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Endoscopy 2018; 50(09): 861-870
DOI: 10.1055/a-0584-7138
Original article
© Georg Thieme Verlag KG Stuttgart · New York

Colonoscopic perforations in the English National Health Service Bowel Cancer Screening Programme

Edmund Derbyshire
1   Department of Gastroenterology, Royal Liverpool University Hospital, Liverpool, United Kingdom
,
Pali Hungin
2   School of Medicine, Pharmacy and Health, Durham University, Stockton-on-Tees, United Kingdom
,
Claire Nickerson
3   Cancer Screening Programmes, Public Health England, Sheffield, United Kingdom
,
Matthew D. Rutter
4   Department of Gastroenterology, University Hospital of North Tees, Stockton-on-Tees, United Kingdom
› Author Affiliations
Further Information

Publication History

submitted: 25 July 2017

accepted after revision: 30 January 2018

Publication Date:
28 March 2018 (online)

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Effective reporting of key performance indicators is essential for balancing the benefits and drawbacks of colonoscopyEndoscopy 2018; 50(09): 837-838
DOI: 10.1055/a-0631-1849

Abstract

Background Perforation is the most serious adverse event associated with colonoscopy. In this study of data from the English National Health Service Bowel Cancer Screening Programme, we aimed to describe the presentation and management of perforations, and to determine factors associated with poorer outcomes post-perforation.

Methods The medical records of patients with a perforation following the national screening colonoscopy were retrospectively examined. All colonoscopies performed from 02/08/2006 to 13/03/2014 were studied. Bowel Cancer Screening Centres across England were contacted and asked to complete a detailed dataset relating to perforation presentation, management, and outcome.

Results 263 129 colonoscopies were analyzed, and the rate of perforation was 0.06 %. Complete data were reviewed for 117 perforations: 70.1 % of perforations (82/117) occurred during therapeutic colonoscopies; 54.9 % (62/113) of patients with perforations who were admitted to hospital and in whom data were complete underwent surgery; 26.1 % (30/115) of hospitalized patients left the hospital with a stoma and 19.1 % (22/115) developed post-perforation morbidity. Perforations not detected during colonoscopy were significantly more likely to require surgery (P = 0.03). Diagnostic perforations were significantly more likely to require surgery (P = 0.002) and were associated with higher rates of post-perforation morbidity (P = 0.01). At presentation, the presence of abdominal pain (P = 0.01), a pulse rate > 100 beats per minute (P = 0.049), and a respiratory rate > 20 breaths per minute (P = 0.01) were significantly associated with the patient having surgery.

Conclusions This is the largest retrospective observational case series in Europe to describe post-perforation presentation, management, and outcomes. We have confirmed that perforation leads to surgical intervention, stoma formation, and post-perforation morbidity. Perforations not recognized during the colonoscopy were significantly more likely to require surgery. Diagnostic perforations were at greater risk of requiring surgery and developing post-perforation morbidity.

 

  • References

  • 1 Gavin DR, Valori RM, Anderson JT. et al. The national colonoscopy audit: a nationwide assessment of the quality and safety of colonoscopy in the UK. Gut 2013; 62: 242-249
    CrossrefPubMedGoogle Scholar
  • 2 Gatto NM, Frucht H, Sundararajan V. et al. Risk of perforation after colonoscopy and sigmoidoscopy: a population-based study. J Natl Cancer Inst 2003; 95: 230-236
    CrossrefPubMedGoogle Scholar
  • 3 Blotière P-O, Weill A, Ricordeau P. et al. Perforations and haemorrhages after colonoscopy in 2010: a study based on comprehensive French health insurance data (SNIIRAM). Clin Res Gastroenterol Hepatol 2014; 38: 112-117
    PubMedGoogle Scholar
  • 4 Rabeneck L, Paszat LF, Hilsden RJ. et al. Bleeding and perforation after outpatient colonoscopy and their risk factors in usual clinical practice. Gastroenterology 2008; 135: 1899-1906
    CrossrefPubMedGoogle Scholar
  • 5 Arora G, Mannalithara A, Singh G. et al. Risk of perforation from a colonoscopy in adults: a large population-based study. Gastrointest Endosc 2009; 69: 654-664
    CrossrefPubMedGoogle Scholar
  • 6 Lohsiriwat V, Sujarittanakarn S, Akaraviputh T. et al. What are the risk factors of colonoscopic perforation?. BMC Gastroenterol 2009; 9: 71
    CrossrefPubMedGoogle Scholar
  • 7 Hamdani U, Naeem R, Haider F. et al. Risk factors for colonoscopic perforation: a population-based study of 80118 cases. World J Gastroenterol 2013; 19: 3596-3601
    CrossrefPubMedGoogle Scholar
  • 8 Warren JL, Klabunde CN, Mariotto AB. et al. Adverse events after outpatient colonoscopy in the Medicare population. Ann Intern Med 2009; 150: 849-858
    CrossrefPubMedGoogle Scholar
  • 9 Heldwein W, Dollhopf M, Meining A. et al. The Munich Polypectomy Study (MUPS): prospective analysis of complications and risk factors in 4000 colonic snare polypectomies. Endoscopy 2005; 37: 1116-1122
    Article in Thieme ConnectPubMedGoogle Scholar
  • 10 Rutter M, Nickerson C, Rees C. et al. Risk factors for adverse events related to polypectomy in the English Bowel Cancer Screening Programme. Endoscopy 2014; 46: 90-97
    Article in Thieme ConnectPubMedGoogle Scholar
  • 11 Hayashi N, Tanaka S, Nishiyama S. et al. Predictors of incomplete resection and perforation associated with endoscopic submucosal dissection for colorectal tumors. Gastrointest Endosc 2014; 79: 427-435
    CrossrefPubMedGoogle Scholar
  • 12 Singh H, Penfold RB, Moffatt M. Predictors of serious complications associated with lower gastrointestinal endoscopy in a major city-wide health region. Can J Gastroenterol 2010; 24: 425-430
    CrossrefPubMedGoogle Scholar
  • 13 Chukmaitov A, Bradley CJ, Dahman B. et al. Association of polypectomy techniques, endoscopist volume, and facility type with colonoscopy complications. Gastrointest Endosc 2012; 77: 436-446
    PubMedGoogle Scholar
  • 14 Lorenzo-Zúñiga V, Moreno de Vega V, Doménech E. et al. Endoscopist experience as a risk factor for colonoscopic complications. Colorectal Dis 2010; 12: 273-277
    CrossrefPubMedGoogle Scholar
  • 15 Iqbal CW, Chun YS, Farley DR. Colonoscopic perforations: a retrospective review. J Gastrointest Surg 2005; 9: 1229-1235
    CrossrefPubMedGoogle Scholar
  • 16 Iqbal CW, Cullinane DC, Schiller HJ. et al. Surgical management and outcomes of 165 colonoscopic perforations from a single institution. Arch Surg 2008; 143: 701-707
    CrossrefPubMedGoogle Scholar
  • 17 Panteris V, Haringsma J, Kuipers EJ. Colonoscopy perforation rate, mechanisms and outcome: from diagnostic to therapeutic colonoscopy. Endoscopy 2009; 41: 941-951
    Article in Thieme ConnectPubMedGoogle Scholar
  • 18 Castellví J, Pi F, Sueiras A. et al. Colonoscopic perforation: useful parameters for early diagnosis and conservative treatment. Int J Colorectal Dis 2011; 26: 1183-1190
    CrossrefPubMedGoogle Scholar
  • 19 Logan RF, Patnick J, Nickerson C. et al. Outcomes of the Bowel Cancer Screening Programme (BCSP) in England after the first 1 million tests. Gut 2012; 61: 1439-1446
    CrossrefPubMedGoogle Scholar
  • 20 Lee TJW, Rutter MD, Blanks RG. et al. Colonoscopy quality measures: experience from the NHS Bowel Cancer Screening Programme. Gut 2012; 61: 1050-1057
    CrossrefPubMedGoogle Scholar
  • 21 Rembacken B, Hassan C, Riemann JF. et al. Quality in screening colonoscopy: position statement of the European Society of Gastrointestinal Endoscopy (ESGE). Endoscopy 2012; 44: 957-968
    Article in Thieme ConnectPubMedGoogle Scholar
  • 22 Rogers BH, Silvis SE, Nebel OT. et al. Complications of flexible fiberoptic colonoscopy and polypectomy. Gastrointest Endosc 1975; 22: 73-77
    CrossrefPubMedGoogle Scholar
  • 23 Smith LE. Fiberoptic colonoscopy: complications of colonoscopy and polypectomy. Dis Colon Rectum 1976; 19: 407-412
    CrossrefPubMedGoogle Scholar
  • 24 Frumorghen P, Demling L. Complications of diagnostic and therapeutic colonoscopy in the Federal Republic of Germany. Results of an inquiry. Endoscopy 1979; 11: 146-150
    Article in Thieme ConnectPubMedGoogle Scholar
  • 25 Macrae FA, Tan KG, Williams CB. Towards safer colonoscopy: a report on the complications of 5000 diagnostic or therapeutic colonoscopies. Gut 1983; 24: 376-383
    CrossrefPubMedGoogle Scholar
  • 26 Hall C, Dorricot N, Donovan I. et al. Colon perforation during colonoscopy: surgical versus conservative management. Br J Surg 1991; 78: 542-544
    CrossrefPubMedGoogle Scholar
  • 27 Lo AY, Beaton HL. Selective management of colonoscopic perforations. J Am Coll Surg 1994; 179: 333-337
    PubMedGoogle Scholar
  • 28 Farley DR, Bannon MP, Zietlow SP. et al. Management of colonoscopic perforations. Mayo Clinica Proceedings 1997; 72: 729-723
    PubMedGoogle Scholar
  • 29 Avgerinos DV, Llaguna OH, Lo AY. et al. Evolving management of colonoscopic perforations. J Gastrointest Surg 2008; 12: 1783-1789
    CrossrefPubMedGoogle Scholar
  • 30 Korman LY, Overholt BF, Box T. et al. Perforation during colonoscopy in endoscopic ambulatory surgical centers. Gastrointest Endosc 2003; 58: 554-557
    CrossrefPubMedGoogle Scholar
  • 31 Crispin A, Birkner B, Munte A. et al. Process quality and incidence of acute complications in a series of more than 230,000 outpatient colonoscopies. Endoscopy 2009; 41: 1018-1025
    Article in Thieme ConnectPubMedGoogle Scholar
  • 32 Reumkens A, Rondagh EJA, Bakker CM. et al. Post-colonoscopy complications: a systematic review, time trends, and meta-analysis of population-based studies. Am J Gastroenterol 2016; 111: 1092-1101
    CrossrefPubMedGoogle Scholar
  • 33 Sagawa T, Kakizaki S, Iizuka H. et al. Analysis of colonoscopic perforations at a local clinic and a tertiary hospital. World J Gastroenterol 2012; 18: 4898-4904
    CrossrefPubMedGoogle Scholar
  • 34 Teoh AYB, Poon CM, Lee JFY. et al. Outcomes and predictors of mortality and stoma formation in surgical management of colonoscopic perforations: a multicenter review. Arch Surg 2009; 144: 9-13
    CrossrefPubMedGoogle Scholar
  • 35 Dafnis G, Ekbom A, Pahlman L. et al. Complications of diagnostic and therapeutic colonoscopy within a defined population in Sweden. Gastrointest Endosc 2001; 54: 302-309
    CrossrefPubMedGoogle Scholar
  • 36 Cai S, Chen T, Yao L. et al. Management of iatrogenic colorectal perforation: from surgery to endoscopy. World J Gastroenterol 2015; 7: 819-823
    CrossrefPubMedGoogle Scholar
  • 37 Magdeburg R, Collet P, Post S. et al. Endoclipping of iatrogenic colonic perforation to avoid surgery. Surg Endosc 2008; 22: 1500-1504
    CrossrefPubMedGoogle Scholar
  • 38 Yang D-H, Byeon J-S, Lee K-H. et al. Is endoscopic closure with clips effective for both diagnostic and therapeutic colonoscopy-associated bowel perforation?. Surg Endosc 2010; 24: 1177-1185
    CrossrefPubMedGoogle Scholar
  • 39 Jovanovic I, Zimmermann L, Fry LC. et al. Feasibility of endoscopic closure of an iatrogenic colon perforation occurring during colonoscopy. Gastrointest Endosc 2011; 73: 550-555
    CrossrefPubMedGoogle Scholar
  • 40 Kim JS, Kim B-W, Kim JIl. et al. Endoscopic clip closure versus surgery for the treatment of iatrogenic colon perforations developed during diagnostic colonoscopy: a review of 115,285 patients. Surg Endosc 2013; 27: 501-504
    CrossrefPubMedGoogle Scholar
  • 41 Burgess NG, Bassan MS, McLeod D. et al. Deep mural injury and perforation after colonic endoscopic mucosal resection: a new classification and analysis of risk factors. Gut 2016; 0: 1-11
    PubMedGoogle Scholar