Endoscopic Complications

Educational Objectives

The goal of this program is to improve management of endoscopic complications. After hearing and assimilating this program, the clinician will be better able to:

1. Achieve hemostasis if bleeding develops during an endoscopic procedure.
2. Choose an appropriate device for closure of gastrointestinal perforations.

Summary

Approaches to hemostasis during endoscopic procedures: injection of medications (typically, epinephrine diluted 1:10,000); thermal therapies using, eg, monopolar forceps, bipolar electrocautery, heater probes, noncontact argon plasma coagulation; mechanical hemostasis — through-the-scope clips (TTSC) and over-the-scope clips (OTSC); band ligators and ligature devices are less commonly used for iatrogenic bleeding (may be best used prophylactically, eg, for a pedunculated polyp with a thick stalk); hemostatic spray — useful as a rescue therapy; rapidly concentrates clotting factors; patients must be closely monitored for rebleeding

Risk for perforation: rates are low in diagnostic upper endoscopy and colonoscopy but may be increased by anatomic and treatment-related risk factors; for therapeutic endoscopy, risk for perforation increases with complexity of the procedure

Management of perforation: identify the perforation during the index procedure; minimize soilage or contamination (leakage of stool or blood through the perforation allows entry of microorganisms from the gastrointestinal [GI] tract into the thorax or peritoneum, creating risk for sepsis); ideally, closure should be endoscopic (if not possible or significant hemodynamic instability exists, transfer the patient to the operating room); perforation during insufflation results in leakage of gas into the extraluminal space, which causes accumulation of tension in the thoracic or peritoneal cavity; decompress by inserting a 14-G angiocatheter needle into peritoneal cavity (can be left in place as an open circuit during closure); when performing resection, use an injectate containing dye that stains the submucosa (to create a target sign)

Management steps for colonoscopy: inform staff of the perforation (if necessary, call for assistance), and maintain composure; if air is being used, switch to CO₂ (absorbed much more rapidly than air) if available; assess the location and size of the defect; administer intravenous antibiotics that cover gram-negative and anaerobic organisms; minimize risk for spillage of GI contents into the extraluminal space via positioning (eg, supine, right lateral); perform serial abdominal examinations to check for tension (if present, decompress); choose a closure modality based on surgeon expertise and availability; after closure, admit the patient for observation; same-day discharge may be possible in selected cases; confirm closure with a contrast imaging study

Devices for perforation closure: TTSC — effective for perforations <2 cm; with perforations >2 cm, wingspan and closer force limitations can compromise tissue apposition; OTSC — 2 types are available (bear claw and padlock); anchors or grasping forceps may be used before clip deployment; endoscopic suturing — rates of technical and clinical success are high but the learning curve is steep; the over-the-scope mounted device extends ≈2 cm from the tip of the scope, so some spaces may be too tight to allow suturing; fitting the scope with the mounted device into the proximal right colon or cecum may be challenging; a newly approved TTS suturing device uses 4 helical tacks that can be placed around the periphery of a perforation or defect; after deployment, the tacks are tethered to a single suture that is tightened and secured with a cinch; fully covered self-expanding metal stents — considered if primary closure is not possible, especially in the esophagus; however, the migration rate is high for a benign use (may be fixed with clips or sutures)

Endoscopic vacuum therapy: a nasogastric (NG) tube is passed through the patient’s nose and extracted through the mouth; a piece of polyurethane foam cut to the size of the defect is tied to the end of the NG tube, then dragged down to and wedged into the area of perforation; the NG tube is connected a continuous suction system; stimulates epithelialization and granulation tissue vascularity to promote closure; the drain must be changed every 2 to 7 days; effective but uncomfortable for patients

Clinical practice updates on management: recommend TTSC or OTSC if a perforation is <2 cm; if >2 cm, endoscopic suturing, a fat patch, or the tulip bundle technique is advised; the American Gastroenterological Association recommends TTSC or the new TTS device for perforation of the right colon

Professional obligations after a complication: for bleeding complications, document the location, applied treatment, and whether hemostasis was achieved; for perforation, document the size, location, and treatment applied and keep images of the perforation; promptly discuss the complication with the patient and family and, if applicable, report the event to the quality officer and/or risk management team without delay

Personal issues after a complication: include shame and fears of damage to one’s reputation; if the clinician’s rate of complications is abnormally high, consider whether burnout and stress are playing a role; coping strategies include discussing cases with colleagues; professional counseling may be necessary

Readings

Burgess NG, Bassan MS, McLeod D, et al. Deep mural injury and perforation after colonic endoscopic mucosal resection: a new classification and analysis of risk factors. Gut. 2017 Oct;66(10):1779-1789. doi: 10.1136/gutjnl-2015-309848. Epub 2016 Jul 27. PMID: 27464708; Hagel AF, Albrecht H, Nägel A, et al. The application of Hemospray in gastrointestinal bleeding during emergency endoscopy. Gastroenterol Res Pract. 2017;2017:3083481. doi:10.1155/2017/3083481; Kumar N, Thompson CC. A novel method for endoscopic perforation management by using abdominal exploration and full-thickness sutured closure. Gastrointest Endosc. 2014;80(1):156-161. doi:10.1016/j.gie.2014.02.022; Lee JH, Kedia P, Stavropoulos SN, et al. AGA Clinical Practice Update on Endoscopic Management of Perforations in Gastrointestinal Tract: Expert Review. Clin Gastroenterol Hepatol. 2021;19(11):2252-2261.e2. doi:10.1016/j.cgh.2021.06.045; Soh JS, Seo M, Kim KJ. Prophylactic clip application for large pedunculated polyps before snare polypectomy may decrease immediate postpolypectomy bleeding. BMC Gastroenterol. 2020 Mar 12;20(1):68. doi: 10.1186/s12876-020-01210-5. PMID: 32164613; PMCID: PMC7069010; Staudenmann D, Choi KKH, Kaffes AJ, et al. Current endoscopic closure techniques for the management of gastrointestinal perforations. Ther Adv Gastrointest Endosc. 2022;15:26317745221076705. Published 2022 Feb 27. doi:10.1177/26317745221076705.

Disclosures

For this program, the following relevant financial relationships were disclosed and mitigated to ensure that no commercial bias has been inserted into this content: Dr. Kumta has been a consultant for Apollo Endosurgery, Boston Scientific, Intuitive Surgical, Olympus. Members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Kumta was recorded at the 45th Annual New York Course: Endoscopy 2021: Back to the Future, held December 16-17, 2021, and presented by the New York Society for Gastrointestinal Endoscopy. For information about upcoming CME activities from this presenter, please visit nysge.org. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.50 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.50 CE contact hours.

Lecture ID:

GE362001

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.