Colonoscopic Perforation Management in the Era of Laparoendoscopy; A Simple Algorithim

Tafadzwa P Makarawo, MD, Edward Itawi, MD, Amir Damadi, MD, Gurteshwar Rana, MD, Vijay K Mittal, MD. Providence Hospital Medical Centers

INTRODUCTION: The role of laparoscopy in the management of iatrogenic colonoscopic injuries has increased as more reports of successful treatments have emerged. Iatrogenic colonoscopic perforations have a varied presentation. Perforations are defined by colonic location, length and degree of tear, time to presentation, and mechanism of injury.

Laparoscopic surgeons have differing levels of skill and institutional resources when faced with this complication. Drawing from the experiences of previously documented literature and that of our own institution, we have formulated a simple algorithm that guides laparoscopic surgeons with varied means in treating colonoscopic perforations.

METHODS AND PROCEDURES: A retrospective review of four patients admitted to our institution following iatrogenic colonic perforation over the course of 2 years was undertaken. For each patient, the initial clinical assessment, resuscitation, surgical management and post-operative recovery was carefully studied and recorded.
A medline search was performed of previous literature on the subject incorporating primarily the search words “colonoscopy”, “perforation” and “laparoscopy”. Twenty articles involving 95 patients were identified and reviewed focusing on patient clinical presentation, laparoscopic interventions and outcomes. From this and our own experiences, we formulated our algorithm.

RESULTS: Between May of 2009 and May 2011, four patients with colonoscopic perforations underwent laparoscopic surgical repair by two attendings. Their presentations and outcomes are summarized below. There were no post-operative complications.

*All patients underwent laparoendoscopy prior to their definitive procedure.

ALOGORITHM:

* Secondary to previous medical or surgical comorbidities

CONCLUSIONS:
Traditionally laparotomy has been the standard of care for treating colonoscopic perforations when conservative management is deemed inappropriate. Our initial experience reinforces previous views that laparoendoscopic surgery is a safe and effective alternative to managing this complication. We have formulated a simple algorithm that we have found helpful to the surgeon considering a laparoscopic approach to managing this condition.

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