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Endoscopic repair by clipping of iatrogenic colonic perforation
Endoscopic repair by clipping of iatrogenic colonic perforation Hiroaki Yoshikane, Hitoshi Hidano, Akira Sakakibara, Tadao Ayakawa, Sumito Mori, Hiroki Kawashima, Hidemi Goto, Yasumasa Niwa,
MD MD MD MD MD MD MD MD
With the widespread use of colonoscopy and the development of new colonoscopic diagnostic techniques, the superficial type of colorectal tumor is being found more frequently. 1 For these colonic lesions, endoscopic mucosal resection (EMR), which was initially developed for the curative t r e a t m e n t of early gastric cancer, 2 is increasingly performed in Japan. It is reasonable to expect t h a t the larger the resected mucosal surface, the greater the likelihood of complications such as bleeding or perforation. We report here a patient with a superficial colonic adenoma who sustained iatrogenic perforation of the descending colon caused by EMR t h a t was successfully treated by endoscopic clipping therapy. CASE REPORT
A 46-year-old man who was shown to have a superficial type of colonic adenoma of about 10 mm in diameter (Fig. 1) at endoscopy underwent EMR. A transparent plastic cap (Distal Attachment, MH-483, Olympus Optical, Ltd., Tokyo, Japan) was fitted to the distal end of the endoscope. Physiological saline solution (2 ml) was injected under the lesion. The lesion was snared and drawn into the cap using the suction function of the endoscope. It was then ligated and resected with electrocautery using a blended current (Fig. 2). When we observed the area of resection (about 15 mm in diameter) we found a central perforation about 4 mm in diameter (Fig. 3). The patient did not have any abdominal pain, but iatrogenic colonic perforation had surely occurred. Endoscopic repair was undertaken. With a rotating clip fixing device (HX-5QR-1, Olympus), five clips were carefully fitted. Although the first was misclipped, the other four were well fitted and the resected surface was closed (Fig. 4). The patient was subsequently treated by withholding of oral intake, administration of antibiotics, and hyperalimentation for 10 days. His posttreatment course was uneventful. Although he had slight tenderness and From the Department of Internal Medicine, Handa City Hospital, Handa, and the Second Department of Internal Medicine, Nagoya University School of Medicine, Nagoya, Japan. Reprint requests: Hiroaki Yoshikane, MD, Internal Medicine, Handa City Hospital, 2-29 Toyo, Handa, Aichi, 475, Japan. Copyright © 1997 by the American Society for Gastrointestinal Endoscopy 0016-5107/97/$5.00 + 0 37/4/84454
464 GASTROINTESTINAL ENDOSCOPY
rebound pain for 3 days, C-reactive protein decreased from 6.7 mg/dL to 0.8 mg/dL in 5 days, and the free air in the abdomen had considerably decreased by the end of I week. He began to eat 9 days after the clipping procedure and was discharged at 2 weeks; clinical follow-up at 3 months disclosed no problems. DISCUSSION
Colonic perforation is an abdominal emergency with high mortality?, 4 The patient's course depends on the presence or absence of sepsis. 5 Peritoneal contamination with intestinal bacteria rapidly leads to endotoxinemia and septic shock. G The course of sepsis, once perforation of the colon has occurred, is independent of the underlying disease. The septic state of the patient cannot be related to the degree of peritonitis. 5 The reported incidence of iatrogenic perforation during therapeutic colonoscopy ranges from 0.15% to 2.14%. ~-9 It is, however, assumed t h a t the increased use of EMR adds to the risk of perforation. This type of perforation differs from t h a t caused by underlying disease because of the intraluminal cleansing t h a t results from bowel preparation. Concerning the m a n a g e m e n t of iatrogenic colon perforation, either primary repair or resection and anastomosis by surgery have been generally performed with acceptable rates of morbidity, l° There are several recent reports of colonic perforation sustained during colonoscopy t h a t was successfully m a n a g e d with conservative measures. 11-1~ Nonoperative m a n a g e m e n t consists of careful clinical observation, intravenous antibiotics, nasogastric tube decompression, and frequent laboratory studies. n,13 Although conservative t r e a t m e n t m a y surely be used when the perforation is small and retroperitoneal, 11 failed nonoperative m a n a g e m e n t with delayed laparotomy results in greater contamination, necessitating major surgery?, 14 Laparoscopic repair of colonic perforation sustained during colonoscopy was introduced in recent years and leads to rapid recovery. 15, 16 In the management of urgent intra-abdominal disorders, laparoscopy is safe and effective. It provides an exact diagnosis and is of assistance in deciding the necessity of prompt operative management. Whenever possible, however, patients and physicians prefer to avoid emergency surgery. In the case presented here we reasoned as follows. The intestinal lumen is, fortunately, clean. Therefore, by at once closing the wound by any means, leakage of fecal m a t t e r to the peritoneal cavity can be minimized, and healing of the wound might occur rapidly. This reasoning proved to be correct. The wound, 15 m m in diameter with a central perforation, was closed with only four VOLUME 46, NO. 5, 1997
Endoscopic repair by clipping of iatrogenic colonic perforation
Figure 1. Endoscopy showing a superficial colonic adenoma about 10 mm in diameter. The lesion became better defined after dye spraying.
H Yoshikane, H Hidano, A Sakakibara, et al.
Figure 3. Endoscopy showing a central hole 4 mm in diameter (large arrowhead) in the resected surface which was 15 mm in diameter "smallarrowheads).The first clip was misapplied.
Figure 2. The lesion was snared and was drawn into the cap using the suction function of the endoscope. Then it was ligated and resected with blended electrosurgical current.
Figure 4. The resected surface was carefully closed with four of five clips using a rotating clip-fixing device.
of the five applied clips. Subsequent bowel rest and administration of antibiotics and hyperalimentation for 10 days facilitated a quick recovery. The most important point in the t r e a t m e n t of iatrogenic perforation is to close the perforation as soon as possible so that fecal matter will not escape into the peritoneal cavity. In our case, it was closed in 30 minutes. The increase in free air accompanying the clipping procedure did not cause any problems. As for the clipping procedure, the rotator function of the device we used, which enables control of the direction of the clip, was very useful for neatly suturing the wound. Another key point is that clips were fitted from both ends of the wound. Although there is one case report of endoscopic closure by
clipping of a gastric perforation after snare excision of a gastric leiomyoma, iv this is the first case report of endoscopic repair of a colonic perforation. In cases of iatrogenic perforation, if the wound is immediately closed with clips, contamination of the peritoneal cavity can be minimized. Although the difference in outcome between conservative management and clipping is unknown, clipping therapy is more certain to prevent contamination of the peritoneal cavity. Although strict precautions in the use of EMR are necessary, iatrogenic perforation is likely to increase because of growing use of this procedure. We firmly believe that the technique of clipping will prove to be useful in the management of patients who sustain iatrogenic perforation. Fur-
VOLUME 4& NO. 5, 1997
GASTROINTESTINAL ENDOSCOPY 465
H Yoshikane, H Hidano, A Sakakibara, et al. t h e r p r o s p e c t i v e s t u d i e s of t h i s t e c h n i q u e i n l a r g e r n u m b e r s of p a t i e n t s a r e w a r r a n t e d .
ACKNOWLEDGMENTS T h e a u t h o r s t h a n k M r . J o h n Cole for h i s a s s i s tance with manuscript preparation.
REFERENCES 1. Kudo S. Endoscopic mucosa] resection of flat and depressed types of early colorectal cancer. Endoscopy 1993;25:455-61. 2. Tada M, Murakami A, Karita M, Yanai H, Oldta K. Endoscopic resection of early gastric cancer. Endoscopy 1993,25: 445-50. 3. Mealy K, Salman A, Arthur G. Definitive one-stage emergency large bowel surgery. Br J Surg 1988;75:1216-9. 4. Krukowski Z, Matheson N. Emergency surgery for diverticular disease complicated by generalized and fecal peritonitis: a review. Br J Surg 1984;71:921-7. 5. Kriwanek S, Armbruster C, Beckerhinn P, Dittrich K. Prognostic factors for survival in colonic perforation. Int J Colorect Dis 1994;9:158-62. 6. Bone R, Fisher C, Clemmer T, Slotman G, Metz C, Balk R. Sepsis syndrome: a valid clinical entity. Crit Care Med 1989;17:389-93. 7. Silvis SE, Nebel O, Rogers G, Sugawa C, Mandelstam P. Endoscopic complications: results of the 1974 ~-nerican Society for Gastrointestinal Endoscopy survey. JAMA 1976;235: 928-30.
466
GASTROINTESTINAL ENDOSCOPY
Endoscopic repair by clipping of iatrogenic colonic perforation 8. Ghazi A, Grossman M. Complications of colonoscopy and pelypectomy. Surg Clin North Am 1982;62:889-96. 9. Macrae FA, Tan KG, Williams CB. Towards safer colenoscopy: a report on the complications of 5000 diagnostic or theraputic colonoscopies. Gut 1983;24:376-83. 10. Gedebou TM, Wong RA, Rappaport WD, Jaffe P, Kahsai D, Hunter GC. Clinical presentation and management of iatrogenic colon perforations. Am J Surg 1996;172:454-8. 11. Thomson SR, Fraser M, Stupp C, Baker LW. Iatrogenic and accidental colon injuries~What to do? Dis Colon Rectum 1994;37:496-502. 12. Hall C, Dorricott NJ, Donovan IA, Neoptolemos JP. Colon perforation during colonoscopy: surgical versus conservative management. Br J Surg 1991;78:542-4. 13. Lo AY, Beaton HL. Selective management of colonoscopic perforations, J Am Coll Surg 1994;179:333-7. 14. Dubas F, Rohner A. Perforations colo-rectalses iatrogenes. Helv Chir Acta 1985;52:681-6. 15. Miyahara M, Kitano S, Shimoda K, Bandoh T, Chikuba K, Maeo S, et al. Laparoscopic repair of a colonic perforation sustained during colenoscopy. Surg Endosc 1996;10:352-3. 16. Goh PMY, Kum CK, Chia TW, Ti TK. Laparoscopic repair of perforation of the colon during colonoscopy. Gastrointest Endosc 1994;40:496-7. 17. Binmoeller KF, Grimm H, Soehendra N. Endoscopic closure of a perforation using metallic clips after snare excision of a gastric leiomyoma. Gastrointest Endosc 1993,39:172-4.
VOLUME 46, NO. 5, 1997
MD MD MD MD MD MD MD MD
With the widespread use of colonoscopy and the development of new colonoscopic diagnostic techniques, the superficial type of colorectal tumor is being found more frequently. 1 For these colonic lesions, endoscopic mucosal resection (EMR), which was initially developed for the curative t r e a t m e n t of early gastric cancer, 2 is increasingly performed in Japan. It is reasonable to expect t h a t the larger the resected mucosal surface, the greater the likelihood of complications such as bleeding or perforation. We report here a patient with a superficial colonic adenoma who sustained iatrogenic perforation of the descending colon caused by EMR t h a t was successfully treated by endoscopic clipping therapy. CASE REPORT
A 46-year-old man who was shown to have a superficial type of colonic adenoma of about 10 mm in diameter (Fig. 1) at endoscopy underwent EMR. A transparent plastic cap (Distal Attachment, MH-483, Olympus Optical, Ltd., Tokyo, Japan) was fitted to the distal end of the endoscope. Physiological saline solution (2 ml) was injected under the lesion. The lesion was snared and drawn into the cap using the suction function of the endoscope. It was then ligated and resected with electrocautery using a blended current (Fig. 2). When we observed the area of resection (about 15 mm in diameter) we found a central perforation about 4 mm in diameter (Fig. 3). The patient did not have any abdominal pain, but iatrogenic colonic perforation had surely occurred. Endoscopic repair was undertaken. With a rotating clip fixing device (HX-5QR-1, Olympus), five clips were carefully fitted. Although the first was misclipped, the other four were well fitted and the resected surface was closed (Fig. 4). The patient was subsequently treated by withholding of oral intake, administration of antibiotics, and hyperalimentation for 10 days. His posttreatment course was uneventful. Although he had slight tenderness and From the Department of Internal Medicine, Handa City Hospital, Handa, and the Second Department of Internal Medicine, Nagoya University School of Medicine, Nagoya, Japan. Reprint requests: Hiroaki Yoshikane, MD, Internal Medicine, Handa City Hospital, 2-29 Toyo, Handa, Aichi, 475, Japan. Copyright © 1997 by the American Society for Gastrointestinal Endoscopy 0016-5107/97/$5.00 + 0 37/4/84454
464 GASTROINTESTINAL ENDOSCOPY
rebound pain for 3 days, C-reactive protein decreased from 6.7 mg/dL to 0.8 mg/dL in 5 days, and the free air in the abdomen had considerably decreased by the end of I week. He began to eat 9 days after the clipping procedure and was discharged at 2 weeks; clinical follow-up at 3 months disclosed no problems. DISCUSSION
Colonic perforation is an abdominal emergency with high mortality?, 4 The patient's course depends on the presence or absence of sepsis. 5 Peritoneal contamination with intestinal bacteria rapidly leads to endotoxinemia and septic shock. G The course of sepsis, once perforation of the colon has occurred, is independent of the underlying disease. The septic state of the patient cannot be related to the degree of peritonitis. 5 The reported incidence of iatrogenic perforation during therapeutic colonoscopy ranges from 0.15% to 2.14%. ~-9 It is, however, assumed t h a t the increased use of EMR adds to the risk of perforation. This type of perforation differs from t h a t caused by underlying disease because of the intraluminal cleansing t h a t results from bowel preparation. Concerning the m a n a g e m e n t of iatrogenic colon perforation, either primary repair or resection and anastomosis by surgery have been generally performed with acceptable rates of morbidity, l° There are several recent reports of colonic perforation sustained during colonoscopy t h a t was successfully m a n a g e d with conservative measures. 11-1~ Nonoperative m a n a g e m e n t consists of careful clinical observation, intravenous antibiotics, nasogastric tube decompression, and frequent laboratory studies. n,13 Although conservative t r e a t m e n t m a y surely be used when the perforation is small and retroperitoneal, 11 failed nonoperative m a n a g e m e n t with delayed laparotomy results in greater contamination, necessitating major surgery?, 14 Laparoscopic repair of colonic perforation sustained during colonoscopy was introduced in recent years and leads to rapid recovery. 15, 16 In the management of urgent intra-abdominal disorders, laparoscopy is safe and effective. It provides an exact diagnosis and is of assistance in deciding the necessity of prompt operative management. Whenever possible, however, patients and physicians prefer to avoid emergency surgery. In the case presented here we reasoned as follows. The intestinal lumen is, fortunately, clean. Therefore, by at once closing the wound by any means, leakage of fecal m a t t e r to the peritoneal cavity can be minimized, and healing of the wound might occur rapidly. This reasoning proved to be correct. The wound, 15 m m in diameter with a central perforation, was closed with only four VOLUME 46, NO. 5, 1997
Endoscopic repair by clipping of iatrogenic colonic perforation
Figure 1. Endoscopy showing a superficial colonic adenoma about 10 mm in diameter. The lesion became better defined after dye spraying.
H Yoshikane, H Hidano, A Sakakibara, et al.
Figure 3. Endoscopy showing a central hole 4 mm in diameter (large arrowhead) in the resected surface which was 15 mm in diameter "smallarrowheads).The first clip was misapplied.
Figure 2. The lesion was snared and was drawn into the cap using the suction function of the endoscope. Then it was ligated and resected with blended electrosurgical current.
Figure 4. The resected surface was carefully closed with four of five clips using a rotating clip-fixing device.
of the five applied clips. Subsequent bowel rest and administration of antibiotics and hyperalimentation for 10 days facilitated a quick recovery. The most important point in the t r e a t m e n t of iatrogenic perforation is to close the perforation as soon as possible so that fecal matter will not escape into the peritoneal cavity. In our case, it was closed in 30 minutes. The increase in free air accompanying the clipping procedure did not cause any problems. As for the clipping procedure, the rotator function of the device we used, which enables control of the direction of the clip, was very useful for neatly suturing the wound. Another key point is that clips were fitted from both ends of the wound. Although there is one case report of endoscopic closure by
clipping of a gastric perforation after snare excision of a gastric leiomyoma, iv this is the first case report of endoscopic repair of a colonic perforation. In cases of iatrogenic perforation, if the wound is immediately closed with clips, contamination of the peritoneal cavity can be minimized. Although the difference in outcome between conservative management and clipping is unknown, clipping therapy is more certain to prevent contamination of the peritoneal cavity. Although strict precautions in the use of EMR are necessary, iatrogenic perforation is likely to increase because of growing use of this procedure. We firmly believe that the technique of clipping will prove to be useful in the management of patients who sustain iatrogenic perforation. Fur-
VOLUME 4& NO. 5, 1997
GASTROINTESTINAL ENDOSCOPY 465
H Yoshikane, H Hidano, A Sakakibara, et al. t h e r p r o s p e c t i v e s t u d i e s of t h i s t e c h n i q u e i n l a r g e r n u m b e r s of p a t i e n t s a r e w a r r a n t e d .
ACKNOWLEDGMENTS T h e a u t h o r s t h a n k M r . J o h n Cole for h i s a s s i s tance with manuscript preparation.
REFERENCES 1. Kudo S. Endoscopic mucosa] resection of flat and depressed types of early colorectal cancer. Endoscopy 1993;25:455-61. 2. Tada M, Murakami A, Karita M, Yanai H, Oldta K. Endoscopic resection of early gastric cancer. Endoscopy 1993,25: 445-50. 3. Mealy K, Salman A, Arthur G. Definitive one-stage emergency large bowel surgery. Br J Surg 1988;75:1216-9. 4. Krukowski Z, Matheson N. Emergency surgery for diverticular disease complicated by generalized and fecal peritonitis: a review. Br J Surg 1984;71:921-7. 5. Kriwanek S, Armbruster C, Beckerhinn P, Dittrich K. Prognostic factors for survival in colonic perforation. Int J Colorect Dis 1994;9:158-62. 6. Bone R, Fisher C, Clemmer T, Slotman G, Metz C, Balk R. Sepsis syndrome: a valid clinical entity. Crit Care Med 1989;17:389-93. 7. Silvis SE, Nebel O, Rogers G, Sugawa C, Mandelstam P. Endoscopic complications: results of the 1974 ~-nerican Society for Gastrointestinal Endoscopy survey. JAMA 1976;235: 928-30.
466
GASTROINTESTINAL ENDOSCOPY
Endoscopic repair by clipping of iatrogenic colonic perforation 8. Ghazi A, Grossman M. Complications of colonoscopy and pelypectomy. Surg Clin North Am 1982;62:889-96. 9. Macrae FA, Tan KG, Williams CB. Towards safer colenoscopy: a report on the complications of 5000 diagnostic or theraputic colonoscopies. Gut 1983;24:376-83. 10. Gedebou TM, Wong RA, Rappaport WD, Jaffe P, Kahsai D, Hunter GC. Clinical presentation and management of iatrogenic colon perforations. Am J Surg 1996;172:454-8. 11. Thomson SR, Fraser M, Stupp C, Baker LW. Iatrogenic and accidental colon injuries~What to do? Dis Colon Rectum 1994;37:496-502. 12. Hall C, Dorricott NJ, Donovan IA, Neoptolemos JP. Colon perforation during colonoscopy: surgical versus conservative management. Br J Surg 1991;78:542-4. 13. Lo AY, Beaton HL. Selective management of colonoscopic perforations, J Am Coll Surg 1994;179:333-7. 14. Dubas F, Rohner A. Perforations colo-rectalses iatrogenes. Helv Chir Acta 1985;52:681-6. 15. Miyahara M, Kitano S, Shimoda K, Bandoh T, Chikuba K, Maeo S, et al. Laparoscopic repair of a colonic perforation sustained during colenoscopy. Surg Endosc 1996;10:352-3. 16. Goh PMY, Kum CK, Chia TW, Ti TK. Laparoscopic repair of perforation of the colon during colonoscopy. Gastrointest Endosc 1994;40:496-7. 17. Binmoeller KF, Grimm H, Soehendra N. Endoscopic closure of a perforation using metallic clips after snare excision of a gastric leiomyoma. Gastrointest Endosc 1993,39:172-4.
VOLUME 46, NO. 5, 1997