MANAGEMENT OF COLONOSCOPIC PERFORATIONS

Objective: To document our evolving surgical management of colonoscopi c perforation and examine factors crucial to the improvement of patien t care. Design: We conducted a computer-based retrospective analysis o f medical records (1980 through 1995). Material and Methods: Among 57, 028 colonoscopic procedures performed, 43 patients (0.075%, or 1 perfo ration in 1,333 procedures) had a colonic perforation. Two additional patients were treated after colonoscopy performed elsewhere. The outco mes analyzed included surgical morbidity and mortality. Results: Twent y-six women and 19 men who ranged in age from 28 to 85 years (median, 69) were treated for colonic perforation. More than 80% of perforation s occurred during the latter half of the study period because of the i ncreased volume of colonoscopic procedures (8 perforations among 12,58 1 examinations from 1980 through 1987 versus 35 perforations among 44, 447 colonoscopies from 1988 through 1995). Emergency laparotomy was pe rformed in 42 patients (93%). Perforations occurred throughout the col on: right side = 10; transverse = 9; and left side = 23. Three patient s without evidence of peritoneal irritation fared well with nonoperati ve management. Most patients underwent primary repair or limited resec tion in conjunction with end-to-end anastomosis. In 14 patients (33%), an ostomy was created. One patient underwent laparotomy without furth er treatment. Intra-abdominal contamination ranged from none (31%) to local soiling (48%) to diffusely feculent (21%). Postoperative complic ations occurred in 12 patients and were associated with older age (P = 0.01), large perforations (P = 0.03), and prior hospitalization (P = 0.04). No postoperative deaths occurred. Conclusion: Despite a consist ently low risk of colonic perforation, the increasing use of colonosco py in our practice has resulted in an increased number of iatrogenic c olonic perforations. In order to minimize morbidity and mortality, pro mpt operative intervention is the best strategy in most patients. Nono perative management is warranted in carefully selected patients withou t peritoneal irritation.