Safety of Lower Endoscopy in the Early Postoperative Period After Colorectal Resection and Anastomosis

C Reategui, A Testa, R Mentz, G da Silva, R Babakhanlou, S D Wexner, D Sands, D Maron, L J Rosen, J G Nogueras, E Weiss. Cleveland Clinic Florida

Introduction: Lower endoscopy is a useful tool in the diagnosis and treatment of several diseases of the colon and rectum. When performed in the postoperative period however, there is a potential risk for anastomotic dehiscence. The aim of this study was to evaluate the safety of lower endoscopy in the early post-operative period after colorectal resection and anastomosis.
Methods and Procedures: After Institutional Review Board approval, patients who underwent lower endoscopy with sedation within one month after surgery between 8/2001 and 7/2010 were identified. Patient’s demographics, type of procedure, lower endoscopy indication, findings and complications were recorded from a prospectively maintained data base and chart review.
Results: 4676 patients underwent colectomy and anastomosis; 61 (1.2%) patients (36 males, 25 females) of mean age of 56.9 (19-92) years underwent flexible sigmoidoscopy within 1 month after resection. 58 patients underwent flexible sigmoidoscopy and 3 colonoscopy at a mean postoperative time of 18 (1-31) days. The most common surgical procedures were left side colectomy in 30 (49.1%) patients, followed by restorative proctectomy in 12 (19.6%), and total proctocolectomy with ileal pouch anal anastomosis in 6 (9%). Indications for lower endoscopy included rectal bleeding in 19 (31.1%) patients, suspected stricture in 18 (29.5%), evaluation prior to stoma closure in 9 (14.7%), suspected leakage in 6 (9.9%), rectal pain in 5 (8.2%), abdominal pain in 2 (3.3%) and anastomotic dehiscence evaluation in 2 (3.3%). 15 (24.5%) patients had abnormal findings: 7 (46.6%) dehiscence, 3 (20%) sinus tract, 2 (13.3%) anastomosis edema, 1 (6.7%) pouch edema, 1 (6.7%) stricture, and 1 (6.7%) ischemia. 32 (52.5%) patients had a protective stoma at the time of endoscopy. There were 4 (6.5%) complications during or after endoscopy: 2 respiratory, 1 cardiac and 1 possibly related to anastomotic dehiscence, all in non-diverted patients. Two patients with prolonged postoperative ileus developed aspiration requiring endotracheal intubation. One patient with multiple comorbidities and postoperative bleeding developed a non-ST elevation myocardial infarction during the procedure. One patient with ileus underwent a negative flexible sigmoidoscopy 13 days following a total colectomy for colonic inertia; she required laparotomy and ileostomy for free perforation from anastomotic dehiscence few days after the procedure. All 4 patients recovered well and were discharged on average on postoperative day 21 (14-35).
Conclusion: Flexible sigmoidoscopy is a relatively safe procedure in the immediate postoperative period. However, in patients with obstruction, ensuring adequate decompression may avoid aspiration upon sedation.

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