties during the colonoscopy had been reported in four patients. All the patients had a symptom-free interval after the colonoscopy, ranging from 4 hours to 7 days, before presenting with signs of splenic injury. In all cases the spleen was torn, and the amount of blood in the peritoneal cavity ranged from 1500 mL to 5000 mL. Two patients died postoperatively. The number of cases reported after 2000 indicates that this potentially lethal complication might be more common than was previously assumed, and it is possibly under-reported. Preventive measures include good colonoscopic technique to avoid loop formation and the use of excessive force; and it is possible that emerging endoscopic technologies will lead to a reduced risk of splenic injury. The information given to patients both before and after the procedure should include information on the signs of this complication, and patients should be also informed that these signs can develop after a symptom-free interval.