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© Borgis - Nowa Medycyna 3/2018, s. 164-175 | DOI: 10.25121/NM.2018.25.3.164
*Jacek Wadełek
Selected complications of colonoscopy – an anaesthetist’s point of view
Wybrane powikłania kolonoskopii – punkt widzenia anestezjologa
Anaesthesiology and Intensive Therapy Department, St. Anna Trauma Surgery Hospital, STOCER Mazovia Rehabilitation Center Sp. z o.o., Warsaw
Head of Department: Elżbieta Kurmin-Gryz, MD
Streszczenie
Kolonoskopia należy do zabiegów wykonywanych powszechnie, zarówno w celu diagnostyki, jak i leczenia wielu schorzeń i objawów. Podczas wykonywania kolonoskopii mogą wystąpić groźne powikłania, takie jak krwawienie i perforacja jelita grubego, zwłaszcza u pacjentów podczas usuwania polipów jelita grubego. Najczęstszym powikłaniem po endoskopowym usuwaniu polipów jest krwawienie. Może ono wystąpić bezpośrednio po polipektomii lub po upływie godzin, a nawet dni od zabiegu. Ostre krwawienie po usunięciu polipów często jest natychmiast rozpoznawane i może być leczone endoskopowo. Do innych, nieendoskopowych sposobów leczenia krwawienia po kolonoskopii należą embolizacja angiograficzna i leczenie operacyjne. Nagła utrata dużej ilości krwi (krwawienie/krwotok wewnętrzny) do dolnego odcinka przewodu pokarmowego może powodować niestabilność krążeniową i konieczność leczenia operacyjnego w trybie natychmiastowym lub pilnym. Chociaż perforacja jelita grubego jest powikłaniem rzadkim, to może skutkować koniecznością wykonania operacji metodą na otwarto, wytworzenia stomii na jelicie grubym, powikłaniami septycznymi, przedłużonym pobytem w szpitalu, a nawet zgonem pacjenta. O postępowaniu z pacjentem po rozpoznaniu perforacji decyduje chirurg, który bierze pod uwagę przede wszystkim: miejsce i rozległość uszkodzenia (mikroperforacja czy rozległe uszkodzenie jelita), stan ogólny pacjenta i współistniejące patologie jelita grubego. Zarówno nagła laparotomia z powodu krwawienia do dolnego odcinka przewodu pokarmowego, jak i z powodu perforacji jelita grubego wymagają współpracy endoskopisty, chirurga i anestezjologa w okresie okołooperacyjnym.
Summary
Colonoscopy is a commonly performed procedure for the diagnosis and treatment of a wide range of conditions and symptoms, as well as for the screening and surveillance of colorectal neoplasia. Serious complications, such as bleeding and perforation, are reported in patients undergoing colonoscopy, especially during polypectomy. Bleeding is the most common complication of colonic polypectomy. It can occur immediately following polypectomy or be delayed from hours to up to days. Acute post-polypectomy haemorrhage is usually immediately apparent and amenable to endoscopic therapy. Nonendoscopic treatment modalities include angiographic embolization and surgery. Acute massive bleeding (internal bleeding/haemorrhage) into the lower gastrointestinal tract may cause hypovolaemia, which decreases cardiac output and tissue oxygen supply, which may require emergency surgery. Although colonic perforation is a rare complication, it is associated with a high rate of morbidity and mortality. This unpleasant complication could result in surgical intervention, stoma formation, intra-abdominal sepsis, prolonged hospital stay, and even death. An extra-intestinal structure identified during endoscopic examination is the most common clinical feature of colonic perforation. The management of patients with colonic perforation should be individualized based on patients’ clinical status and underlying diseases, the nature of perforation, and concomitant colorectal pathologies. Patients with both acute massive bleeding and lower gastrointestinal perforation may need emergency laparotomy, which requires perioperative cooperation of an endoscopist, a surgeon and an anaesthetist.



Introduction
Recent years have witnessed a particularly noticeable development in minimally invasive surgery, including colonoscopy. This development is accompanied by advances in anaesthetic techniques. Full collaboration between surgical and anaesthetic teams, with mutual understanding of needs and expectations, is a necessary condition for the further development of endoscopic surgery. The use of diagnostic and therapeutic colonoscopy has increased since the introduction of flexible fibre endoscopes. Much significance is currently attached to one-day procedures. This faces anaesthetic teams with a range of challenges related to general anaesthesia and analgosedation, both of which are intended to protect the patient against pain and other unpleasant experiences during colonoscopy, and may also contribute to reduced frequency of hospitalisations. The more common use of colonoscopy is also associated with increased rates of complications after therapeutic colonoscopy, e.g. polypectomy. Since these complications are relatively rare and may be the reason for lawsuits for damages, no prospective randomised studies to assess their incidence have been conducted. The paper discusses the mechanism, diagnosis and management of the two most common colonoscopic complications, i.e. colonoscopic perforation and bleeding.
Lower gastrointestinal perforation
Lower GI perforation is defined as a traumatic loss of intestinal wall integrity. The extent of perforation can vary from microinjuries to extensive damage to the intestinal wall. Due to the varying level of intestinal preparation, overall patient’s health status and the time elapsed between perforation and diagnosis, the extent of injury has a significant impact on the treatment used and prognosis. Minor perforations are caused by direct mechanical trauma to the large intestine, such as forcing the endoscope tip through the intestinal diverticulum mistaken for the colonic lumen, lateral perforation of the colonic flexure or transverse tear at the site of a large tight bowel stenosis. Colonic perforation due to pressure forces during an attempt to improve visualisation by means of increased colonic distension under gas pressure is also theoretically possible. However, such mechanism is rare. It was shown in one of publications that gas pressure of 4.07 psi (about 52 mmHg) is necessary to rupture normal human intestine (1). A more recent study showed that sigmoid pressure of 169 mmHg is necessary for its rupture (2, 3). Mechanical intestinal trauma during biopsy and electrical or thermal injury associated with polypectomy and post-polypectomy electrocoagulation is another mechanism underlying colonic perforation. Extensive colon damage is less common and may be caused by lateral colonoscope compression on the distended colonic wall. This compression may lead to a longitudinal dissection of the sigmoid or transverse colon wall during attempts at proximal colonoscopic manoeuvres. This type of colonic tears is particularly dangerous due to large size and the fact that they often develop beyond the field of vision. If such a mechanism of colonic trauma is suspected, urgent surgical intervention is needed. The incidence of colonoscopic perforation is estimated at 0.2% for diagnostic and 0.6% for colonoscopy with colon wall biopsy (4), but it may be actually less common (5). About 50-60% of colonic perforations occur in the sigmoid colon and the rectum, while caecal perforations account for 10-20% of cases (6). Risk factors for colonoscopic perforation include age > 75 years and comorbidities, as well as diverticulosis and constipations in the case of screening (7). Indications for surgical treatment include peritoneal symptoms, unsuccessful conservative treatment and size of perforation (> 1 cm) (8). Conservative treatment is mainly used in stable patients, without peritoneal symptoms, with early diagnosis of perforation in the retroperitoneal part of the large intestine (9, 10).
Anaesthetic management in suspected colon wall damage

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otrzymano: 2018-08-07
zaakceptowano do druku: 2018-08-28

Adres do korespondencji:
*Jacek Wadełek
Oddział Anestezjologii i Intensywnej Terapii Szpital Chirurgii Urazowej św. Anny w Warszawie Mazowieckie Centrum Rehabilitacji „STOCER” Sp. z o.o.
ul. Barska 16/20, 02-315 Warszawa
tel.: +48 (22) 579-52-58
WAD_jack@poczta.fm

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