Treatment of colonic perforations during colonoscopy in 2009

Objectives Colonic perforations during a colonoscopy can occur when there is excessive pressure oil the colonic wall, during a therapeutic procedure (coagulation, polypectomy, mucosectomy) or by a reaction secondary to the use of a high frequency current in the colon with persistency of fermentation gas. It is very rare, about 2 %, and sometimes even between 0.5 and 1 % during screening colonoscopies in subjects at average risk of colorectal cancer. The purpose of this review is to discuss existing arguments and objectives in order to position endoscopic treatrnent with clips compared with a standard surgical approach. Methodology Standard treatment is surgery and is associated with mortality ranging between 3 and 10 %: The procedure is a single suture in 1/3 of cases with the risk of temporary or permanent stomy ranging from 11 to 39 %. Results The first endoscopic closure with clips was conducted in 1997 and since then 84 cases have been reported in the literature. A Successful closure with clips was described in 69 to 100 % of cases for the largest series but this success only represents a sub-group of patients only representing 19, 56 and 90 % of 23 to 30 perforations recorded in the three largest series. Endoscopic closure call only be considered if diagnosis is made during a colonoscopy with excellent colonic preparation, total exsufflation towards the end of the closure and accurate marking of the anatomical site of the perforation closed with clips. However, treatment relies oil medical-surgical monitoring and approach; the discovery of a pneumoperitoneum in all asymptomatic patient is not a formal indication for surgery. All perforations whose diagnosis is delayed are generally associated with abdominal or peritoneal symptoms, which is an indication for surgery. Conclusions The perfection of endoscopic closure equipment or suturing paves the way for considering a change to this algorithm. However, treatment will always be based on the need to recognise the perforation during the initial colonoscopy and to have cost-effective equipment to treat these perforations; the circumstances of which mean that they cannot be secondarily treated by a referring centre. Key points: - existing Colonic perforations are rare and mainly occur during therapeutic colonoscopy; Treatment in the event of delayed diagnosis or peritoneal symptoms is surgery; A single suture during surgery is possible but only in 1/3 of cases; Endoscopic treatment is only possible if diagnosis is immediate and the perforation small (< 10 mm). - new Clip closure provides good results if it is complete and done during a colonoscopy with excellent preparation and with an exsufflated colon; Pluri-daily monitoring is medical-surgical and the onset of: local or diffuse peritoneal symptoms most often in the first 24 hours must invoke second-intent surgery.