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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 50  |  Issue : 6  |  Page : 195-199

Long-term follow-up for patients with colonic perforation due to colonoscopy: From clinical and medicolegal viewpoints


Department of Surgery, Division of Colorectal Surgery, National Taiwan University Hospital, Taipei, Taiwan

Date of Submission15-May-2017
Date of Decision17-Jul-2017
Date of Acceptance13-Sep-2017
Date of Web Publication08-Dec-2017

Correspondence Address:
Dr. Jin-Tung Liang
Department of Surgery, Division of Colorectal Surgery, National Taiwan University Hospital, No 7, Chung-Shan South Road, Taipei
Taiwan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/fjs.fjs_81_17

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  Abstract 


Background: This retrospective study analyzes the clinicopathologic features and medicolegal debates on this complication.
Methods: There were 29 records of colonic perforations, whose charts were retrospectively reviewed.
Results: A total of 26 perforations occurred as a result of diagnostic colonoscopy, and three occurred after therapeutic colonoscopy. Eight perforations were diagnosed immediately during the procedure, based on the revelation of intraperitoneal organs with bleeding of bowel wall on the colonoscopic monitor. Twenty patients were diagnosed as a hollow-organ perforation within 12 h after the completion of colonoscopy, whereas one perforation was found more than 24 h after colonoscopy. Abdominal pain and distention are the most common symptoms. All the patients underwent emergency surgery. One patient had wound infection, and two patients had leakage of the repair site. One patient aged 80 died of pulmonary septic complication. Our hospital paid all additional expenses which were not covered by the National Health Insurance Bureau for all patients, ranging from 500.0 to 1500.0 US dollars (mean ± standard deviation, 549.0 ± 145.0 US dollars). Four patients (13.8%) asked for further compensation of the complication and one litigated.
Conclusions: Iatrogenic colonic perforation due to endoscopy is potentially lethal, especially for aged patients. Some patients and their family viewed the perforation as malpractice and asked for compensations. Usually, the primary repair of the perforation site is safe, and long-term follow-up reveals no sequelae after adequate treatment.

Keywords: Colon perforation, colonoscopy, iatrogenic


How to cite this article:
Chen TC, Hung JS, Lin BR, Huang J, Liang JT. Long-term follow-up for patients with colonic perforation due to colonoscopy: From clinical and medicolegal viewpoints. Formos J Surg 2017;50:195-9

How to cite this URL:
Chen TC, Hung JS, Lin BR, Huang J, Liang JT. Long-term follow-up for patients with colonic perforation due to colonoscopy: From clinical and medicolegal viewpoints. Formos J Surg [serial online] 2017 [cited 2018 Jul 18];50:195-9. Available from: http://www.e-fjs.org/text.asp?2017/50/6/195/220350




  Introduction Top


During the medical career as an endoscopist, the physician seems to be inevitable to run the risk of being accused of iatrogenic colonic perforation. The incidence of perforation has been reported to range from 0.04% to 0.9% in diagnostic colonoscopy, and from 0.06% to 0.7% in therapeutic colonoscopy.[1],[2],[3],[4],[5],[6],[7] Management of patients with perforation has been evolving. Some authors believe that all patients with a colonic perforation after colonoscopy should be immediately managed with surgery.[8] Others suggested selective management depending on whether the perforation happened during diagnostic or therapeutic settings, degree of bowel preparation, and the presence of signs of peritonitis.[9],[10],[11]

Since iatrogenic perforation may be viewed as a result of malpractice, successful management of perforation will help the endoscopists circumvent the medicolegal problem. Moreover, although there had been some reports discussing the outcome of these patients, only very few studies discussed the medicolegal issues. Therefore, the experiences for managing such patients in this study will be helpful not only in facilitating the future prevention and appropriate treatment of this complication but also in ameliorating the medicolegal conflict, if it unavoidably occurs.


  Patients and Methods Top


A retrospective chart review of all patients with colonic perforation due to colonoscopy was undertaken. All patients underwent traditional sedation-free colonoscopy. The data collected included the patients' demography aspect, endoscopic procedure, diagnosis, treatment, outcome, and the amount of compensation if exists. The continuous data were presented as mean ± standard deviation (SD).

Ethical approval

The study was conducted in accordance with the Declaration of Helsinki and was approved by the local ethics committee of the institute. Informed written consent was obtained from all patients prior to their enrollment in this study.


  Results Top


Demography

From January 1995 to December 2004, 7722 colonoscopies were carried out at Division of Colorectal Surgery of National Taiwan University Hospital, resulting in 29 (0.38%) colonic perforations. The patients' demographic data and comorbidities were listed in [Table 1]. The indications for colonoscopy included screening, anal bleeding, obstruction of bowel, tumor, and polypectomy. Twenty-six perforations occurred as a result of diagnostic colonoscopies, and three perforations occurred after polypectomies.
Table 1: The patients' demographic data and comorbidities

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Diagnosis of perforation

Eight perforations were diagnosed during the colonoscopy, based on the revelation of intraperitoneal organs with colonic intraluminal bleeding on the colonoscopic monitor. The remaining 21 patients complained of abdominal pain, distention, or both. Because of their abdominal discomfort, they visited the hospital again, and a series of work-up was undertaken, and the final diagnosis was reached. One 80-year-old patient presented with septic shock and respiratory failure when he came back to hospital 24 h after the colonoscopy. In 11 of the 21 patients, pneumoperitoneum can be demonstrated by chest roentgenograms or computed tomography (CT) of the abdomen.

Treatment

Operation was performed within 12 h after the colonoscopy in 28 patients, and 24 h after the procedure in one patient. The choice of surgical approach depended on each surgeon's personal convictions about this kind of complication and was not dictated by any predetermined code. The surgical methods were summarized in [Table 2].
Table 2: Surgical methods

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Among these 29 patients, the location of perforation was in the left-sided colon except one in the cecum after polypectomy [Table 3]. The size of perforation ranged from 0.2 to 4.0 cm, with the median being 1.63 ± 1.13 cm. In one patient, only pneumoretroperitoneum was found, but without contamination of the peritoneal cavity.
Table 3: Sites of perforation

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Clinical outcome

The hospital stay was 14.2 ± 12.2 days (range, 8.0–40.0 days). The postoperative course was uneventful in 25 (86.2%) patients. One patient had wound infection, and two patients had leakage of the repair site. One patient aged 80 died of pulmonary complications and uncontrolled sepsis. The overall mortality rate is 3.7%.

Medicolegal issues

The health insurance system in Taiwan covered more than 90% of the fee of medical treatment in all the patients. Our hospital paid the remaining fee for all the patients, ranging from 500.0 to 1500.0 US dollars (mean ± SD, 549.0 ± 145.0 US dollars).

Four patients (13.8%) asked for further compensation of the perforation, which they viewed as malpractice. All four patients had undergone primary repair without a diverting colostomy, and their postoperative courses were uneventful. The attending endoscopist, the colorectal surgeons, lawyers, and social workers participated in the negotiation in this situation. Three patients compromised after our hospital had paid each of them about US 2000.0 dollars. The remaining one patient did not concede and litigated for indemnification. Eventually, our hospital paid her 10,000.0 US dollars, and she revoked the lawsuit.


  Discussion Top


Colonoscopy has been widely used since the 1970s as the primary diagnostic tool for the patients with suspected lesions of large bowel. This procedure carries a relatively low risk of perforation. There is still lacking a consensus on the management of this iatrogenic injury. To determine the optimal treatment, we analyzed clinicopathologic data as well as medicolegal disputes in our hospital. Some authors claimed that the treatment strategies should be determined based on the patient's general condition, the peritoneal hygiene, the underlying mechanism causing perforation, and the size of perforation. It is our opinion that not only this clinical factors but also the avoidance of the potential dispute should be taken into consideration.

Colonoscopic perforation may be due to direct perforation by the forceful insertion of the instrument tip, antimesenteric tears secondary to “slide-by” technique, pneumatic perforation due to excessive air inflation, or it may be caused by biopsy, diathermy, or polypectomy.[9],[12] In our series, perforations were usually the results of mechanical trauma by an instrument and were mostly in the left colon. Remarkably, five patients had the previous major abdominal surgery, and the presence of bowel adhesion was considered. The most frequent site of perforation in our series is the junction of the rectum and sigmoid colon, consistent with other reports.[12],[13] This can be explained by the redundancy of sigmoid colon with relatively narrowed bowel lumen, the higher incidence of diverticular disease,[9] and the acute anatomical angle of the rectosigmoid junction.

Although no patient in our series suffered from perforation due to air inflation, Kozarek et al. have shown that during colonoscopy intraluminal pressure may be generated to such an enough level as to rupture the colon, especially in the presence of underlying diseases.[9],[14] Experimental studies in human cadavers have shown that cecum, transverse colon, sigmoid colon, and rectum are in the decreasing order of frequency of susceptibility to rupture. The pressure required to rupture, the cecum was the lowest (81 mmHg), compared with 169 mmHg for the sigmoid colon.[14]

The clinical presentation of colonic perforation varies greatly and depends on the size, site and mechanism of perforation, the underlying pathology, degree of peritoneal contamination, and the patient's general condition. Except those patients diagnosed immediately during the endoscopic procedures, abdominal pain, either localized or diffuse, was the most common symptom in our series. The onset of abdominal pain was usually within 12 h after the colonoscopy but may be delayed up to 24 h in our series. It has been a report of delayed cecal perforation with pain onset 2 days after the colonoscopy.[15] Gedebou et al. showed that other clinical symptoms of colonic perforation include fever, bleeding, abdominal distention, nausea/vomiting, and subcutaneous emphysema [8] in decreasing frequency. To improve the early diagnostic rate, it needs to emphasized that when the patients complained of abdominal discomfort after colonoscopy, the diagnosis of colonic perforation should be therefore kept in mind.

In our series, pneumoperitoneum was demonstrated by chest X-rays in only half of the patients and facilitated the surgical intervention. Remarkably, the perforation may be present without extravasated air. It is worth noting that 10 of our patients were subjected to laparotomy based merely on the clinical suspicion of perforation. Failure to detect pneumoperitoneum on chest roentgenograms does not exclude the necessity of laparotomy. Furthermore, the quantity of intraperitoneal air is related to the duration of perforation. The size of bowel perforation found at surgery did not correlate with the amount of free air found on preoperative CT scan.[16]

It has been proposed that perforations caused by diagnostic colonoscopy warrant surgical intervention, whereas conservative treatment should be first considered in stable patients with perforations as a result of therapeutic colonoscopy [11],[17],[18] However, it had been reported that conservative management of colonoscopic perforation can be misleading,[19] resulting in mortality. Colonic perforations due to colonoscopy were all managed by emergency surgery in our series. Our main concern is that when medical treatment fails, delayed surgery can deteriorate the patient's prognosis,[20] and therefore intensify the conflict between patients and doctors. If patients died after the initial attempt of conservative treatment, their family may regard conservative treatment as the surgeon's deliberate delay in rescuing the patient's life. The treatment outcome in our series is acceptable, resulting in the mortality rate of only 3.7%. However, about 14% of the patients still thought the hospital should indemnify for the iatrogenic colon perforation, even though they had an uneventful recovery from the injury.

The surgical treatment can be either single-procedure or double-staged methods. Single-procedure surgery can be used when it is performed at an early stage, and the results are usually good as long as the patient is with the following favorable factors: a small-sized perforation, proper colonic preparation, and minimal peritoneal contamination. Our series showed that primary repair without a diverting colostomy was a satisfactory surgical strategy, resulting in leakage of repair site in two patients and mortality in one elderly patient. This low mortality rate may be attributed to adequate mechanical bowel preparation before the due colonoscopic examination, early diagnosis and prompt treatment of perforation.[21] However, one 80-year-old patient still died of this complication. In elderly patients with coexisting medical conditions, the outlook remains grim.[22] A diverting colostomy sometimes increases morbidity,[8],[23] particularly because it is sometimes permanent.[23],[24] However, double-staged surgery should be considered when the risk of leakage is high, such as a large amount of peritoneal excrement exists, the patients are undernourished, and/or they have many underlying diseases. The mortality seems to depend more on the general condition of the individual patient than on the type of surgery used.[11]

All the patients in the present study underwent traditional open laparotomy to manage their colonoscopic complications. However, many authors carried out laparoscopic treatment for this iatrogenic perforation. Some authors showed that laparoscopic treatment brought a definitive treatment of this major complication in a minimally invasive way, and recommended the use of laparoscopic approach in substitution for more extensive procedures.[25],[26] However, it still needs further large-scaled randomized studies to establish the safety and efficacy of laparoscopic approaches.

Currently, sedative and analgesic medications have been used widely to provide patients comfort to reduce procedure time and improve examination quality during colonoscopy.[27],[28],[29] In the gastrointestinal department, around 80% of patients whose colonoscopy was performed under sedation. Therefore, the present article could provide the historical data for the evaluation of the cost performance of sedative colonoscopy, which is nowadays nearly a routine procedure during daily practice.

Four patients (13.8%) asked for further compensation of the perforation, even after they had undergone primary repair without a diverting colostomy, and their postoperative course was uneventful. In contrast, other more severe cases did not ask for further compensation. The reasons are that the patients will sue or not depends on the attitude of colonoscopists before and after the examination. If the patient is well informed before the examination regarding the possible complications, feel the friendly attitude, and gentle manipulation from the examiner, and has received the warm care when postexamination abdominal pain suggestive of colonic perforation occurred, usually they can be appeased, and the medicolegal can be prevented.


  Conclusion Top


Colonoscopy carries a low risk of colonic perforation which is sometimes lethal. Forceful insertion of instrument, overinflation of air, and/or careless use of electrocautery should be avoided. The diagnosis may be based on clinical presentations of peritonitis and/or image findings. Immediate one-staged surgery results in an acceptable low mortality and morbidity rate. Some patients and their family may view the iatrogenic injury as malpractice and litigate for compensation, even though recovery from the injury is smooth.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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