Perforation and post-polypectomy bleeding complicating colonoscopy in a population-based screening program

Abstract

Background and study aims We aimed to estimate the rate of hospital admissions for perforation and for post-polypectomy bleeding, after outpatient colonoscopy following a first positive fecal occult blood test screen through the population-based ColonCancerCheck program in Ontario, Canada.

Patients and methods We identified all individuals aged 50 to 74 years with a first positive CCC gFOBT screening result from 2008 to 2017 who underwent outpatient colonoscopy ≤ 6 months later and who did not receive a diagnosis of CRC ≤ 24 months later. We identified inpatient hospital admissions for colonic perforation ≤ 7 days after and for post-polypectomy bleeding ≤ 14 days following colonoscopy.

Results Among 121,626 individuals who underwent colonoscopy, the rate of perforation was 0.6 per 1000 from 2008 to 2012 and 0.4 per 1000 from 2013 to 2017. The rate was elevated among those aged 70 to 74 years; those with comorbidities; when colonoscopy was performed by endoscopists other than gastroenterologists or endoscopists with low prior year volume; and when polypectomy was performed during colonoscopy. The rate of bleeding was 4.3 per 1000 and was elevated among those aged 70 to 74 years, those with comorbidity, and with complex polypectomy. Both outcomes were more common among those aged 70 to 74 years, those with a 5-year cumulative Charlson score ≥ 1, those with prior hospitalization for ischemic heart disease, and those with endoscopists whose prior year colonoscopy volume was in the three lower quartiles.

Conclusions Colonic perforation and post-polypectomy bleeding, among participants of population-based colorectal screening programs who test positive in the absence of colorectal cancer, are infrequent but serious complications, which increase with participant age and comorbidity, and with endoscopist characteristics.

Publication History

Received: 22 July 2020

Accepted: 23 November 2020

Article published online:
15 April 2021

• References

• 1 Towler B, Irwig L, Glasziou P. et al. A systematic review of the effects of screening for colorectal cancer using the faecal occult blood test, hemoccult. BMJ 1998; 317: 559-565
• 2 Canadian Task Force on Preventive Health Care. Colorectal cancer screening: Recommendation statement from the Canadian Task Force on Preventive Health Care. CMAJ 2001; 165: 206-208
• 3 Public Health Agency of Canada Recommendations for population-based colorectal cancer screening: National Committee on Colorectal Cancer Screening. Public Health Agency of Canada; 2002 Available at (accessed July 18, 2019): https://www.canada.ca/en/public-health/services/reports-publications/technical-report-national-committee-colorectal-cancer-screening/national-committee-colorectal-cancer-screening.html
• 4 Rabeneck L, Tinmouth JM, Paszat LF. et al. Ontarioʼs ColonCancerCheck: results from canadaʼs first province-wide colorectal cancer screening program. Cancer Epidemiol Biomarkers Prev 2014; 23: 508-515
• 5 Paszat L, Sutradhar R, Tinmouth J. et al. Interval colorectal cancers following guaiac fecal occult blood testing in the Ontario ColonCancerCheck Program. Can J Gastroenterol Hepatol 2016; 2016: 4768728
• 6 Deyo RA, Cherkin DC, Ciol MA. Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. J Clin Epidemiol 1992; 45: 613-619
• 7 Johns Hopkins ACG System. (accessed June 16, 2020): www.hopkinsacg.org/
• 8 Rabeneck L, Paszat LF, Hilsden RJ. et al. Bleeding and perforation after outpatient colonoscopy and their risk factors in usual clinical practice. Gastroenterology 2008; 135: 1899-1906 , 1906.e1
• 9 Rabeneck L, Saskin R, Paszat LF. Onset and clinical course of bleeding and perforation after outpatient colonoscopy: a population-based study. Gastrointest Endosc 2011; 73: 520-523
• 10 Stuart EA, Lee BK, Leacy FP. Prognostic score-based balance measures can be a useful diagnostic for propensity score methods in comparative effectiveness research. J Clin Epidemiol 2013; 66: S84-S90
• 11 Austin PC. Using the standardized difference to compare the prevalence of a binary variable between two groups in observational research. Commun Statistics Sim Comput 2009; 38: 1228-1234
• 12 Derbyshire E, Hungin P, Nickerson C. et al. Colonoscopic perforations in the English National Health Service Bowel Cancer Screening Programme. Endoscopy 2018; 50: 861-870
• 13 Derbyshire E, Hungin P, Nickerson C. et al. Post-polypectomy bleeding in the English National Health Service Bowel Cancer Screening Programme. Endoscopy 2017; 49: 899-908
• 14 Zorzi M, Mangone L, Sassatelli R. et al. Screening for colorectal cancer in Italy: 2011-2012 survey. Epidemiol Prev 2015; 39: 115-125
• 15 Vermeer NC, Snijders HS, Holman FA. et al. Colorectal cancer screening: Systematic review of screen-related morbidity and mortality. Cancer Treat Rev 2017; 54: 87-98
• 16 Reumkens A, Rondagh EJ, Bakker CM. et al. Post-colonoscopy complications: a systematic review, time trends, and meta-analysis of population-based studies. Am J Gastroenterol 2016; 111: 1092-1101
• 17 Wang L, Mannalithara A, Singh G. et al. low rates of gastrointestinal and non-gastrointestinal complications for screening or surveillance colonoscopies in a population-based study. Gastroenterology 2018; 154: 540-555.e8
• 18 Bielawska B, Hookey LC, Sutradhar R. et al. anesthesia assistance in outpatient colonoscopy and risk of aspiration pneumonia, bowel perforation, and splenic injury. Gastroenterology 2018; 154: 77-85.e3
• 19 Laanani M, Coste J, Blotière PO. et al. Patient, procedure, and endoscopist risk factors for perforation, bleeding, and splenic injury after colonoscopies. Clin Gastroenterol Hepatol 2019; 17: 719-727.e13
• 20 Forbes N, Boyne DJ, Mazurek MS. et al. Association Between endoscopist annual procedure volume and colonoscopy quality: systematic review and meta-analysis. Clin Gastroenterol Hepatol 2020; 18: 2192-2208
• 21 Tinmouth J, Kennedy EB, Baron D. et al. Colonoscopy quality assurance in Ontario: Systematic review and clinical practice guideline. Can J Gastroenterol Hepatol 2014; 28: 251-274
• 22 Wieten E, Spaander MC, Kuipers EJ. Accrediting for screening-related colonoscopy services: What is required of the endoscopist and of the endoscopy service?. Best Pract Res Clin Gastroenterol 2016; 30: 487-495
• 23 Bronzwaer MES, Depla ACTM, van Lelyveld N. et al. Quality assurance of colonoscopy within the Dutch national colorectal cancer screening program. Gastrointest Endosc 2019; 89: 1-13
• 24 Tinmouth J, Patel J, Hilsden RJ. et al. Audit and feedback interventions to improve endoscopist performance: Principles and effectiveness. Best Pract Res Clin Gastroenterol 2016; 30: 473-485
• 25 Bishay K, Causada-Calo N, Scaffidi MA. et al. Associations between endoscopist feedback and improvements in colonoscopy quality indicators: a systematic review and meta-analysis. Gastrointest Endosc 2020;