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Endoscopic management of postoperative ileocolonic anastomotic bleeding by using water submersion
Endoscopic management of postoperative ileocolonic anastomotic bleeding by using water submersion Niraj Gor, MD, Abhitabh Patil, MD Chicago, Illinois, USA
CASE REPORT A 54-year-old woman presented with a 3.5-cm tubulovillous polyp with central necrosis in the ascending colon found on screening colonoscopy that could not be removed endoscopically. The patient underwent an uncomplicated right hemicolectomy with an ileocolonic anastomosis created with a GIA stapler (Covidien, Mansfield, Mass). On the third postoperative day, significant hematochezia developed, resulting in hemodynamic instability and a 5-g/dL decrease in hemoglobin over a 12-hour period. Despite aggressive resuscitative measures, the bleeding persisted, and the patient remained unstable. Discussion with the multidisciplinary care team, which consisted of the colorectal surgeon, intensive care specialist, interventional radiologist, and anesthesiologist determined that a second operative intervention was likely inevitable. However, a less-invasive endoscopic attempt at hemostasis appeared to be a reasonable alternative with the understanding that, if the hemostasis were unsuccessful or complicated, the patient would proceed to operative treatment with likely revision of the anastomosis. After a full discussion of the risks, benefits, and alternatives of both treatment options, the patient and family opted for the less-invasive approach. In preparation, a rapid purge was performed. This consisted of 4 L of polyethylene glycol via a nasogastric tube over a 2-hour period while resuscitation efforts were continued. Once the patient was prepped, an adult colonoscope was advanced to the ileocolonic anastomosis by using a water submersion technique with air insufflation disengaged. The colonoscopy showed an active bleeding vessel at the distal margin of the anastomosis (Fig. 1). Four endoclips were deployed and successful hemostasis was achieved (Fig. 2). After endoscopic intervention, the patient’s hemodynamic status and clinical condition rapidly improved. The patient was discharged home 72 hours after the procedure.
DISCUSSION Massive GI bleeding immediately after colorectal surgery is typically managed with conservative measures. If such measures fail, then bleeding is managed operatively with revision of the anastomosis.1 Endoscopy is generally not recommended in the immediate postoperative period because excessive air insufflation, torque, or inadvertent pressure from the endoscope could potentially disrupt a newly created anastomosis. www.giejournal.org
Figure 1. Actively bleeding vessel at the ileocolonic anastomosis.
Figure 2. Successful hemostasis after endoclip placement.
There are several studies that evaluated water submersion endoscopy.2-5 Frossard et al6 described 2 patients with colorectal anastomosis in whom lower GI bleeding developed in the perioperative period who were successfully treated with water submersion sigmoidoscopy and endoclip placement. To our knowledge, this is the first reported case of a patient with an ileocolonic anastomosis in whom significant hematochezia developed in the perioperative period that was successfully treated with water submersion endoscopy and endoclip placement. Volume 74, No. 3 : 2011 GASTROINTESTINAL ENDOSCOPY 721
Brief Reports
In this case, the colorectal surgeon was prepared to revise the surgical anastomosis should endoscopic measures have failed to control the bleeding. The perceived benefits of decreased hospital stay, blood transfusion requirements, morbidity, mortality, and cost outweighed the anticipated risk of anastomotic disruption. Endoscopic intervention also appeared more favorable compared with radiographic embolization, which could have potentially resulted in ulceration with repeat bleeding likely requiring surgery.7 Moreover, the clinical consequence of endoscopic failure to control bleeding or a complication of the endoscopy such as a perforation would not alter the patients accepted need for surgery. In conclusion, this case suggests that an aggressive endoscopic approach in the management of immediate postoperative anastomotic lower GI bleeding can be successfully performed. We believe that further experience in this arena may show that colonoscopy can be performed safely and effectively in patients with postoperative ileocolonic anastomotic hemorrhage. Ultimately, endoscopic management may prove to be more cost-effective than repeat surgery and potentially result in improved clinical outcomes. DISCLOSURE The authors disclosed no financial relationships relevant to this publication.
722 GASTROINTESTINAL ENDOSCOPY Volume 74, No. 3 : 2011
REFERENCES 1. Martinez-Serrano M, Pares D, Pera M, et al. Management of lower gastrointestinal bleeding following colorectal resection and stapled anastomosis. Tech Coloproctol 2009;13:49-53. 2. Leung F. Methods of reducing discomfort during colonoscopy. Dig Dis Sci 2008;53:1462-7. 3. Leung F. Water related techniques for performance of colonoscopy. Dig Dis Sci 2008;53:2847-50. 4. Leung FW, Aharonian HS, Leung JW, et al. Impact of a novel water method on scheduled unsedated colonoscopy in U.S. veterans. Gastrointest Endosc 2009;69:546-50. 5. Huh K, Rex D. Advances in colonoscope technique and technology. Rev Gastroenterol Disord 2008;8:223-32. 6. Frossard, JL, Gervaz P, Huber O. Water immersion sigmoidoscopy to treat acute GI bleeding in the perioperative period after surgical colorectal anastomosis. Gastrointest Endosc 2010;71:167-70. 7. Gillespie CJ, Sutherland AD, Mossop PJ, et al. Mesenteric embolization for lower gastrointestinal bleeding. Dis Colon Rectum 2010;9:1258-64.
Rush University Medical Center, Chicago, Illinois, USA. Reprint requests: Niraj Gor, MD, Department of Gastroenterology, Rush University Medical Center, 1725 West Harrison Street, Professional Building, Suite 207, Chicago, IL 60612. Copyright © 2011 by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00 doi:10.1016/j.gie.2011.01.033
www.giejournal.org
CASE REPORT A 54-year-old woman presented with a 3.5-cm tubulovillous polyp with central necrosis in the ascending colon found on screening colonoscopy that could not be removed endoscopically. The patient underwent an uncomplicated right hemicolectomy with an ileocolonic anastomosis created with a GIA stapler (Covidien, Mansfield, Mass). On the third postoperative day, significant hematochezia developed, resulting in hemodynamic instability and a 5-g/dL decrease in hemoglobin over a 12-hour period. Despite aggressive resuscitative measures, the bleeding persisted, and the patient remained unstable. Discussion with the multidisciplinary care team, which consisted of the colorectal surgeon, intensive care specialist, interventional radiologist, and anesthesiologist determined that a second operative intervention was likely inevitable. However, a less-invasive endoscopic attempt at hemostasis appeared to be a reasonable alternative with the understanding that, if the hemostasis were unsuccessful or complicated, the patient would proceed to operative treatment with likely revision of the anastomosis. After a full discussion of the risks, benefits, and alternatives of both treatment options, the patient and family opted for the less-invasive approach. In preparation, a rapid purge was performed. This consisted of 4 L of polyethylene glycol via a nasogastric tube over a 2-hour period while resuscitation efforts were continued. Once the patient was prepped, an adult colonoscope was advanced to the ileocolonic anastomosis by using a water submersion technique with air insufflation disengaged. The colonoscopy showed an active bleeding vessel at the distal margin of the anastomosis (Fig. 1). Four endoclips were deployed and successful hemostasis was achieved (Fig. 2). After endoscopic intervention, the patient’s hemodynamic status and clinical condition rapidly improved. The patient was discharged home 72 hours after the procedure.
DISCUSSION Massive GI bleeding immediately after colorectal surgery is typically managed with conservative measures. If such measures fail, then bleeding is managed operatively with revision of the anastomosis.1 Endoscopy is generally not recommended in the immediate postoperative period because excessive air insufflation, torque, or inadvertent pressure from the endoscope could potentially disrupt a newly created anastomosis. www.giejournal.org
Figure 1. Actively bleeding vessel at the ileocolonic anastomosis.
Figure 2. Successful hemostasis after endoclip placement.
There are several studies that evaluated water submersion endoscopy.2-5 Frossard et al6 described 2 patients with colorectal anastomosis in whom lower GI bleeding developed in the perioperative period who were successfully treated with water submersion sigmoidoscopy and endoclip placement. To our knowledge, this is the first reported case of a patient with an ileocolonic anastomosis in whom significant hematochezia developed in the perioperative period that was successfully treated with water submersion endoscopy and endoclip placement. Volume 74, No. 3 : 2011 GASTROINTESTINAL ENDOSCOPY 721
Brief Reports
In this case, the colorectal surgeon was prepared to revise the surgical anastomosis should endoscopic measures have failed to control the bleeding. The perceived benefits of decreased hospital stay, blood transfusion requirements, morbidity, mortality, and cost outweighed the anticipated risk of anastomotic disruption. Endoscopic intervention also appeared more favorable compared with radiographic embolization, which could have potentially resulted in ulceration with repeat bleeding likely requiring surgery.7 Moreover, the clinical consequence of endoscopic failure to control bleeding or a complication of the endoscopy such as a perforation would not alter the patients accepted need for surgery. In conclusion, this case suggests that an aggressive endoscopic approach in the management of immediate postoperative anastomotic lower GI bleeding can be successfully performed. We believe that further experience in this arena may show that colonoscopy can be performed safely and effectively in patients with postoperative ileocolonic anastomotic hemorrhage. Ultimately, endoscopic management may prove to be more cost-effective than repeat surgery and potentially result in improved clinical outcomes. DISCLOSURE The authors disclosed no financial relationships relevant to this publication.
722 GASTROINTESTINAL ENDOSCOPY Volume 74, No. 3 : 2011
REFERENCES 1. Martinez-Serrano M, Pares D, Pera M, et al. Management of lower gastrointestinal bleeding following colorectal resection and stapled anastomosis. Tech Coloproctol 2009;13:49-53. 2. Leung F. Methods of reducing discomfort during colonoscopy. Dig Dis Sci 2008;53:1462-7. 3. Leung F. Water related techniques for performance of colonoscopy. Dig Dis Sci 2008;53:2847-50. 4. Leung FW, Aharonian HS, Leung JW, et al. Impact of a novel water method on scheduled unsedated colonoscopy in U.S. veterans. Gastrointest Endosc 2009;69:546-50. 5. Huh K, Rex D. Advances in colonoscope technique and technology. Rev Gastroenterol Disord 2008;8:223-32. 6. Frossard, JL, Gervaz P, Huber O. Water immersion sigmoidoscopy to treat acute GI bleeding in the perioperative period after surgical colorectal anastomosis. Gastrointest Endosc 2010;71:167-70. 7. Gillespie CJ, Sutherland AD, Mossop PJ, et al. Mesenteric embolization for lower gastrointestinal bleeding. Dis Colon Rectum 2010;9:1258-64.
Rush University Medical Center, Chicago, Illinois, USA. Reprint requests: Niraj Gor, MD, Department of Gastroenterology, Rush University Medical Center, 1725 West Harrison Street, Professional Building, Suite 207, Chicago, IL 60612. Copyright © 2011 by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00 doi:10.1016/j.gie.2011.01.033
www.giejournal.org