Drainage via colonic transendoscopic enteral tubing increases our confidence in rescuing endoscopy-associated perforation

A 25-year-old woman with stricturing Crohn’s disease in the transverse colon underwent endoscopic balloon dilation. A colonic transendoscopic enteral tube (outer diameter 2.7 mm, FMT-DT-F-27/1350; FMT Medical, Nanjing, China) with loops was fixed onto the ascending colon wall by endoscopic clips [1] after dilation ([Fig. 1]). The colonic transendoscopic enteral tube was primarily for frequently delivering medications and for transplantation of washed microbiota [2] after endoscopy-associated perforation and bleeding were excluded. However, perforation was identified on X-ray ([Fig. 2]) when she complained of abdominal pain and fever 1 day after endoscopy. The transendoscopic enteral tube was immediately used to drain the air and fluid in the colon using syringe suction ([Fig. 3]). She recovered rapidly and started enteral nutrition 4 days later. Interestingly, she suffered another endoscopic dilation-induced perforation 1 year later and was successfully rescued in time by the same colonic transendoscopic enteral tube technique and antibiotics.

Fig. 1 The transendoscopic enteral tube was fixed by two clips on the proximal bowel wall in a patient with Crohn’s disease.

Fig. 2 A perforation was identified on abdominal X-ray 1 day post-procedure.

Fig. 3 Frequent suction using a syringe via the transendoscopic enteral tube.

In order to confirm the rescue value of transendoscopic enteral tube drainage for endoscopy-associated perforation, a 51-year-old man with ulcerative colitis and laterally spreading mild dysplasia in the sigmoid colon was similarly managed. The perforation was identified on computed tomography 3 days after endoscopic submucosal dissection (ESD) ([Fig. 4]), although antibiotics were used post-ESD. The colonic transendoscopic enteral tube was fixed onto the descending colon wall for drainage ([Video 1]). He recovered very quickly and started enteral nutrition 4 days later.

Fig. 4 Computed tomography revealed a perforation after endoscopic submucosal dissection in a patient with ulcerative colitis.

Video 1 The key steps for using a colonic transendoscopic enteral tube and drainage to treat a perforation.

If perforations are identified in patients with Crohn’s disease, an urgent evaluation and surgery consultation should be done [3]. The majority of iatrogenic sigmoid perforations in ulcerative colitis patients were considered for sub-total colectomy with end ileostomy, staged total proctocolectomy with ileal pouch, segmental colectomy with primary anastomosis, segmental colectomy with colostomy, or primary surgical repair [4]. This report indicates for the first time that timely drainage using a colonic transendoscopic enteral tube could be the core management approach to avoid surgery in patients with an endoscopy-associated perforation.

Endoscopy_UCTN_Code_CPL_1AM_2AH

Publication History

Article published online:
12 May 2021

• References

• 1 Zhang T, Long C, Cui B. et al. Colonic transendoscopic tube-delivered enteral therapy (with video): a prospective study. BMC Gastroenterol 2020; 20: 135
• 2 Fecal Microbiota Transplantation-standardization Study Group. Nanjing consensus on methodology of washed microbiota transplantation. Chin Med J (Engl) 2020; 133: 2330-2332
• 3 Shen B, Kochhar G, Navaneethan U. et al. Practical guidelines on endoscopic treatment for Crohn's disease strictures: a consensus statement from the Global Interventional Inflammatory Bowel Disease Group. Lancet Gastroenterol Hepatol 2020; 5: 393-405
• 4 DiCaprio D, Lee-Kong S, Stoffels G. et al. Management of iatrogenic perforation during colonoscopy in ulcerative colitis patients: a survey of gastroenterologists and colorectal surgeons. Int J Colorectal Dis 2018; 33: 1607-1616