Iatrogenic perforation during colonoscopy in the endoscopic suturing era: surgical emergency or endoscopic clinical practice?

A 46-year-old man with end-stage renal disease and a surgical history of three kidney transplants underwent colonoscopy to assess eligibility for retransplantation. Water exchange CO₂-insufflated colonoscopy was performed under deep sedation.

After traversing about 50 cm of the fixed and acutely angulated sigmoid colon, an iatrogenic perforation was promptly recognized: a transmural wall defect 20 mm in diameter ([Fig. 1]). Broad-spectrum antibiotic therapy was started. After a prompt multidisciplinary evaluation, immediate endoscopic closure under general anesthesia was planned ([Video 1]).

Fig. 1 Sigmoid colon iatrogenic perforation (white dashed line) with a visible fragment of omentum (asterisk).

Video 1 Simultaneous endoscopic full-thickness closure of an iatrogenic sigmoid perforation after diagnostic colonoscopy.

The perforation site was reached with a double-channel endoscope (GIF2T160; Olympus Europe, Hamburg, Germany). Endoscopic peritoneal exploration was done in order to rule out leaked luminal contents and visceral injuries.

An angiocatheter attached to a syringe half-filled with normal saline was percutaneously inserted under direct endoscopic view for capnoperitoneum management ([Fig. 2]). A full-thickness continuous suture incorporating an omental flap was performed using the OverStitch suturing device (Apollo Endosurgery, Austin, Texas, USA), thus creating an omental patch endoscopically.

Fig. 2 Percutaneous insertion of an angiocatheter under endoscopic view for capnoperitoneum management. a Focus on the cannula into the peritoneal cavity. b The connected syringe half-filled with sterile saline solution and visible bubble inside.

The complete closure was confirmed by full luminal distension restoration and by the negative air-leak pressure test. Furthermore, neither contrast medium nor CO₂ extravasation was observed on fluoroscopy. The angiocatheter was extracted after removal of all residual peritoneal gas.

Over the subsequent 48 hours, broad-spectrum antibiotics, fluid replacement, and fasting were prescribed. The patient remained asymptomatic: the physical examination was negative for signs of peritonitis and the bowel remained canalized. Abdominal computed tomography performed on Day 2 showed intact anastomotic site without free fluid collections ([Fig. 3]). Oral feeding was resumed, and the patient was discharged on the following day.

Fig. 3 Abdominal computed tomography showing intact anastomotic site (red dashed line) with no evidence of leakage.

Colonic perforations are potentially life-threatening complications of both diagnostic and therapeutic colonoscopies, with a reported incidence of 0.03 % – 0.8 % and up to 5 %, respectively [1]. The sigmoid colon is the most common perforation site during diagnostic procedures [2]. The availability of full-thickness endoscopic suturing systems can help to confine surgery to highly selected cases.

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• References

• 1 Paspatis GA, Dumonceau JM, Barthet M. et al. Diagnosis and management of iatrogenic endoscopic perforations: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement. Endoscopy 2014; 46: 693-711
• 2 Lüning TH, Keemers-Gels ME, Barendregt WB. et al. Colonoscopic perforations: a review of 30,366 patients. Surg Endosc 2007; 21: 994-997