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Characteristics and endoscopic treatment of interventional and non-interventional iatrogenic colorectal perforations in centers with high endoscopic expertise: a retrospective multicenter study

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Abstract

Background

Iatrogenic colorectal perforation is a rare event with a relevant mortality and the need for surgical therapy in around ¾ of cases.

Methods

In this retrospective multicentric cohort study iatrogenic colorectal perforations from 2004 to 2021 were analyzed. Primary outcome parameters were incidence and clinical success of 1st line endoscopic treatment. Comparative analysis of interventional and non-interventional perforations was performed and predictors for clinical success of endoscopic therapy were identified.

Results

From 103,570 colonoscopies 213 (0.2%) iatrogenic perforations were identified. 68.4% were interventional (80 during polypectomy/EMR, 54 during ESD and 11 for other reasons) and 31.6% non-interventional perforations (39 by the tip, 19 by the shaft, 7 by inversion, two by biopsy and one by distension). Incidence of 1st line endoscopic therapy was 61.0% and clinical success 81.5%. Other non-surgical therapies were conducted in 8.9% with clinical success in 94.7% of cases. In interventional perforations both incidence and clinical success of 1st line endoscopic therapy were significantly higher compared to non-interventional perforations [71.7% vs. 38.2% (p < 0.01) resp. 86.5% vs. 61.5% (p < 0.01)]. Mortality was 2.3% and significantly lower in the group of interventional perforations (0.7% vs. 5.9%, p = 0.037). Multivariable analysis revealed perforation size < 5 mm as only independent predictor for clinical success of 1st line endoscopic treatment [OR 14.85 (1.57–140.69), p = 0.019].

Conclusions

Endoscopic therapy is treatment of choice in the majority of iatrogenic colorectal perforations. In case of interventional perforations it is highly effective but only a minority of non-interventional perforations are good candidates for endoscopic treatment.

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Abbreviations

ASA:

American Society of Anesthesiology

cm:

Centimeter

EMR:

Endoscopic mucosal resection

ESD:

Endoscopic submucosal dissection

ESGE:

European Society of Gastroenterology

HGIEN:

High grade intraepithelial neoplasia

LGIEN:

Low grade intraepithelial neoplasia

OTSC:

Over-the-scope-clip

TTSC:

Through-the-scope-clip

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Acknowledgements

The authors acknowledge the consultation of Dr. Enya Weber from the Institute of Medical Biometrics and Statistics (University of Freiburg) for the statistical analysis. The study was registered in the German Registry of Clinical Studies (DRKS) with the registry number DRKS500028012.

Funding

No funding was received for this study.

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Authors and Affiliations

  1. Department of Medicine and Gastroenterology, Evangelisches Diakoniekrankenhaus Freiburg, Academic Teaching Hospital, University of Freiburg, Wirthstraße 11, 79110, Freiburg, Germany

    Ingo Steinbrück & Hans-Peter Allgaier

  2. Department of Gastroenterology, Asklepios Klinik Altona, Academic Teaching Hospital University of Hamburg, Hamburg, Germany

    Jürgen Pohl, Johannes Grothaus & Friedrich Hagenmüller

  3. Department of Gastroenterology, Hepatology and Endoscopy, Asklepios Klinik Barmbek, Academic Teaching Hospital University of Hamburg, Hamburg, Germany

    Thomas von Hahn

  4. Department of Gastroenterology, St. Anna Hospital Herne, Academic Teaching Hospital Ruhr University Bochum, Herne, Germany

    Viktor Rempel

  5. Department of Gastroenterology, Sana Klinikum Lichtenberg, Academic Teaching Hospital, Universtiy of Berlin, Berlin, Germany

    Siegbert Faiss

  6. Department of Medicine and Gastroenterology, Gemeinschaftskrankenhaus Bonn, Academic Teaching Hospital, University of Bonn, Bonn, Germany

    Franz Ludwig Dumoulin

  7. Department of Gastroenterology and Hepatology, University of Freiburg, Freiburg, Germany

    Arthur Schmidt

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  1. Ingo Steinbrück
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Correspondence to Ingo Steinbrück.

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Disclosures

Dr. Ingo Steinbrück, Prof. Dr. Siegbert Faiss, Prof. Dr. Tsuneo Oyama, Franz Ludwig Dumoulin and Prof. Dr. Hans-Peter Allgaier received lecture fees and travel grants from Olympus Medical. Prof. Dr. Thomas von Hahn received consulting and lecture fees from Olympus Medical. Prof. Dr. Arthur Schmidt received lecture fees from Ovesco Endoscopy, Olympus Medical and Falk Foundation, travel grants from Ovesco Endoscopy and consulting fees from KLS Martin. Dr. Viktor Rempel received lecture fees from Olympus Medical and Microtec and travel grants from Olympus Medical. Prof. Dr. Jürgen Pohl, Prof. Dr. Friedrich Hagenmüller and Dr. Johannes Grothaus have no conflicts of interest or financial ties to disclose.

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Supplementary Information

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464_2023_9920_MOESM1_ESM.docx

Supplementary file1 (DOCX 16 KB)—Supplementary Table 1s: Outcome parameters, causes/co-factors and possible predictive factors for clinical success of 1st line endoscopic therapy (TTSC= Through-the-scope-clip, OTSC= Over-the-scope-clip, ASA= American Society of Anesthesiology).

464_2023_9920_MOESM2_ESM.docx

Supplementary file2 (DOCX 19 KB)—Supplementary Table 2s: Surgically treated perforations (EMR= Endoscopic mucosal resection, ESD= Endoscopic submucosal Dissection).

464_2023_9920_MOESM3_ESM.docx

Supplementary file3 (DOCX 19 KB)—Supplementary Table 3s: Perforations with conservative treatment/external drainage (EMR= Endoscopic mucosal resection, ESD= Endoscopic submucosal dissection).

464_2023_9920_MOESM4_ESM.docx

Supplementary file4 (DOCX 17 KB)— Supplementary Table 4s: Characteristics of the five unsuccessfully treated patients (IP= Interventional perforation, NIP= Non-interventional perforation).

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Steinbrück, I., Pohl, J., Grothaus, J. et al. Characteristics and endoscopic treatment of interventional and non-interventional iatrogenic colorectal perforations in centers with high endoscopic expertise: a retrospective multicenter study. Surg Endosc 37, 4370–4380 (2023). https://doi.org/10.1007/s00464-023-09920-z

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