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on perforation caused by diagnostic colonoscopy in retroflexion. It is a rare complication, and the clinical experience on its nonsurgical treatment is quite poor.
A retroflexed colonoscope may also facilitate the endoscopic removal of early neoplastic lesions in difficult colonic positions with retrograde fold involvement.
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 1Colonic perforation during retroflexion-assisted EMR.
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.
Retroflexion in the rectum is performed routinely during colonoscopy in an attempt to detect lesions that could be missed by forward viewing alone. Case reports of rectal perforation caused by this procedure have been published, but the frequency of this serious complication in large series is unknown. In addition, there are few reports regarding the management of colonoscopic rectal perforations.
Retroflexion of the colonoscope to examine the rectal vault is considered an essential part of colonoscopy because of significant information provided by retroflexed view compared with standard forward view.1,2 Only a few cases of rectal perforation secondary to retroflexion are reported.3 We describe a case of rectal perforation after retroflexion of the colonoscope in a healthy rectum during a screening colonoscopy.
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