Advertisement

Retroflexion-assisted EMR in the colon with immediate closure of a procedure-related perforation

      To the Editor:
      We have read with interest the articles by Quallick and Brown
      • Quallick M.R.
      • Brown W.R.
      Rectal perforation during colonoscopic retroflexion: a large, prospective experience in an academic center.
      as well as Tribonias et al
      • Tribonias G.
      • Konstantinidis K.
      • Theodoropoulou A.
      • et al.
      Rectal perforation caused by colonoscopic retroflexion.
      on perforation caused by diagnostic colonoscopy in retroflexion. It is a rare complication, and the clinical experience on its nonsurgical treatment is quite poor.
      • Tribonias G.
      • Konstantinidis K.
      • Theodoropoulou A.
      • et al.
      Rectal perforation caused by colonoscopic retroflexion.
      • Ahlawat S.K.
      • Charabaty A.
      • Benjamin S.
      Rectal perforation caused by retroflexion maneuver during colonoscopy: closure with endoscopic clips.
      • Bechtold M.L.
      • Hammad H.T.
      • Arif M.
      • et al.
      Perforation upon retroflexion: an endoscopic complication and repair.
      A retroflexed colonoscope may also facilitate the endoscopic removal of early neoplastic lesions in difficult colonic positions with retrograde fold involvement.
      • Pishvaian A.C.
      • Al-Kawas F.H.
      Retroflexion in the colon: a useful and safe technique in the evaluation and resection of sessile polyps during colonoscopy.
      • Rex D.K.
      • Khashab M.
      Colonoscopic polypectomy in retroflexion.
      However, there is no experience on perforation during retroflexion-assisted endotherapy.
      A 74-year-old man was referred to us for EMR of a large, flat adenoma at the rectosigmoid junction. Because it was partly visualized on forward inspection, its real extent and size were assessed in retrograde view. By using a 130-cm length high-resolution colonoscope (CF-H180 AL; Olympus Optical Co, Ltd, Tokyo, Japan) in retroflexed position, with a 15-mm diameter distal attachment and a large, hexagonal snare (Wilson-Cook, Winston-Salem, NC), we first removed the farther edge of the 6-cm lesion. During piecemeal EMR, a retroflex colonoscope maneuver revealed a 1-cm perforation at 5 to 6 cm above the resection site. The pericolic fat was visible (Fig. 1). The endoscopic view suggested the presence of interposed sigmoid mesocolon rather than a true communication with the peritoneal cavity. Nine metallic clips (QuickClips II; Olympus; and Resolution clips; Boston Scientific, Natick, Mass) were applied, with defect closure. After that, the resection procedure was successfully completed (Fig. 2). CT scans demonstrated small amounts of air around the sigmoid wall. Broad-spectrum antibiotics were administered intravenously. Oral alimentation was discontinued for 5 days, and the recovery was uneventful. The patient was discharged 2 days later. Histology showed high-grade dysplasia and foci of adenocarcinoma in situ.
      Figure thumbnail gr1
      Figure 1Colonic perforation during retroflexion-assisted EMR.
      Figure thumbnail gr2
      Figure 2Complete EMR in retroflexion with immediate closure of the iatrogenic perforation.
      Our case supports that a colonoscopic, retroflexion-assisted EMR with intraprocedural perforation can be successfully completed in experienced hands with immediate defect closure.

      References

        • Quallick M.R.
        • Brown W.R.
        Rectal perforation during colonoscopic retroflexion: a large, prospective experience in an academic center.
        Gastrointest Endosc. 2009; 69: 960-963
        • Tribonias G.
        • Konstantinidis K.
        • Theodoropoulou A.
        • et al.
        Rectal perforation caused by colonoscopic retroflexion.
        Gastrointest Endosc. 2010; 71: 662
        • Ahlawat S.K.
        • Charabaty A.
        • Benjamin S.
        Rectal perforation caused by retroflexion maneuver during colonoscopy: closure with endoscopic clips.
        Gastrointest Endosc. 2008; 67: 771-773
        • Bechtold M.L.
        • Hammad H.T.
        • Arif M.
        • et al.
        Perforation upon retroflexion: an endoscopic complication and repair.
        Endoscopy. 2009; 41: E155-E156
        • Pishvaian A.C.
        • Al-Kawas F.H.
        Retroflexion in the colon: a useful and safe technique in the evaluation and resection of sessile polyps during colonoscopy.
        Am J Gastroenterol. 2006; 101: 1479-1483
        • Rex D.K.
        • Khashab M.
        Colonoscopic polypectomy in retroflexion.
        Gastrointest Endosc. 2006; 63: 144-148

      Linked Article