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Colonoscopic Polypectomy: Silent Perforation
Vol. 70, No.1
GASTROENTEROLOGY 70:112-113, 1976 Copyright © 1976 by The Williams & Wilkins Co.
Printed in U.S.A.
COLONOSCOPIC POLYPECTOMY: SILENT PERFORATION B.
F. OVERHOLT,
WILSON,
M.D., R.
LESLIE HARGROVE,
M.D., R.
KENT FARRIS,
M.D.,
AND
B. M.
R.N.
Section of Gastroenterology, Saint Mary's Memorial Hospital, Knoxville, Tennessee
The management of colon polyps has been completely revolutionized since the introduction of colonoscopic polypectomy.1-3 The reductions in patient time, cost, morbidity, and mortality are major advantages. Reported complications include primarily hemorrhage (1.7%) and frank clinical perforation (0.32%).4 This report describes a silent perforation after the removal of a broad based polyp through the colonscope. Case Report
a recent review 5 as well as in the American Society for Gastrointestinal Endoscopy's survey of complications of R. H., a 62-year-old white female, presented for evaluation 4 Hemorrhage in 1.7% and perforation in endoscopy. of constipation. Physical examination and sigmoidoscopy were normal. Stool guaiacs were positive. Barium enema and upper 0.32% occurred in 6214 cases of colonoscopic polypectogastrointestinal X-rays were negative. Colonoscopy revealed a mies reported in ASGE survey. Further analysis reveals 2-cm polyp in the proximal sigmoid colon presenting with a six cases of transient fever and abdominal pain after short stalk measuring approximately 1.5 cm in diameter. Using polypectomy.6 In light of the present report, these six the American Cystoscope Makers, Incorporated snare applied cases may represent small perforations that have been several millimeters from the base of the stalk and utilizing the effectively walled off, preventing frank peritonitis. Pneumotome (settings no. 25, and no. 35), the polyp was The present report documents a definite but asymptotransected with some difficulty due to the thickness of the matic perforation occurring after the rather difficult stalk. Once the snare had been tightened against the stalk, current application intermittently over approximately 5 to 7 removal of a colon polyp located on a relatively broad sec was required for transection. It was noted that the coagulation necrosis extended into the bowel wall and in fact a small negative defect or excavation was created in the colon wall. However, after the polypectomy the patient remained asymptomatic. No fever or abdominal pain occurred. She was placed on a low residue diet for several days and discharged. The pathological specimen revealed a polypoid adenocarcinoma infiltrating into the polyp stroma, but not into the stalk. Three weeks later the patient underwent laparotomy for resection of the area of involved colon. Intra-operative colonoscopy was performed to aid the surgeon in location of the site. No additional lesions were found. A thickened area approximately \14 cm in diameter was found at the site of the previous polypectomy. The mesenteric nodes were grossly and histologically normal. A 30-cm segment of colon was resected and the gross specimen examined. Figure 1 shows the mucosal surface of the polypectomy site with a central depression demonstrating the healing at the site of the previous polypectomy. Figure 2 demonstrates the histological specimen. Perforation associated with the coagulation necrosis had occurred, but the pericolonic fat in the area had walled off the site effectively, preventing any abscess formation.
Discussion With the tremendous increase in the number of colon polyps being removed through the colonos cope, a word of caution is appropriate. An occasional case report or presentation of post-polypectomy hemorrhage or perforation is available for review. That these complications occur more frequently than is apparent is documented in Received April 8, 1975. Accepted July 18, 1975.
FIG. 1. Mucosal surface demonstrating central depression and healing at the site of polypectomy done 3 weeks earlier.
FIG. 2. Histology of the cross section demonstrating mucosal healing over the central depression (ulcer) and the necrosis extending through the colon wall with pericolonic fat adherent to the serosal surface at the "perforation" site.
112
113
CASE REPORTS
January 1976
stalk. One can reasonably speculate that such occurrences are more frequent than appreciated. Perhaps any polypectomy with coagulation necrosis extending into the colon wall proper or with an excavation created in the bowel wall by the procedure should be suspected of potential subclinical perforation. A low residue diet, rest, avoidance of strenuous activity, and careful follow-up would be wise in such cases. Colonoscopic polypectomy has significantly reduced the morbidity and mortality of colonic polypectomy, but the procedure is associated with a definite, albeit small, risk of recognizable complications. Adequate training and experience as emphasized by the American Society for Gastrointestinal Endoscopy Standards of Training and Practice and by Geenen et al. 7 will undoubtedly reduce the complication rate of colonoscopic polypectomy and should be considered essential before attempting these procedures. Summary
An asymptomatic transmural colonic perforation after colonoscopic polypectomy is reported. It is speculated
that such cases occur more frequently than has been recognized. Caution should be taken with the patient if coagulation necrosis during polypectomy extends into the bowel wall or if any degree of excavation of the bowel wall occurs. REFERENCES 1. Wolff WI, Shinya H: A new approach to colonic polyps. Ann Surg 178:367-378, 1973 2. Williams CB, Hunt RN, Loose H , et al: Colonoscopy in the management of colon polyps. Br J Surg 61:673-682, 1974 3. Wolff WI, Shinya H: New approaches to the management of colon polyps. Adv Surg 7:45-67, 1973 4. Complications of endoscopy. American Society for Gastrointestin al Endoscopy Survey 1971-1973. (in press) a review. Gastroenterol ogy 5. Overholt BF: Colonoscopy : 68: 1308-1320, 1975 6. Rogers BHG: Complications o f flexible fiberoptic col os copy a nd polypectomy: An analysis of the 1974 survey conducted by the American Society for Gastrointestinal Endoscopy. (in press). 7. Geenen JE , Schmitt WG Jr, Hogan WJ : Complications of colonoscopy. Gastroenterology 66:812, 1974
GASTROENTEROLOGY 70:112-113, 1976 Copyright © 1976 by The Williams & Wilkins Co.
Printed in U.S.A.
COLONOSCOPIC POLYPECTOMY: SILENT PERFORATION B.
F. OVERHOLT,
WILSON,
M.D., R.
LESLIE HARGROVE,
M.D., R.
KENT FARRIS,
M.D.,
AND
B. M.
R.N.
Section of Gastroenterology, Saint Mary's Memorial Hospital, Knoxville, Tennessee
The management of colon polyps has been completely revolutionized since the introduction of colonoscopic polypectomy.1-3 The reductions in patient time, cost, morbidity, and mortality are major advantages. Reported complications include primarily hemorrhage (1.7%) and frank clinical perforation (0.32%).4 This report describes a silent perforation after the removal of a broad based polyp through the colonscope. Case Report
a recent review 5 as well as in the American Society for Gastrointestinal Endoscopy's survey of complications of R. H., a 62-year-old white female, presented for evaluation 4 Hemorrhage in 1.7% and perforation in endoscopy. of constipation. Physical examination and sigmoidoscopy were normal. Stool guaiacs were positive. Barium enema and upper 0.32% occurred in 6214 cases of colonoscopic polypectogastrointestinal X-rays were negative. Colonoscopy revealed a mies reported in ASGE survey. Further analysis reveals 2-cm polyp in the proximal sigmoid colon presenting with a six cases of transient fever and abdominal pain after short stalk measuring approximately 1.5 cm in diameter. Using polypectomy.6 In light of the present report, these six the American Cystoscope Makers, Incorporated snare applied cases may represent small perforations that have been several millimeters from the base of the stalk and utilizing the effectively walled off, preventing frank peritonitis. Pneumotome (settings no. 25, and no. 35), the polyp was The present report documents a definite but asymptotransected with some difficulty due to the thickness of the matic perforation occurring after the rather difficult stalk. Once the snare had been tightened against the stalk, current application intermittently over approximately 5 to 7 removal of a colon polyp located on a relatively broad sec was required for transection. It was noted that the coagulation necrosis extended into the bowel wall and in fact a small negative defect or excavation was created in the colon wall. However, after the polypectomy the patient remained asymptomatic. No fever or abdominal pain occurred. She was placed on a low residue diet for several days and discharged. The pathological specimen revealed a polypoid adenocarcinoma infiltrating into the polyp stroma, but not into the stalk. Three weeks later the patient underwent laparotomy for resection of the area of involved colon. Intra-operative colonoscopy was performed to aid the surgeon in location of the site. No additional lesions were found. A thickened area approximately \14 cm in diameter was found at the site of the previous polypectomy. The mesenteric nodes were grossly and histologically normal. A 30-cm segment of colon was resected and the gross specimen examined. Figure 1 shows the mucosal surface of the polypectomy site with a central depression demonstrating the healing at the site of the previous polypectomy. Figure 2 demonstrates the histological specimen. Perforation associated with the coagulation necrosis had occurred, but the pericolonic fat in the area had walled off the site effectively, preventing any abscess formation.
Discussion With the tremendous increase in the number of colon polyps being removed through the colonos cope, a word of caution is appropriate. An occasional case report or presentation of post-polypectomy hemorrhage or perforation is available for review. That these complications occur more frequently than is apparent is documented in Received April 8, 1975. Accepted July 18, 1975.
FIG. 1. Mucosal surface demonstrating central depression and healing at the site of polypectomy done 3 weeks earlier.
FIG. 2. Histology of the cross section demonstrating mucosal healing over the central depression (ulcer) and the necrosis extending through the colon wall with pericolonic fat adherent to the serosal surface at the "perforation" site.
112
113
CASE REPORTS
January 1976
stalk. One can reasonably speculate that such occurrences are more frequent than appreciated. Perhaps any polypectomy with coagulation necrosis extending into the colon wall proper or with an excavation created in the bowel wall by the procedure should be suspected of potential subclinical perforation. A low residue diet, rest, avoidance of strenuous activity, and careful follow-up would be wise in such cases. Colonoscopic polypectomy has significantly reduced the morbidity and mortality of colonic polypectomy, but the procedure is associated with a definite, albeit small, risk of recognizable complications. Adequate training and experience as emphasized by the American Society for Gastrointestinal Endoscopy Standards of Training and Practice and by Geenen et al. 7 will undoubtedly reduce the complication rate of colonoscopic polypectomy and should be considered essential before attempting these procedures. Summary
An asymptomatic transmural colonic perforation after colonoscopic polypectomy is reported. It is speculated
that such cases occur more frequently than has been recognized. Caution should be taken with the patient if coagulation necrosis during polypectomy extends into the bowel wall or if any degree of excavation of the bowel wall occurs. REFERENCES 1. Wolff WI, Shinya H: A new approach to colonic polyps. Ann Surg 178:367-378, 1973 2. Williams CB, Hunt RN, Loose H , et al: Colonoscopy in the management of colon polyps. Br J Surg 61:673-682, 1974 3. Wolff WI, Shinya H: New approaches to the management of colon polyps. Adv Surg 7:45-67, 1973 4. Complications of endoscopy. American Society for Gastrointestin al Endoscopy Survey 1971-1973. (in press) a review. Gastroenterol ogy 5. Overholt BF: Colonoscopy : 68: 1308-1320, 1975 6. Rogers BHG: Complications o f flexible fiberoptic col os copy a nd polypectomy: An analysis of the 1974 survey conducted by the American Society for Gastrointestinal Endoscopy. (in press). 7. Geenen JE , Schmitt WG Jr, Hogan WJ : Complications of colonoscopy. Gastroenterology 66:812, 1974