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Lu Y, Mo L, Chen J, Peng W. Perforation of barium sulfate enterography in an infant: A case report. Medicine (Baltimore) 2024; 103:e37926. [PMID: 38669395 PMCID: PMC11049704 DOI: 10.1097/md.0000000000037926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 03/28/2024] [Indexed: 04/28/2024] Open
Abstract
RATIONALE Barium peritonitis is an inflammatory response that occurs when barium accidentally enters the abdominal cavity during a barium test. In extreme circumstances, it has the potential to harm various organs and even result in death. PATIENT CONCERNS A 3-month-old infant was diagnosed with multiple organ failure after severe barium peritonitis. DIAGNOSIS Multiple organ dysfunction is associated with barium peritonitis. INTERVENTIONS The infant underwent surgical intervention and received ventilator support, anti-infection therapy, myocardial nutrition, liver and kidney protection, rehydration, circulation stabilization, and other symptomatic supportive care. OUTCOMES The patient experienced clinical death after treatment and resuscitation was unsuccessful. LESSONS Barium enema perforation complications are uncommon, but can lead to fatal injuries with a high mortality rate. This case highlights the importance of raising awareness among clinicians about the risks of gastroenterography in infants and children and actively preventing and avoiding similar serious complications. The mortality rate can be reduced by timely multidisciplinary consultation and joint management once a perforation occurs.
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Affiliation(s)
- Yixing Lu
- Department of Anesthesiology, Maternal and Child Health Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
| | - Lixian Mo
- Department of Pediatric Surgery, Maternal and Child Health Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
| | - Junhong Chen
- Department of Pathology, Maternal and Child Health Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
| | - Wei Peng
- Department of Anesthesiology, Maternal and Child Health Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
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Clinical characteristics and outcome of iatrogenic colonic perforation related to diagnostic vs. therapeutic colonoscopy. Surg Endosc 2022; 36:5938-5946. [PMID: 35048189 PMCID: PMC9283341 DOI: 10.1007/s00464-022-09010-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 01/03/2022] [Indexed: 12/19/2022]
Abstract
Aim 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. Methods We 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. Results 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 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. Conclusion 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.
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3
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Thompson EV, Snyder JR. Recognition and Management of Colonic Perforation following Endoscopy. Clin Colon Rectal Surg 2019; 32:183-189. [PMID: 31061648 DOI: 10.1055/s-0038-1677024] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Although rare, perforation can be a devastating complication of colonoscopy. Incidence ranges from 0.012 to 0.65% during diagnostic procedures and is higher in therapeutic procedures. Early diagnosis and management are of paramount importance to decrease morbidity. Diagnostic imaging after colonoscopy can reveal extraintestinal air, but overall clinical status including leukocytosis, fever, pain, and peritonitis is equally important to determine management. With the expanding availability of complex endoscopic interventions, an increasing number of perforations are recognized during colonoscopy or immediately afterward based on high degree of suspicion. Colonoscopic management of these early perforations may be feasible and avoid the morbidity of surgery. Patients who require surgery may be managed with laparoscopic or open surgical techniques. Surgical management may consist of primary repair of the injury, resection with anastomosis, or resection with ostomy. Mechanical bowel preparation before endoscopy decreases fecal contamination after perforation, often obviating the need for ostomy creation.
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Affiliation(s)
- Earl V Thompson
- Division of Colon and Rectal Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Jonathan R Snyder
- Division of Colon and Rectal Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
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Kumar P, Gupta P, Bhatia V, Singh H. 'White lines' in abdomen: fatal complication of a fluoroscopy procedure. Trop Doct 2018; 48:377-378. [PMID: 30089421 DOI: 10.1177/0049475518792401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Prem Kumar
- 1 Senior Resident, Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Pankaj Gupta
- 2 Assistant Professor, Department of Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Vikas Bhatia
- 3 Assistant Professor, Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Harjeet Singh
- 4 Assistant Professor, Department of General Surgery, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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Lara LF, Avalos D, Huynh H, Jimenez-Cantisano B, Padron M, Pimentel R, Erim T, Schneider A, Ukleja A, Parlade A, Castro F. The safety of same-day CT colonography following incomplete colonoscopy with polypectomy. United European Gastroenterol J 2015; 3:358-363. [PMID: 26279844 PMCID: PMC4528210 DOI: 10.1177/2050640615577881] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Accepted: 02/24/2015] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Concerns about the risk of bowel perforation for same-day computed tomography colonography (CTC) following an incomplete colonoscopy with polypectomy may lead to unnecessarily postponing the CTC. OBJECTIVE The objective of this article is to describe the complications including colon perforations associated with same-day CTC in a cohort who had polypectomies but an incomplete colonoscopy. DESIGN We conducted a retrospective study. SETTING Our study took place in a single, tertiary referral center. PATIENTS We studied consecutive patients who had CTC the same day as an incomplete colonoscopy with polypectomy. INTERVENTIONS Interventions included optical colonoscopy (OC), endoscopic polypectomies, and same-day CTC. MAIN OUTCOME MEASUREMENTS Our main outcome measurements included perforation rate with long-term follow-up. RESULTS A total of 3% of patients undergoing colonoscopy from January 2008 to December 2012 had same-day CTC following incomplete OC, and 72 polypectomies were performed in 34 (or 17%) of these patients. Incomplete colonoscopies were due to colon tortuosity and looping (25), severe angulations (five), colon mass (two), colon stenosis (one), bradycardia (one). Fifty-three percent of the OCs were screening for colon neoplasia, 29% diagnostic and 18% were surveillance of colon polyps. Most polyps were ≤ 5 mm, and found in the left colon. There were no reported complications or perforations associated with same-day CTCs during short- and long-term follow-up. LIMITATIONS Limitations of our analysis included retrospective single-center design, small number of patients for the occurrence, referral to same-day CTC was not standardized, inability to establish safety of CTC for specific scenarios such as after complex polypectomies, strictures, or advanced IBD. CONCLUSIONS Radiologists' apprehension to perform a CTC the same day as an incomplete colonoscopy following polypectomies because of perceived risk of perforation may be unfounded. More data are needed to determine the safety of same-day CTC in patients with high-risk findings during colonoscopy such as a stricture, severe IBD, and after complex polypectomies.
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Morino M, Risio M, Bach S, Beets-Tan R, Bujko K, Panis Y, Quirke P, Rembacken B, Rullier E, Saito Y, Young-Fadok T, Allaix ME. Early rectal cancer: the European Association for Endoscopic Surgery (EAES) clinical consensus conference. Surg Endosc 2015; 29:755-73. [DOI: 10.1007/s00464-015-4067-3] [Citation(s) in RCA: 92] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 01/07/2015] [Indexed: 12/13/2022]
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Vahedian-Ardakani J, Nazerani S, Saraee A, Sarmast A, Saraee E, Keramati MR. Proper management for morbid iatrogenic retroperitoneal barium insufflation. Ann Coloproctol 2015; 30:285-9. [PMID: 25580416 PMCID: PMC4286776 DOI: 10.3393/ac.2014.30.6.285] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2014] [Accepted: 06/25/2014] [Indexed: 02/03/2023] Open
Abstract
A barium enema is a diagnostic and therapeutic procedure commonly used for colon and rectum problems. Rectal perforation with extensive intra- and/or extraperitoneal spillage of barium is a devastating complication of a barium enema that leads to a significant increase in patient mortality. Due to the low number of reported cases in recent scientific literature and the lack of experience with the management of these cases, we would like to present our treatment approach to a rare case of retroperitoneal contamination with barium, followed by its intraperitoneal involvement during a diagnostic barium enema. Our experience with long-term management of the patient and the good outcome will be depicted in this paper.
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Affiliation(s)
| | - Shahram Nazerani
- Department of Surgery, Iran University of Medical Sciences, Tehran, Iran
| | - Amir Saraee
- Department of Surgery, Iran University of Medical Sciences, Tehran, Iran
| | - Ali Sarmast
- Department of Surgery, Iran University of Medical Sciences, Tehran, Iran
| | - Ehsan Saraee
- Department of Surgery, Iran University of Medical Sciences, Tehran, Iran
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Abstract
AIM Adequate colonic imaging is generally an invasive procedure with attendant risks, particularly perforation. Endoscopy, barium enema and computed tomographic colonography (CTC) are the main techniques for investigating patients with symptoms of, or screening for, colorectal cancer. The potential complications of these investigations have to be weighed against the benefits. This article reviews the literature on the incidence, presentation and management of iatrogenic colonic perforation at colonic imaging. METHOD A literature review of relevant studies was undertaken using PubMed, Cochrane library and personal archives of references. Manual cross-referencing was performed, and relevant references from selected articles were reviewed. Studies reporting complications of endoscopy, barium enema and CT colonography were included in this review. RESULTS Twenty-four studies were identified comprising 640,433 colonoscopies, with iatrogenic perforation recorded in 585 patients (0.06%). The reported perforation rate with double-contrast barium enema was between 0.02 and 0.24%. Serious complications with CTC were infrequent, though nine perforations were reported in a case series of 24,365 patients (0.036%) undergoing CTC. CONCLUSION Perforation remains an infrequent and almost certainly under-reported, complication of all colonic imaging modalities. Risk awareness, early diagnosis and active management of iatrogenic perforation minimizes an adverse outcome.
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Affiliation(s)
- J S Khan
- Queen Alexandra Hospital, Portsmouth, UK.
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9
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Benign pneumoperitoneum after colonoscopy. Case Rep Med 2010; 2010:631036. [PMID: 20592984 PMCID: PMC2892687 DOI: 10.1155/2010/631036] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2010] [Revised: 04/14/2010] [Accepted: 05/12/2010] [Indexed: 11/25/2022] Open
Abstract
Pneumoperitoneum frequently indicates a perforated abdominal viscus that requires emergent surgical management. However; pneumoperitoneum, on rare occasion, can occur without perforation. In these cases, it is defined as benign pneumoperitoneum. Benign pneumoperitoneum means asymptomatic free intra-abdominal air or pneumoperitoneum without peritonitis and can occur occasionally with colonoscopy. In this paper, we present a rare case of benign pneumoperitoneum that developed after diagnostic colonoscopy and review it in conjunction with the current literature.
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Schoellhammer HF, Gregorian AC, Sarkisyan GG, Petrie BA. How important is rigid proctosigmoidoscopy in localizing rectal cancer? Am J Surg 2009; 196:904-8; discussion 908. [PMID: 19095107 DOI: 10.1016/j.amjsurg.2008.08.005] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2008] [Revised: 08/23/2008] [Accepted: 08/23/2008] [Indexed: 12/28/2022]
Abstract
BACKGROUND Colonoscopic localization of rectal and rectosigmoid tumors may be inaccurate. Rigid proctosigmoidoscopy has been suggested as an adjunctive technique to accurately localize rectal tumors as it may alter treatment options. METHODS A retrospective review was performed of patients with rectal and rectosigmoid cancer from 2001 to 2006. Patients were stratified into 1 of 4 anatomic regions based on colonoscopic localization of the tumor. The distances of the tumor from the anal verge by colonoscopy were compared with distances obtained via rigid proctosigmoidoscopy. RESULTS Rigid proctosigmoidoscopy localization likely changed the treatment options in 21% of lower rectal tumors, 14% of middle rectal tumors, 38% of upper rectal tumors, and 29% of rectosigmoid tumors. Overall, this modality impacted 25% of patients. CONCLUSIONS Rigid proctosigmoidoscopy localization of rectal tumors can significantly change treatment options and should be performed on all patients with colonoscopic localization of a cancer thought to be in the rectosigmoid or rectum.
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Affiliation(s)
- Hans F Schoellhammer
- Department of Surgery, Harbor-UCLA Medical Center, 1000 West Carson St., Torrance, CA 90509, USA
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Jafri SMR, Arora A. Silent perforation: an iatrogenic complication of colonoscopy. Surg Laparosc Endosc Percutan Tech 2008; 17:452-4. [PMID: 18049414 DOI: 10.1097/sle.0b013e3180dca5c4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
A 55-year-old woman presented with a complaint of 3 months of bloody diarrhea with an approximately 8 stools per day. She initially underwent a flexible sigmoidoscopy at an outside hospital with biopsies showing acute and chronic colitis. She was started on asacol 2 tablets 3 times per day. Her symptoms persisted and she was placed on prednisone with only transient improvement in her symptoms. She continued to have diarrhea and malaise with 30-lb weight loss over 2 months. Outpatient colonoscopy was performed for evaluation of this change in bowel habit. Colonoscopy showed 2-cm terminal ileal polyp, focal ulcer of the cecum, and severe ulcerative colitis from mid-ascending colon to rectum, with touch friability, spontaneous bleeding, pseudopolyps, and ulceration. Multiple biopsies were taken of the friable and ulcerated regions. After colonoscopy, the patient remained stable with no complaints of pain. She was then taken for computed tomographic enterography showing severe colitis but also reflecting a large amount of air surrounding the right abdominal structures including the liver, gallbladder, right kidney, and right side of the colon. Air extended inferiorly into the right thigh and superiorly into the chest where it reached the mediastinum and pericardium. There was also a small amount of air in the peritoneal cavity under the diaphragm and adjacent to the liver. These findings were thought most likely secondary to asymptomatic colonic perforation secondary to colonoscopy. The patient remained stable, afebrile, and pain-free small bowel pathology from colonoscopy revealed carcinoid tumor of the terminal ileum. The patient remained stable despite intraperitoneal, retroperitoneal, and subcutaneous free air on follow-up x-ray. Patient underwent elective ileocecectomy 2 weeks later with postoperative films showing no evidence of free air. Iatrogenic perforation of the colon is a rare but feared complication of coloscopy with an incidence in some studies of 0.03% to 0.09%. This case demonstrates asymptomatic colonic perforation to a dramatic effect.
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12
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Endoclipping of iatrogenic colonic perforation to avoid surgery. Surg Endosc 2007; 22:1500-4. [DOI: 10.1007/s00464-007-9682-1] [Citation(s) in RCA: 113] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2007] [Revised: 08/30/2007] [Accepted: 10/03/2007] [Indexed: 12/16/2022]
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Tulchinsky H, Madhala-Givon O, Wasserberg N, Lelcuk S, Niv Y. Incidence and management of colonoscopic perforations: 8 years' experience. World J Gastroenterol 2006; 12:4211-4213. [PMID: 16830377 PMCID: PMC4087376 DOI: 10.3748/wjg.v12.i26.4211] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2005] [Revised: 07/10/2005] [Accepted: 07/15/2005] [Indexed: 02/06/2023] Open
Abstract
AIM To review the experience of a major medical teaching center with diagnostic and therapeutic colonoscopies and to assess the incidence and management of related colonic perforations. METHODS All colonoscopies performed between January 1994 and December 2001 were studied. Data on patients, colonoscopic reports and procedure-related complications were collected from the departmental computerized database. The medical records of the patients with post procedural colonic perforation were reviewed. RESULTS A total of 120067 colonoscopies were performed during the 8 years of the study. Seven colonoscopic perforations (4 females, 3 males) were diagnosed (0.058%). Five occurred during diagnostic and two during therapeutic colonoscopy. Six were suspected during or immediately after colonoscopy. All except one had signs of diffuse tenderness and underwent immediate operation with primary repair done in 4 patients. No deaths were reported. CONCLUSION Perforation rate during colonoscopy is low. Nevertheless, it is a serious complication and its early recognition and treatment are essential to optimize outcome. In patients with diffuse peritonitis early operative intervention makes primary repair a safe option.
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Affiliation(s)
- Hagit Tulchinsky
- Department of Surgery B, Sourasky Medical Center, 6 Veizman St., Tel Aviv 64239, Israel.
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14
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Nezhat C, de Fazio A, Nicholson T, Nezhat C. Intraoperative sigmoidoscopy in gynecologic surgery. J Minim Invasive Gynecol 2006; 12:391-5. [PMID: 16213423 DOI: 10.1016/j.jmig.2005.03.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2004] [Accepted: 03/28/2005] [Indexed: 12/20/2022]
Abstract
Intraoperative sigmoidoscopy is underused by the majority of practicing gynecologists and is not widely taught in obstetrics and gynecology training programs. In this report, a step-by-step approach is provided in order to perform sigmoidoscopy. Indications for use, along with various intraoperative applications, are discussed. Results from our center's experience with its use during laparoscopic treatment of adhesions, endometriosis, and associated disease of the bowel also are provided. Intraoperative sigmoidoscopy is a safe and efficacious procedure that can aid in the evaluation and treatment of pelvic pathology and facilitate identification and management of bowel injuries. It should be considered a valuable adjunct when such cases are encountered by gynecologic and pelvic surgeons.
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Affiliation(s)
- Ceana Nezhat
- Atlanta Center for Special Pelvic Surgery, Atlanta, Georgia 30342, USA.
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15
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Abstract
PURPOSE Rectal injuries during barium enema are rare but life-threatening complications. The last review about this subject was published more than ten years ago. In the present review, we present an overview on the subject and especially focus on changes in treatment strategies and developments of less risky visualization techniques. METHODS A literature search was performed in the PubMed library using the key words-barium enema, complications, peritonitis, and rectal perforation-as well as related articles and other references obtained from these articles. RESULTS The most frequent cause of perforation is iatrogenic and catheter-related. Other causes are related to weakness of the colorectal wall or obstruction. Five types of perforations have been described: 1) perforations of the anal canal below the levator; 2) incomplete perforations; 3) perforations into the retroperitoneum; 4) transmural perforations into adjacent viscera; 5) perforations into the free intraperitoneal cavity. Most incomplete perforations and one-half of the retroperitoneal perforations have minimal clinical signs. Intraperitoneal perforations lead to the most catastrophic course, starting with rectal bleeding and mild abdominal complaints. This is rapidly followed by progressive sepsis and peritonitis, and leads to a high mortality rate. Surgery is not always required for intramural or small retroperitoneal perforations. These can be treated conservatively and require surgical debridement only in case of large amounts of extravasation or abscesses. Surgical repair of large rectal mucosal lesions or anal sphincter lesions is advised. Perirectal abscesses require drainage. Intraperitoneal perforations with gross extravasation need immediate aggressive surgical treatment in a critical care setting, because the threat of shock is high. Intraperitoneal perforations, neglected perforations, gross barium extravasation, poorly prepared colon, and venous intravasation of barium are prognostically unfavorable. The severest late complication in intraperitoneal perforations is ileus. Meticulous technical performance of the barium enema is the most important factor in prevention. CONCLUSIONS Rectal perforations after barium enema are rare. The overall mortality rate decreased in recent decades from approximately 50 to 35 percent as the result of advances in supportive and intensive care. Because of these advances, more aggressive surgical strategies were undertaken. With the advent of endoscopy, less barium enemas are performed. Consequently, the absolute incidence of complications has decreased. It is expected that in the future barium enemas will be replaced by more sensitive and less risky techniques, such as CT colonography and magnetic resonance colonography.
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Affiliation(s)
- Peter W de Feiter
- Department of Surgery, University Hospital Maastricht, Maastricht, The Netherlands.
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Lazović R, Krivokapić Z. [The role of enterostomy in the management of colonic injuries]. ACTA CHIRURGICA IUGOSLAVICA 2005; 52:73-82. [PMID: 16119318 DOI: 10.2298/aci0501073l] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The circumstances, evaluation and results of the management of 67 colonic and rectal injuries during the period 1992-2003 in Clinical Centre of Podgorica are presented. In 32 war and 37 civilian injuries to colon, several systems of the severity trauma determination, as well as systems of grading and classification of injuries of colon were evaluated, and the surgical access according to achieved results was investigated in order to determine the use of enetrostomy in the management of these inuries. From the presented and statistically evaluated results, it can be concluded that Flintzs 3 grade classification can be used as the most reliable indicative and prognostic system. For the succes of One stage surgical procedure, the most critical fact is differentiation between Flintzs Grade I and II (Chi Square 4.514; P) as well between Grade II and III. That means that by using One stage procedure, unfavourable results may be expected not only in Grade II, but as well in border cases between II and III. Also, according to the presented results, there were not differences observed in the success of management between Grade II and III (Chi Square 0.678; P0.05). That means that using Two stage procedure, unfavourable results can be prevented not only in the borderline cases between Grades II and III, but also in the Grade III. Two stage surgical approach in the repair of injuried colon remains valuable and usefull surgical procedure, even in spite of success of surgical technology and operative technique, in cases with severe and multiple abdminal injuries, and in borderline decision making. These procedures are also inevitable in the management of any complication of primary repair of the colonic wound. Using rational evaluation and good surgical techniqe, primary repair of can be used in almost 50% of civilian and war injuries injuries of colon.
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Affiliation(s)
- R Lazović
- Centar za abdominalnu hirurgiju KC Podgorica
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17
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Abstract
Acute diverticulitis is a frequent and important diagnosis in gastrointestinal disease, most commonly involving the colon. It is estimated that approximately 15% to 30% of patients with diverticulosis develop symptomatic diverticulitis at some point in the natural history of the condition, often requiring medical and/or surgical therapy. The clinical diagnosis is often difficult to make, and several radiological studies have been used over the past decades to assist in the diagnosis of acute diverticulitis. These include barium enema, ultrasound, and computed tomography (CT). A number of studies over the past decade have shown CT to be the preferable initial examination because of its ability to demonstrate not only the extent of intramural inflammation but also the degree of pericolic disease, including intraperitoneal inflammation, perforation, and abscess formation. Additional benefits of CT imaging include guiding therapeutic interventions in complicated forms of diverticular disease and providing an alternative diagnosis in patients without diverticulitis. The accuracy, techniques, criteria for diagnosis, and staging and applications of CT imaging in acute diverticulitis are discussed.
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Affiliation(s)
- Tara Lawrimore
- Department of Radiology, Harvard Medical School, Cambridge, Massachusetts, USA
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Cobb WS, Heniford BT, Sigmon LB, Hasan R, Simms C, Kercher KW, Matthews BD. Colonoscopic Perforations: Incidence, Management, and Outcomes. Am Surg 2004. [DOI: 10.1177/000313480407000902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Fiberoptic colonoscopy provides superior diagnostic and therapeutic capabilities in the treatment of lower gastrointestinal disease processes. A well-recognized, but uncommon, complication during the procedure is perforation. The purpose of this study was to determine the incidence of colonoscopic perforation, define risk factors, assess the management of these complications, and evaluate outcomes. From January 1997 through December 2003, 43,609 colonoscopies were performed in our medical center. There were 14 (0.032%) perforations (1 in 3115 procedures); 7 from diagnostic and 7 from therapeutic procedures. General surgeons performed 1243 procedures (2.9%), and their rate of perforation was 0.080 per cent compared with 0.031 per cent for gastroenterologists during the same period. Half of the perforations occurred in the rectosigmoid, and the most common mechanism was mechanical (n = 6). Perforation was identified immediately during endoscopy in 50 per cent of the patients. Thirteen of 14 perforations were treated within 24 hours; 1 was delayed 48 hours. Initial surgical management was undertaken in 11/14 patients. Initial nonoperative treatment was attempted in three and was successful in only one patient. The mean length of stay following perforation was 11.2 days (range, 4–36 days). Three patients (21.4%) had 7 postoperative complications. Colonoscopic perforations are uncommon but can be recognized early and managed surgically with acceptable morbidity and postoperative length of stay.
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Affiliation(s)
- William S. Cobb
- From the Carolinas Laparoscopic and Advanced Surgery Program, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - B. Todd Heniford
- From the Carolinas Laparoscopic and Advanced Surgery Program, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Lee B. Sigmon
- From the Carolinas Laparoscopic and Advanced Surgery Program, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Reem Hasan
- From the Carolinas Laparoscopic and Advanced Surgery Program, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Connie Simms
- From the Carolinas Laparoscopic and Advanced Surgery Program, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Kent W. Kercher
- From the Carolinas Laparoscopic and Advanced Surgery Program, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Brent D. Matthews
- From the Carolinas Laparoscopic and Advanced Surgery Program, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
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20
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Lazović R, Krivokapić Z. [Endoscopic perforations of colon and rectum]. ACTA CHIRURGICA IUGOSLAVICA 2004; 51:111-5. [PMID: 16018377 DOI: 10.2298/aci0403111l] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
Although fiberoptic examination of the colon is nowdays considered to be safe procedure, endoscopic perforation remains rare, but serious and potentially life threatening complication. General incidence od diagnostic and interventional perforations of colon ranges, according to the literature between 0.1-0.9%, or for diagnostic procedure about 0.17%, and for interventional 0.41%, with general mortality rate of 0.006%. In spite of the general trend for diminishing this occdurence, it is necessary to compare various experiences in order to achieve an algorrhithm of early diagnostic and the way of the surgical management of this particular kind of perforation. The aim of this work is to present the experience in 1995-2004 period, upon 7 (0.12%) cases of surgically treated perforations of colon after 5,680 performed diagnostic colonoscopies. In all 7 cases the reason for perforation was not basically pathologiocal process. 4 cases of perforations were recognized immediately, and they were managed by direct suture of the perforation. In 3 cases diagnosis was late from 1 to 3 days, and two-step operative procedure was performed in septic condition. Subjective and clinical signs of perforations were not always unifrom, but in all 7 cases there were clear X-ray signs of free intraabdominal air. Surgical treatment was successfull, and without deaths. In the algorrhithm of surgical diagnostic and procedure, the same principles and criteria used for civilian injuries of colon are to be used.
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Sorantin E, Werkgartner G, Balogh E, Vilanova i Bartroli A, Palagyi K, Nyul LG, Rusko L. Virtual Dissection and Automated Polyp Detection of the Colon Based on Spiral CT - Techniques and Preliminary Experience on a Cadaveric Phantom. Eur Surg 2002. [DOI: 10.1046/j.1563-2563.2002.02018.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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23
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Tran DQ, Rosen L, Kim R, Riether RD, Stasik JJ, Khubchandani IT. Actual Colonoscopy: What are the Risks of Perforation? Am Surg 2001. [DOI: 10.1177/000313480106700906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Recent studies have suggested that virtual colonoscopy (VC) and actual colonoscopy (AC) have similar efficacy for detection of polyps >6 mm. However, procedural risks with emerging technology such as VC need to be assessed before widespread implementation. We propose to demonstrate complication rates after AC that can be used for a comparative benchmark in VC. From 1994 to 1999 all patients undergoing AC who sustained perforation that required operation were analyzed for the mortality and complications. There were 26,162 consecutive colonoscopies that required 21 operations for perforation. Of these 16,948 (65%) colonoscopies were diagnostic and 9,214 (35%) were therapeutic with 11 (0.06%) and 10 (0.11%) operations respectively. Overall risk for colonoscopic perforation that requires operation was one in 1,246 (one in 1,541 for diagnostic and one in 921 for therapeutic). Five perforations were oversewn, 15 were resected (five with stoma), and one was drained. One patient died. There were two reoperations. Mortality was 0.006 per cent (one in 16,948) for diagnostic and zero for therapeutic colonoscopy. Overall risk for perforation that requires operation or mortality after AC is low. Virtual colonoscopists who propose screening and subsequent therapeutic interventions need to report high volume without complications as the perforation rate requiring operation was one in 1,246.
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Affiliation(s)
- De Q. Tran
- Department of Surgery, Division of Colon and Rectal Surgery, Lehigh Valley Hospital, Allentown, Pennsylvania
| | - Lester Rosen
- Department of Surgery, Division of Colon and Rectal Surgery, Lehigh Valley Hospital, Allentown, Pennsylvania
| | - Ran Kim
- Department of Surgery, Division of Colon and Rectal Surgery, Lehigh Valley Hospital, Allentown, Pennsylvania
| | - Robert D. Riether
- Department of Surgery, Division of Colon and Rectal Surgery, Lehigh Valley Hospital, Allentown, Pennsylvania
| | - John J. Stasik
- Department of Surgery, Division of Colon and Rectal Surgery, Lehigh Valley Hospital, Allentown, Pennsylvania
| | - Indru T. Khubchandani
- Department of Surgery, Division of Colon and Rectal Surgery, Lehigh Valley Hospital, Allentown, Pennsylvania
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Abstract
Colorectal cancer is an important problem in the United States, with over 130,000 new cases and 55,000 deaths each year. There is now strong evidence that screening for colorectal cancer with fecal occult blood testing can decrease mortality, and additional evidence that removing benign adenomas can decrease cancer incidence. Evidence-based screening guidelines depend on colorectal cancer risk. Individuals at higher risk because of a personal or family history deserve more intensive screening than asymptomatic individuals over age 50.
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Affiliation(s)
- J F Helm
- Department of Medicine, University of South Florida, Tampa, USA
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25
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Schoenfeld P, Piorkowski M, Allaire J, Ernst R, Holmes L. Flexible sigmoidoscopy by nurses: state of the art 1999. Gastroenterol Nurs 1999; 22:254-61. [PMID: 10855122 DOI: 10.1097/00001610-199911000-00006] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Although screening flexible sigmoidoscopy is associated with a significant decrease in colorectal cancer mortality, less than 50% of eligible Americans have had a sigmoidoscopy. As the United States population ages, over 50 million Americans will be eligible for colorectal cancer screening with flexible sigmoidoscopy. The projected increase in a population eligible for screening is expected to increase demand for this procedure and may result in overwhelming currently available endoscopic resources. Gastroenterology nurses should actively seek training to perform flexible sigmoidoscopy to accommodate this increased demand. Current barriers to nurse-performed sigmoidoscopy are prohibitions by state Boards of Nursing and lack of procedural reimbursement for nurse endoscopists performing flexible sigmoidoscopy. The lack of research about the effectiveness of this practice is a contributing factor to the hindrances in the development of this nursing role. This review outlines research about the effectiveness of flexible sigmoidoscopy by nurses, legal and reimbursement issues, and details the scope of training programs used by institutions with nurse endoscopists.
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Affiliation(s)
- P Schoenfeld
- Division of Gastroenterology, National Naval Medical Center, Bethesda, Maryland 20889, USA
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26
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Abstract
Preventive medicine is an increasingly important area of clinical practice. Conceptually, preventive medicine involves three tasks of the clinician: screening, counseling, and immunization/prophylaxis. This opening article reviews some of the basic tenets underlying screening including basic epidemiologic principles, characteristics of a good screening situation, barriers to screening, and some of the potential hazards of screening.
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Affiliation(s)
- C Nielsen
- Department of General Internal Medicine, Cleveland Clinic Foundation, Ohio, USA
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27
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Abstract
The clinical diagnosis of appendicitis and diverticulitis remains challenging. Clinical diagnosis alone can lead to unnecessary hospitalizations and surgeries, prolonged periods of hospital observation, and delays prior to necessary medical or surgical treatment. Helical CT combined with recently reported techniques for imaging appendicitis and diverticulitis offers rapid and accurate confirmation or exclusion of these entities as well as identification of alternative conditions that can clinically mimic them. More routine use of helical CT holds great promise for improving patient care and lowering hospital resource use in patients with clinically suspected appendicitis and diverticulitis.
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Affiliation(s)
- P M Rao
- Harvard Medical School, Boston, Massachusetts, USA.
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28
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Abstract
Screening sigmoidoscopy is associated with a 45% to 80% reduction in colorectal cancer mortality. Although less than 50% of eligible Americans have been screened with flexible sigmoidoscopy (FS), the use of this procedure is rising rapidly. By the year 2000, as many as 10 million screening FS per year could be performed. To accommodate the increased demand, many medical centers have trained paramedical personnel (i.e. physician assistants, nurses, and gastroenterology technicians) to perform FS. However, as a result of the paucity of research about this practice, only physicians receive a professional fee for performing screening FS. Many state Boards of Nursing explicitly prohibit registered nurses (RNs) from performing this procedure. This review outlines research about the effectiveness of paramedical endoscopists, medico-legal and reimbursement issues, and outlines a training program in FS for paramedical personnel.
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Affiliation(s)
- P Schoenfeld
- Division of Gastroenterology, National Naval Medical Center, Bethesda, Maryland 20889, USA.
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29
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Abstract
Randomized, controlled trials have shown with certainty that screening for colorectal cancer reduces morbidity and is cost-effective. Factors that increase the risk of colorectal cancer include a personal or family history of adenomatous polyps or colorectal cancer, certain genetic syndromes and chronic inflammatory bowel disease.
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Affiliation(s)
- M A Jednak
- Division of Gastroenterology, University of Michigan Medical Center, Ann Arbor, Michigan 48109-0362, USA
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30
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Gedebou TM, Wong RA, Rappaport WD, Jaffe P, Kahsai D, Hunter GC. Clinical presentation and management of iatrogenic colon perforations. Am J Surg 1996; 172:454-7; discussion 457-8. [PMID: 8942543 DOI: 10.1016/s0002-9610(96)00236-x] [Citation(s) in RCA: 89] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Because iatrogenic colonic perforation is uncommon, surgical management of this complication has been based on the civilian trauma experience. In this study, we determine the incidence, clinical presentation, and management of colonic perforations resulting from colonoscopy or barium enema. PATIENTS AND METHODS The medical records of all patients with colorectal perforations due to barium enema or colonoscopy seen over a 5-year period were reviewed. RESULTS Twenty-one patients, 12 males and 9 females aged 66 +/- 16 years, undergoing evaluation for polyps and bleeding (11), diverticulosis (4), diarrhea (2), or miscellaneous indications (4) sustained colonic perforation from colonoscopy (18; 0.20%) or barium enema (3; 0.10%). Abdominal pain, 66% (13), and fever, 24% (5), were the most frequent symptoms encountered and extraluminal air, 67% (14), the most common radiologic finding. The site of perforation was the rectosigmoid in 62% (13) of patients. Eighteen patients underwent surgery; 11 within 24 hours (group I) and 7 patients within 6.0 +/- 4 days (group II). Fifty percent (9 of 18) had primary repair or resection with anastomosis without mortality. Of the 6 patients initially treated nonoperatively, 3 subsequently underwent surgery. Both deaths, one in group I and one in group II, occurred in patients who had colonic diversion for perforation following colonoscopy. CONCLUSION We conclude that in the absence of significant contamination either primary repair or resection and anastomosis can be performed with acceptable morbidity for iatrogenic perforations of the colon.
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Affiliation(s)
- T M Gedebou
- Department of General Surgery, University of Arizona Health Sciences Center, Tucson 85724, USA
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31
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Hulse PA, Hartley RW, Martin DF. Localized perforation into the transverse mesocolon demonstrated during barium enema--rare but benign. Clin Radiol 1994; 49:889-90. [PMID: 7828400 DOI: 10.1016/s0009-9260(05)82884-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
We report two cases demonstrating the presence of gas in the transverse mesocolon following asymptomatic perforation, shown during barium enema examination. The appearances, diagnosis and successful conservative management are described.
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Affiliation(s)
- P A Hulse
- Department of Radiology, Withington Hospital, South Manchester University Hospitals NHS Trust
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32
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Affiliation(s)
- P M Goh
- Department of Surgery, National University Hospital, Singapore
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33
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Regan MC, Boyle B, Stephens RB. Laparoscopic repair of colonic perforation occurring during colonoscopy. Br J Surg 1994; 81:1073. [PMID: 7922069 DOI: 10.1002/bjs.1800810750] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- M C Regan
- Department of Surgery, St James's Hospital, Dublin, Ireland
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34
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Kirk J, Staren ED, Franklin J, Saclarides TJ. Voice changes: an initial manifestation of colonic perforation. Gastrointest Endosc 1994; 40:125. [PMID: 8163126 DOI: 10.1016/s0016-5107(94)70045-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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35
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Shimbo T, Glick HA, Eisenberg JM. Cost-effectiveness analysis of strategies for colorectal cancer screening in Japan. Int J Technol Assess Health Care 1994; 10:359-75. [PMID: 8070999 DOI: 10.1017/s0266462300006607] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
To determine the cost-effectiveness of colorectal cancer screening strategies in Japan and to determine the influence of long-term compliance with screening programs on the selection of strategies, the natural history of a simulated cohort of 40-year-old Japanese of both genders was modeled with and without colorectal cancer screening until age 75 years. Survival, number of complications, and direct medical costs were compared among several combinations of screening examinations. In addition, the age of initiating screening was varied, as was the long-term compliance rate. Strategies using immunological fecal occult blood test were found to be the most cost-effective. Immunological fecal occult blood test followed by colonoscopy, if positive, would save 24.05 (5.88 discounted) days of life and cost 28,420 yen (US $210) per screened person, thus offering a cost-effectiveness ratio of 1.765 million yen (US $13,100) per year of life saved. If long-term compliance is 100%, initiating screening at age 40 years offers more years of life saved and a low incremental cost of screening. However, if more likely dropout rates are considered, initiation at age 40 years is dominated by later initiation of screening.
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36
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37
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Abstract
BACKGROUND Unexplained vascular collapse, airway obstruction, shock, and death after procedures as innocuous as barium enema or anorectal manometry have recently been shown to be due to allergy to latex and anaphylactoid reaction. METHOD To review existing medical literature on latex anaphylaxis and to determine who is most at risk and what methods might best prevent morbidity from this condition. RESULTS Those most at risk for this catastrophe are patients whose mucous membranes have been extensively exposed to latex, such as patients with spina bifida who frequently undergo urethral catheterization and individuals who have had many previous operative procedures: CONCLUSIONS Avoidance of latex exposure is the best prophylaxis in high-risk groups. Prompt resuscitation is critical once the syndrome becomes clinically apparent.
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Affiliation(s)
- J Kokoszka
- Section of Colon and Rectal Surgery, University of Illinois College of Medicine at Chicago 60612
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38
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Luchette FA, Doerr RJ, Kelly K, Kulaylat M, Stephan RM, Hassett JM. Colonoscopic impaction in left colon strictures resulting in right colon pneumatic perforation. Surg Endosc 1992; 6:273-6. [PMID: 1448745 DOI: 10.1007/bf02498858] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Colonic perforation during flexible colonoscopy is a rare but recognized complication. We reviewed 4,593 colonoscopies performed from 1984 to 1989. The perforation rate for diagnostic colonoscopy was 0.17% (6/3,538) and for therapeutic colonoscopy it was 2% (21/1,055). Four perforations of the right colon occurred at a site proximal to the level of the impacted colonoscope. The lesions being evaluated were obstructive in nature: two diverticular strictures (sigmoid colon), one ischemic stricture (descending colon), and one annular carcinoma (descending colon). The four perforations occurred in the right colon and manifested as distension with pneumoperitoneum or retroperitoneal emphysema. Operative management included total abdominal colectomy in two patients (ileoproctostomy in one and ileostomy in one) and right colectomy in two. Outcome was favorable in all cases.
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Affiliation(s)
- F A Luchette
- State University of New York, Department of Surgery, Buffalo 14215
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39
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Abstract
The barium enema is a safe and accurate diagnostic study of the colon but, in rare cases, complications may result. Many of these can be prevented by proper equipment and careful attention to technique. When a complication does occur, prompt recognition and management is vital in decreasing morbidity and mortality. Perforation of the bowel is the most frequent serious complication, occurring in approximately 0.02% to 0.04% of patients. Rarely the colon may burst due to excessive transmural pressure alone. However, a colon weakened by iatrogenic trauma or disease is more likely to perforate during an enema than is a normal healthy bowel. Injury to the rectal mucosa or anal canal due to the enema tip or retention balloon is probably the most common traumatic cause of barium enema perforation. Inflation of a retention balloon within a stricture, neoplasm, inflamed rectum, or colostomy stoma is particularly hazardous. Recent deep biopsy or polypectomy with electrocautery makes the bowel more vulnerable to rupture. The tensile strength of the bowel wall is impaired in elderly patients, patients receiving long-term steroid therapy, and in disease states including neoplasm, diverticulitis, inflammatory bowel disease, and ischemia. Intraperitoneal perforation leads to a severe, acute peritonitis with intravascular volume depletion. The ensuing shock may be rapidly fatal. Prompt fluid replacement and laparotomy are essential. If the patient survives the initial shock and sepsis, later complications caused by dense intraperitoneal adhesions may develop. Extraperitoneal perforation is usually less catastrophic but may result in pain, sepsis, cellulitis, abscess, rectal stricture, or fistula. Intramural extravasation often forms a persistent submucosal barium granuloma which may ulcerate or be mistaken for a neoplasm. The most dramatic complication of barium enema is venous intravasation of barium. Fortunately, this is quite rare as it may be immediately lethal. Most cases have been attributed to trauma from the enema tip or retention balloon, mucosal inflammation, or misplacement of the tip in the vagina. Bacteremia has been found in as many as 23% of patients following barium enema and, in rare cases, may cause symptomatic septicemia. Other less common complications include barium impaction, water intoxication, allergic reactions, and cardiac arrhythmias. Preparatory laxatives and cleansing enemas have been implicated in some instances of dehydration, rectal trauma, water intoxication, and perforation. Careful review of the indications for examination, previous radiographs, and clinical history will identify many of the patients at greater risk for complications so that appropriate precautions may be observed.(ABSTRACT TRUNCATED AT 400 WORDS)
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Affiliation(s)
- S M Williams
- Department of Radiology, University of Nebraska Medical Center, Omaha
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40
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Hall C, Dorricott NJ, Donovan IA, Neoptolemos JP. Colon perforation during colonoscopy: surgical versus conservative management. Br J Surg 1991; 78:542-4. [PMID: 2059801 DOI: 10.1002/bjs.1800780509] [Citation(s) in RCA: 106] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
A survey of endoscopy units in the West Midlands, UK, was undertaken to ascertain the management of colonic perforation during colonoscopy. Fifteen perforations were reported from a total of 17,500 colonoscopies performed in 14 units (a rate of 0.09 per cent). In seven patients the diagnosis was suspected or diagnosed immediately and in the remaining eight 2-72 h later. Four patients with associated pathology (carcinoma, Crohn's disease, ulcerative colitis and a polyp) had resection and primary anastomosis. Seven patients had a simple oversew, four of these having had a delayed diagnosis. In four cases the site of perforation was not identified, but only one patient had conservative treatment. Three patients had drainage and a defunctioning colostomy. There was no significant morbidity following treatment. It is recommended that patients who have had a good bowel preparation should be treated conservatively unless there is a large perforation or an underlying carcinoma.
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Affiliation(s)
- C Hall
- Academic Department of Surgery, Dudley Road Hospital, Birmingham, UK
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41
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Fry RD, Shemesh EI, Kodner IJ, Fleshman JW, Timmcke AE. Perforation of the rectum and sigmoid colon during barium-enema examination. Management and prevention. Dis Colon Rectum 1989; 32:759-64. [PMID: 2758944 DOI: 10.1007/bf02562124] [Citation(s) in RCA: 28] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Perforation of the rectum or sigmoid colon complicated 5 of 2200 barium-enema examinations performed during a 4-year period. Three patients with rectal perforations manifested by air extravasation were successfully treated with intravenous antibiotics and complete bowel rest. Two patients with barium extravasation were treated with immediate operation and colostomy. All five patients recovered. Perforation was found to be associated with a rectal stricture due to ulcerative colitis, a rectal cancer, an incarcerated inguinal hernia, fulminant ulcerative colitis, and a normal colon in an elderly patient. To determine the pressure in the rectum that could potentially be generated during a barium-enema examination, the pressures created by a standard barium delivery set were measured, using 1-meter columns of water, 25 percent diatrizoate sodium (Hypaque), 20 percent barium, and 80 percent barium. The columns generated pressures of 70, 85, 95, and 120 mm Hg respectively. Squeezing the delivery bag increased the pressure 21 to 79 percent or a maximum of 55 mm Hg. Colorectal perforation during barium-enema examination that was not accompanied by barium extravasation could be successfully treated nonoperatively. The associated pathology and our studies of pressures generated during a barium-enema examination allow us to suggest that the incidence of colorectal perforation during barium-enema radiography can be reduced by 1) performing proctoscopy prior to barium enema, 2) avoiding the use of the rectal balloon in patients with known rectal lesions, 3) avoiding barium studies in patients with active colitis, 4) avoiding generation of pressure greater than that created by a column of barium suspension of one meter, and 5) using a lower concentration of barium when possible.
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Affiliation(s)
- R D Fry
- Department of Surgery, Jewish Hospital of St. Louis, Washington University Medical Center, Missouri
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42
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Carpio G, Albu E, Gumbs MA, Gerst PH. Management of colonic perforation after colonoscopy. Report of three cases. Dis Colon Rectum 1989; 32:624-6. [PMID: 2737065 DOI: 10.1007/bf02554186] [Citation(s) in RCA: 59] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
In a review of 5424 colonoscopies performed in the last ten years at Bronx-Lebanon Hospital Center, 14 perforations related to the procedure were found. Seven perforations occurred during therapeutic colonoscopies (polypectomies) and seven during diagnostic colonoscopies. Eight patients were treated surgically and six nonsurgically. The decision about whether or not to perform surgery for a colonoscopically induced perforation depends on the clinical condition of the patient. Nonsurgical management is indicated if the patient's general condition remains stable, if the perforation has been diagnosed late, if the pneumoperitoneum that led to the diagnosis does not increase in size, if there are no signs of peritonitis, if the patient does not have a distal obstruction, and if the patient's condition improves in response to conservative treatment.
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Affiliation(s)
- G Carpio
- Department of Surgery, Bronx-Lebanon Hospital Center, New York
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43
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Abstract
Perforation of the colon or rectum during the course of barium-enema examination is estimated to occur in approximately 500 patients annually in the United States. It has been over 30 years since the last collective review on this subject reported a prohibitively high mortality and morbidity. Since that time, much has been learned about the treatment of patients with peritonitis and bowel perforation, many new and more effective antibiotics have become available, and the management of shock has become infinitely more sophisticated. A review of recently reported cases suggests that the mortality rate and possibly the early morbidity have fallen markedly. Late complications such as adhesive small-bowel obstruction and retroperitoneal fibrosis with ureteral stenosis are well described, but data on the incidence of these long-term sequelae are still not available.
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Affiliation(s)
- R P Cordone
- Department of Surgery, New York Infirmary, Beekman Downtown Hospital, New York
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44
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Joseph AM, Crowson TW, Rich EC. Cost effectiveness of HemoQuant versus Hemoccult for colorectal cancer screening. J Gen Intern Med 1988; 3:132-8. [PMID: 3128650 DOI: 10.1007/bf02596117] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Initial reports on HemoQuant, a new quantitative test for occult gastrointestinal bleeding, suggest it is more sensitive than Hemoccult. Increased detection of upper gastrointestinal tract bleeding and dietary hemoglobin may reduce HemoQuant's specificity in the screening setting. The authors performed a cost effectiveness analysis comparing Hemoccult and HemoQuant for colorectal cancer screening using assumptions based on probabilities and costs in the current literature, varying the specificity of HemoQuant. The analysis showed the marginal cost effectiveness of Hemoccult versus no test to be $43,000, and HemoQuant versus Hemoccult to be $296,000 if HemoQuant specificity is 0.95. The marginal cost effectiveness ratio increased to $601,000 if three HemoQuant tests were used. Survival benefit was small and highly dependent on Hemoccult sensitivity and mortality from colonoscopy if HemoQuant specificity was less than 0.9. The authors conclude that unless the high sensitivity reported for HemoQuant is accompanied by a specificity comparable to that of Hemoccult, HemoQuant may not be an acceptable alternative for colorectal cancer screening.
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Affiliation(s)
- A M Joseph
- Department of Medicine, Veterans Administration Medical Center, Minneapolis, MN
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45
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Selby JV, Friedman GD, Collen MF. Sigmoidoscopy and mortality from colorectal cancer: the Kaiser Permanente Multiphasic Evaluation Study. J Clin Epidemiol 1988; 41:427-34. [PMID: 3367172 DOI: 10.1016/0895-4356(88)90043-1] [Citation(s) in RCA: 58] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
The Kaiser Permanente Multiphasic Evaluation Study is often cited as evidence from a randomized trial that screening sigmoidoscopy reduces mortality from colorectal cancer. To examine the role of sigmoidoscopy in this reduction, we reviewed the 110 incident cases of colorectal cancer occurring among the 10,713 subjects from randomization in 1964 through 1982. Tumor stage at diagnosis, location, mode of discovery, and current mortality status were determined for each. We also reanalyzed chart review data for the years 1965 through 1974 to assess the difference in exposure to sigmoidoscopy between groups. Study group subjects, who were urged to have annual multiphasic health checkups (MHC), had both a lower cumulative incidence (4.3 vs 6.7 cases per 1000 persons) and a better stage distribution (86 vs 54% Stage B or better) than nonurged control subjects for colorectal cancers arising within reach of the sigmoidoscope. The lowered incidence accounted for two-thirds of the total difference in mortality. No appreciable difference in removal of colorectal polyps was seen between groups. Only a slight excess in exposure to sigmoidoscopy was seen in the study group (30 vs 25% of subjects examined at least once between 1965 and 1974), which was unlikely to account for more than a small fraction of the study group's decrease in mortality. Although the Multiphasic Evaluation Study did find a significantly lower mortality from colorectal cancer in the study group, it did not achieve a substantial difference in exposure to sigmoidoscopy. Its results are therefore inconclusive with respect to sigmoidoscopy and should not be used as evidence either for or against sigmoidoscopic screening.
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Affiliation(s)
- J V Selby
- Division of Research, Kaiser Permanente Medical Care Program, Oakland, CA 94611
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46
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Barry MJ, Mulley AG, Richter JM. Effect of workup strategy on the cost-effectiveness of fecal occult blood screening for colorectal cancer. Gastroenterology 1987; 93:301-10. [PMID: 3109993 DOI: 10.1016/0016-5085(87)91019-5] [Citation(s) in RCA: 35] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Physicians respond to a positive fecal occult blood test with a variety of workup strategies. To study the effect of the choice of strategy on the net costs and health benefits of colorectal cancer screening using this test, we used a decision analysis model to compare seven strategies that physicians might choose to examine a positive "screenee." Strategies using rigid or flexible sigmoidoscopy alone are not only insensitive, but also have high cost-effectiveness ratios. The strategy of air contrast barium enema alone had the lowest cost-effectiveness ratio. Rigid sigmoidoscopy combined with barium enema had a lower cost-effectiveness ratio than primary colonoscopy, but the strategy of primary colonoscopy could have an equal or better ratio depending on assumptions about test costs and the benefit of removing benign polyps. The primary colonoscopy strategy is both more effective and less costly than the combination of flexible sigmoidoscopy and barium enema. The optimal strategy will vary with local factors, and with the perspective of the decision-maker.
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Abstract
Accidental anorectal injuries are becoming less common. This case, where impalement of the anorectal region by the shaft of a stool occurred to a junior surgeon at work, illustrates a previously unrecognized menace.
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Abstract
A rare, if not unique, case of sigmoid colon perforation by a balloon, self-inserted transanally, is described. Mechanical properties of the sigmoid colon make it prone to rupture by pneumatic distention. Management depends on amount of peritoneal contamination, timing, and associated injury. With prompt surgery, isolated traumatic sigmoid colon perforations have a good prognosis.
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