3/21/2017 RiskofcolonperforationduringcolonoscopyatBaylorUniversityMedicalCenter

Proc(BaylUnivMedCent).2015Jan28(1):36. PMCID:PMC4264696

RiskofcolonperforationduringcolonoscopyatBaylorUniversityMedical
Center
DanielE.Polter,MD
FromtheDepartmentofInternalMedicine,BaylorUniversityMedicalCenteratDallas.
Correspondingauthor.
Correspondingauthor:DanielE.Polter,MD,DepartmentofInternalMedicine,BaylorUniversityMedicalCenteratDallas,3600GastonAvenue,Suite
260WadleyTower,Dallas,TX75246(email:daniel.polter@baylorhealth.edu).

Copyright2015,BaylorUniversityMedicalCenter

ThisarticlehasbeencitedbyotherarticlesinPMC.

Abstract Goto:

Colonoscopyisanimportantprocedureinpreventingcoloncancer.Theriskofcolonicperforationduring
colonoscopyattheBaylorUniversityMedicalCenter(BUMC)GastrointestinalLaboratorywaschosenasa
surrogatemarkerforthesafetyofcolonoscopy.Arecent2yearexperienceatBUMCwasexaminedandcompared
withreportsinthemedicalliterature.Theresultsarepresentedherealongwithadiscussionofproblemsinherent
withdifferenthealthcaresystemsandtheirabilitytoaccuratelytrackcomplications.Itwasconcludedthat
colonoscopyatBUMCisassafeasthatreportedbycomparablehealthcaresystems.Theriskofperforationat
BUMCwas0.57per1000proceduresor1in1750colonoscopies.Continuedeffortstomakecolonoscopysafer
areneeded.

Colonoscopyplaysanimportantroleinthediagnosisandmanagementofcolonicdiseasesandinthepreventionof
coloncancer(13).However,complicationsassociatedwiththisprocedurecanbequiteserious(4).Thefrequency
ofcomplicationsisdependentontheskillofphysiciansdoingtheprocedure,onsafeguardsthatareinplacewithin
thelaboratorywheretheprocedureiscarriedout,andwhethercolonoscopyisdoneforscreeningorfordiagnostic
ortherapeuticindications.Majorcomplicationsincludeadversesedationoranestheticeventsincludingaspiration
pneumonia,postpolypectomybleeding,diverticulitis,intraperitonealhemorrhage,andcolonicperforation(57).

Assessingthecomplicationrateofcolonoscopyisrelativelyeasilydoneincountrieswheremedicalcareis
sponsoredbythegovernment,becausecompleteandlifetimemedicalrecordsareavailableonalmostallpatients.In
someintegratedhealthcaresystems,suchasKaiserPermanenteintheUnitedStates,complicationsfrom
colonoscopycanalsobeaccuratelydetermined(8).Thelatterarereferredtointhisreportasclosedsystems.
However,assessingthesafetyofcolonoscopyinprivatehealthcaresystemssuchasBaylorismuchmoredifficult
becausepatientsmayreceivemedicalcareinotherhospitalswithdifferentmedicalrecords.Forexample,thereare
27gastroenterologistsand8colorectalsurgeonswhodocolonoscopiesintheBaylorUniversityMedicalCenter
(BUMC)GastrointestinalLaboratory.Someofthesephysicianspracticeinseveralhospitalsandmayperform
colonoscopiesinindependentoutpatientfacilitieswithinthecommunity.Systemssuchasthisarereferredtoas
opensystemsinthisreport.

AlthoughcolonoscopyhasbeendoneatBUMCforover40years,therehasneverbeenacomprehensive
assessmentofcomplications.Topartiallyrectifythisdeficiency,itwasdecidedtouseperforationrateasasurrogate
measureofcolonoscopysafetyingeneral.Perforationwaschosenbecauseitalwaysdemandshospitalizationand
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4264696/ 1/5
3/21/2017 RiskofcolonperforationduringcolonoscopyatBaylorUniversityMedicalCenter

oftenrequiressurgery,andrecordsofadmissionandsurgerywouldbeavailableforstudy.Moreover,mostpatients
experiencingcolonicperforationwouldbeexpectedtoreturntoBUMCforhospitalcare.

METHODS Goto:

Uponapprovaloftheinstitutionalreviewboard,wereviewedtheBUMCelectronichealthrecordsfromJanuary1,
2011,throughDecember31,2012,andidentifiedallpatientsdischargedwithadiagnosisofcolonicperforation.
WethenidentifiedthosewhohadundergonecolonoscopyatBUMCwithinthemonthpriortoadmissionfor
colonicperforation.Thesenumberswerethencomparedwiththenumberofcolonoscopyproceduresperformedin
theBaylorGastrointestinalLaboratoryforanypurpose.Aliteraturesearchwasthenconductedtodeterminethe
ratesofcolonicperforationduringcolonoscopyatotheropenandclosedhealthcareinstitutions.

RESULTS Goto:

Perforationrate
Atotalof10,534colonoscopieswereperformedatBUMCfromJanuary1,2011,throughDecember31,2012.Of
thisnumber,3137(30%)wereforscreeningofhealthypersonsforcolonpolypsandcoloncancer.Duringthistime
frame,107patientsweredischargedfromBUMCwithadiagnosisofcolonicperforationfromallcauses.As
showninTable1,fivepatientshadundergonecolonoscopyatBUMCwithin1monthpriortoadmission,andone
hadundergoneflexiblesigmoidoscopy.Bydefinition,thesewereassumedtorepresentcolonicperforationdueto
colonoscopy.ThecalculatedincidenceofcolonicperforationduetocolonoscopyatBUMCduringthis2year
periodwas0.57per1000procedures,or1per1750procedures.TwoadditionalpatientswereadmittedtoBUMC
withcolonicperforationaftercolonoscopydoneelsewhere.Theywerenotincludedinthecalculations.

Table1.
CasesofcolonicperforationatBaylorUniversityMedicalCenteratDallas,
20112012

Literaturereview
InTable2,theaverageperforationrateforsixopensystemreportsinvolving187,810patientswas0.59per1000
colonoscopies(922).Table3summarizes10studieswith603,132patientsinclosedsystemswithanaverage
perforationrateof0.74per1000procedures.Figure1summarizestheaveragecolonoscopicperforationratesin
bothopenandclosedsystems.TheBaylorrateof0.57per1000proceduresisincludeditiscomparabletothe
0.59per1000rateinopensystemsandlessthanthe0.74per1000rateinclosedsystems.

Figure1.
Colonicperforationsper1000procedures.

Table2.
Perforationsduringcolonoscopyinsixopensystems

Table3.
Perforationsduringcolonoscopyinclosedsystems

ClinicalfeaturesofBaylorperforations

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Noperforationsoccurredinthe3137patientswhounderwentscreeningcolonoscopy.Allofthesixperforations
occurredinthe7347patientsexaminedfordiagnosticortherapeuticreasons.Moreover,allofthesixperforations
occurredinpatientswhowerefoundtohavecolonicdisease.Thediagnosisofcolonicperforationwasmade
immediatelyintwopatientsandaslongas22daysaftercolonoscopyinone.Threepatientsdiedandthree
recovered.Onepatienthadsevereulcerativecolitis,threehadischemiccolitis,andtwohadradiationcolitis.Four
patientsunderwentimmediatecolectomy,andoneunderwentadivertingcolostomy.Onepatientdeveloped
multiorganfailureandwasdeterminednottobeanoperativecandidate.Onepatientdevelopedaperforated
duodenalulcerpostcolectomyanddied.Onepatientwithischemiccolitisdiedaftercolectomy.Twopatientshada
sigmoidstricture,duetoischemiainoneandtoradiationintheother.Thelatterpatienthadasigmoidstentplaced.
Threepatientsweremenandthreewerewomen.Theagerangedfrom18to79years.Thosewhodiedwere53,
68,and79yearsofage.Oneendoscopisthadtwoperforations.Hewasoneofthehighestvolumeendoscopistson
ourstaff.

DISCUSSION Goto:

TheBaylorperforationrateof0.57per1000procedureiscomparabletothatreportedinotheropensystems,
whichaveraged0.59per1000,andlessthantherateof0.74per1000inclosedsystems.Thehigherratein
closedsystemsislikelyduetomorecompleteretrievalofcomplications.

Howcantheriskofcolonicperforationatcolonoscopybereduced?Itisimportanttobeawareofriskfactorsthat
increasethelikelihoodofperforation,whichincludefemalesex,increasingage,obstruction,polypectomy,
inflammatoryboweldisease,stricturedilation,thermalcautery,andcomorbidities(23,24).Sedation,especially
withpropofol,shouldbekeptaslightaspossiblesothatpatientsexperiencingpainordiscomfortcanbeidentified
andcorrectivemaneuversinstituted.Patientswithinflammatoryboweldisease,includingulcerativecolitis,Crohn's
colitis,ischemiccolitis,andradiationcolitis,shouldbeapproachedwithspecialcare(25).

Dilationofcolonicstricturesmustbedonecautiously.Barotraumacanresultincolonicperforationandcanbe
avoidedbyfrequentmonitoringofabdominaldistentionandminimalairorCO2insufflationduringtheprocedure.
Specialcaremustbeemployedduringresectionofsessileorflatcolonlesionswiththermalcautery.Thesalinelift
techniqueisindicatedinresectingtheselesions.Hotbiopsyforcepsarethoughttobeassociatedwithanincreased
riskofperforationandshouldnotbeused(23).

Avoidingscreeningcolonoscopyinpersonsoverage80withapreviousnormalexamandnoriskfactorsshouldbe
considered.Lowvolumecolonoscopistshaveanincreasedrateofcomplicationsandmayneedtobemonitored.
Endoscopistswhohavedifficultyreachingthececummayrequiremonitoring(26).Regularlyscheduledmorbidity
andmortalityconferenceswhereallseriouscomplicationsarereviewedshouldhelpidentifysafetyconcernsand
promotebestpractices(25).

ThisstudyindicatesthatcolonoscopyasperformedatBUMCisassafeasthatreportedintheliteraturefrom
comparableinstitutions.However,weshouldcontinuouslystrivetoreducecomplicationsinsofaraspossible.The
measurescitedaboveshouldhopefullyreducetherisksofthisimportantprocedure.Periodicmonitoringofthe
colonoscopicperforationrateatBUMC,asdoneinthisstudy,shouldrevealhoweffectiveoureffortsare.The
safetyandwelfareofourpatientsshouldbeourprimarygoals.

Acknowledgments Goto:

IwouldliketoacknowledgetheextensiveassistanceofDr.JohnS.Fordtranintheorganization,review,and
completionofthisstudy.

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