Surgical management and outcomes of 165 colonoscopic perforations from a single institution

Background: Increasing use of colonoscopy is making iatrogenic perforations more common. We herein present our experience with operative management of colonoscopic-related perforations. Design: Retrospective review (1980-2006) Setting: Tertiary referral center. Patients: A total of 258 248 colonoscopies performed in patients, from which we identified 180 iatrogenic perforations (incidence, 0-.07%). Of these, 165 perforations were managed operatively. Results: Patients underwent primary repair (29%), resection with primary anastomosis (33%), or fecal diversion (38%). Patients presenting within 24 hours (78%) were more likely to have minimal peritoneal contamination (64 patients [50%] vs 6 [17%]; P=.01) and to undergo primary repair or resection with anastomosis (86 [67%] patients vs 13 [36%]; P<.01). Patients presenting after 24 hours (22%) were more likely to have feculent contamination (16 patients [44%] vs 4 [11%1; P=.02) and to receive an ostomy (23 patients [64%] vs 43 [33%]; P=.02). The sigmoid colon was the most frequent site of perforation, followed by the cecum (53% and 24%, respectively; P <.001); blunt or torque injury exceeded polypectomy and thermal injuries (55% vs 27% and 18%, respectively; P <.001). Patients with blunt injuries were more likely to receive a stoma than were those with polypectomy and thermal perforations (44 patients vs 9 and 9, respectively; P=.02), as were patients with feculent peritonitis compared with those with moderate and minimal soilage (28 patients [78%] vs 28 [42%] and 6 [ 10%] respectively; P=.002). Operative morbidity was 36%, with a mortality rate of 7%. Multivariate analysis indicated that blunt injuries, poor bowel preparation, corticosteroid use, and being younger than 67 years were risk factors for postoperative morbidity (P <=.01); no factors correlated with death. Conclusions: Colonoscopic perforation occurs in fewer than I in 1000 patients and is associated with significant morbidity and mortality. Prompt diagnosis and operative therapy are critical in most cases.