Iatrogenic colorectal perforation during therapeutic colonoscopy is
a rare but serious complication [1]. It is usually
managed with immediate open surgery. However, conservative therapy has recently
been advocated [2], provided that adequate
precolonoscopic bowel preparation has been carried out and that no peritoneal
signs are present [3]. Asymptomatic perforations after
colonoscopic polypectomy have been conservatively managed using close
observation, even in the presence of intra-abdominal free air
[4]. Recently, endoclip closure was used to treat
iatrogenic colonic perforation conservatively [5];
however, endoclipping cannot be used to repair perforations that are larger
than the endoclip (diameter 11 mm) [5].
We report the case of a large iatrogenic rectal perforation due to
endoscopic mucosal resection (EMR) and its subsequent conservative
treatment.
A 65-year-old woman with a flat 30-mm-wide rectal adenoma underwent
EMR after injection of 0.4 % sodium hyaluronate ([Fig. 1 a]).
Fig. 1 a A flat, 30-mm-wide
rectal adenoma underwent endoscopic mucosal resection. b
An approximately 25-mm-wide perforation was noted at the mucosectomy site, and
the marginal mucosa of the perforation was circumferentially attached to the
tissue adjacent to the rectum using endoclips. c Closure
of the perforation was confirmed 10 days later.
The lesion was completely removed; however, a 25-mm-wide perforation
was noted on the posterior wall at 10 cm from the anal verge. The
perforation was too large to be closed by endoclipping, so the marginal mucosa
of the perforation was circumferentially attached to the presacral tissue
adjacent to the rectum using endoclips ([Fig. 1 b]). Computed tomography (CT) revealed
free air in the presacral space, but no pneumoperitoneum ([Fig. 2 a]).
Fig. 2 a CT scan of the abdomen
after endoscopic mucosal resection revealed free air in the presacral space,
but no pneumoperitoneum. b The amount of free air had
not increased on the next day.
The patient was asymptomatic and her general status was stable.
Therefore, conservative treatment was instituted, with intravenous antibiotic
injections and discontinuance of oral nutrition. On the next day, the
patient’s white blood cell count and C-reactive protein level were
normal; the amount of free air observed on CT had not increased ([Fig. 2 b]). Proctoscopy revealed closure of
the perforation 10 days later ([Fig. 1 c]),
and the patient was discharged on day 16. At 2 years after EMR she has had no
further complication. The resected specimen was 38 mm wide, and the
pathological diagnosis was tubulovillous adenoma (diameter 30 mm;
[Fig. 3]).
Fig. 3 The resected specimen
was 38 mm wide, and the pathological diagnosis was tubulovillous
adenoma.
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