I'm delighted to introduce our next speaker, Dr. Shivangi Kothari. She is an Associate Professor of Medicine and the Associate Director of Endoscopy at the University of Rochester in New York. And she will be presenting today on immediate post-endoscopic management of colonic perforations, what to do when your patient hits recovery. All right. I would like to thank the ASG and the course directors for an amazing course, and thank you for inviting me to speak on a topic that's very close to my heart. And these are my disclosures. And a few disclaimers. We're not just going to talk about when the patient hits recovery, but how do we minimize complications, identify them early, manage them pre-, intra-, and post-procedure. And all the perforations shown in the talk are not mine. The main thing is this happens to all of us. It's happened to all of us. I was told very early on in my training that, Shivangi, if you've not had a perforation, it will happen at some point, because statistics have a way to catch up to you. You've just not done enough procedures then. So the goal is that we talk about it, we learn from each other's experience, and we do what's best for our patients and help minimize the risks of our invasive interventions. So what happens when we see this as an endoscopist, there is complete anxiety and panic attack in the unit and the room. And the goal is that, as Ezio said and Dan, the main thing is that we stay calm, because you control the tone in the room. Know your toolbox, know what armamentarium you have to manage any perforation, and understand that it's inherent, and the early identification and management is key. Call for a second opinion. If you have a senior partner or colleague in the next room, and if you feel like when you're in the eye of the storm, you may not be thinking clearly, get help. Seek advice, even from your nurses. They may suggest something or tell you what's in the toolbox that you may not be aware of. Multidisciplinary management of these patients is very essential. Have a favorite surgeon on your speed dial always. Communicate well with the patient, with your team in the room, even after the procedure. Communicate well what happened and follow up on your patient and learn from the event. You do not want to ignore your patient's symptoms. Do not discharge a patient with symptoms. If the patient in recovery room is complaining of abdominal pain, make sure you thoroughly assess it, get an x-ray or follow up, and you're not discharging patients with active symptoms. And do not fix a problem inadequately or beat yourself and lose confidence. The three steps that we'll be talking about first is pre-procedure identification of high-risk patients for perforation, intra-procedure identification and early management, and post-procedure early recognition and subsequent management. So factors that contribute to a procedure being high-risk, they are patient-related factors, elderly patients, history of radiation, severe diverticulosis, presence of inflammatory bowel disease, which can increase the risk by eight-folds, steroid use, altered anatomies. And then there are, of course, the procedure-related factors. Most of the perforation, 70% to 80% happen in the rectum or the rectal sigmoid, whether it's a difficult case, sharp angulations, strictures, significant looping, poor bowel prep, you can't see where you're going, barotrauma. And of course, with increasing interventions, the risk of perforation with a screening colonoscopy is much lesser versus when you're doing a dilation or EMR or ESD. And of course, endoscopist volume also contributes to it. Some of the potential solutions is, of course, a good bowel prep. Ask for pressure early on if there is severe diverticulosis, sharp angulations. Consider using a smaller caliber scope. We have now the slimmer caliber pediatric scope. So have a low threshold to switch to the smaller caliber scope. Change the patient positions, but make sure that you're not pushing through resistance, you're not putting in big loops, which could hurt the patient. And 40% to 60% of the perforations can be identified intra-procedure and managed successfully. If you see visible fat or a visible perforation, or when you're doing an EMR and you see a target sign, and I will show you a couple of pictures and videos of that, suddenly you can't keep insufflation, patient's hemodynamics changes, or they're developing a tension pneumoperitoneum. Be vigilant in the procedure to identify the perforation and fix it. Because if you look at the ESG guidelines, endoscopic closure has made it to the guidelines because it has shown to decrease the need for surgery. So if you identify it in the procedure and you fix it, you are saving the patient from a big surgery. And then of course, if patient comes with a delayed presentation after 24 hours, has active leakage, has sepsis, or it's a large perforation, those are the patients that will truly need surgery. But for the ones that you can identify during the procedure, that is your window to fix it. So what tools do we have? And you have repeatedly seen this theme all morning. These are some of the tools in our armamentarium that help us fix perforations. Scope clips can help close perforations up to 10 millimeters. Over the scope clips can close slightly bigger perforations up to 3 centimeters. And then endoscopic suturing allows us to close bigger defects. So when you look at the Sydney classification of heat injury to the muscle, target sign is basically a type 3 injury, which means it's not a frank perforation, but the muscle has been breached. So what you're seeing at the undersurface of the cut polyp is a breached muscle and you want to clip close this defect. Type 4 perforation is a frank perforation, and 5 is when you have leakage of fecal material out of the perforation. So when you're doing endoclip closure of a perforation, you hear this term zipper close. Basically it's placing clips in close proximity, 1 to 2 millimeters apart. And now we have wider span clips to close bigger defects. And you want to make sure you grab enough tissue that will help hold that clip in place. So you don't want to just close the mucosa on top, but you want to grab enough tissue to close the defect and grab the entire layer of the wall. And this can be successful over 95% of the times. Here you can see in this video, a sessile polyp being adequately raised. You want to create a good submucosal cushion because that will help protect your muscle layer and a stiff snare being used to resect it. You want to jiggle a little to make sure that the whole wall is not moving and you don't have the muscle. But as soon as you resect, on initial exam, the base looks beautiful. But on a little more detailed view, the muscle has been breached. So at this point, you want to make sure that you close that defect with the linear clip placement because this is what we call as a type 3 injury. And this was successfully closed. Coming to type 4 perforations, again, another sessile polyp examined well. Your nice type 2 polyp injected, raised well. And of course, I also like to inject and resect and then you go to the subsequent part of the polyp. And as soon as the resection is performed, you see a frank perforation. So yeah, everybody gasped in the room. So you want to make sure you're using CO2 at this point. You keep your calm. And this is your window. The through-the-scope clips work beautifully because you can close them in a linear fashion. You don't have to pull the scope up, load another device, and go close the perforation. This is the target sign. You're seeing the muscle on the undersurface of the polyp. This is another polyp resected. The fat you are seeing, this is not submucosal fat. This is the fat you don't want to see. This is the peritoneal fat. And you want to make sure that you close this perforation well. And as I said, through-the-scope clips provide us the ability to close it right there. And then you don't have to pull the scope, load another device, and this is your window to fix it. You're monitoring the patient's vitals, monitoring the abdomen. Doesn't just happen with EMR, as I said, as the invasiveness of procedures go up. This is a very scarred polyp, ESD being performed, and you can see the muscle gets breached. At this point, one could argue, do you continue the dissection? Do you abort? The first goal is a little more dissection was performed, and the perforation was closed, and then subsequently the ESD could be completed. But the main thing is that you're staying vigilant, you identify it, and actually the little more dissection helped create that window to close the perforation with endoclips. Sometimes if it's a big perforation and a large polyp, you may not be able to complete the entire dissection then, and either talk to your surgical colleagues or bring patient back another day once they're stabilized. This is a perforation happened to my colleague during a screening colonoscopy, and I was called in to help close it. We're using the over-the-scope clip here, and using the twin grasper to grasp the hole into the clip, and you want to make sure you've adequately pulled it inside and then deployed the over-the-scope clip. It gives us the ability to a full thickness resection, and has over 85% success rate in a review that we've published, and know which clip loads on which scope. So that is key, and you want to make sure about different diameters load on different gastroscopes or pediatric colonoscopes and the adult colonoscopes. Endoscopic suturing gives us the ability for a full thickness closure again. The double-channel platform, again, you have to pull the scope out, load the device, and go in and close the perforation, and you can close bigger size perforations with this. The new single-channel platform is great for mucosal closures. I personally feel for a full thickness closure, the double-channel platform is great. Again, if you're pulling your scope out and you're going back in with the over-the-scope clip, you could place an endoclip away from that area so you can identify where the perforation is, so just keep that in mind. So intra-procedure management, stay calm, communicate, switch to CO2. You're thinking antibiotics, you're thinking IV hydration, you're thinking bowel rest, and if the patient is developing pneumoperitoneum, keep a large bowl angiocatheter available to decompress that abdomen. Intra-procedure management is your key, and you can have over 90% success in managing the perforations. Your surgeons are your friends, and I will come to that, because patients, if they don't respond to endoscopic closure or they do come back septic, you will need the surgeons to step in, so multidisciplinary management is key. Post-procedure, the patient can present early with the recovery room. They can come a few days, 24 hours later, and there is a whole spectrum from just abdominal pain or distention to full-blown sepsis, leukocytosis that they can present with. If a free x-ray just shows a large amount of air, it's not always a reason for panic. You could get a CT with a water-soluble contrast and see if there is an ongoing leak or if there is truly a large perforation. Talk with your radiology colleagues. Sometimes they may ask for rectal contrast, so make sure you get the right study that's going to give the right information and help you and the surgeon manage the patient. When you look at the guidelines, within four hours, if the patient has a great prep, you can go back in and fix the perforation if you know exactly where the perforation is. You're closely monitoring these patients. You're not just sending them home. If they do develop ongoing abdominal pain or signs of sepsis, get a CAT scan. See if there is an active leak, and for large perforations, patients with sepsis, peritonitis, those will have to go for surgical repair. This is a case of a patient from our ASC, and I was the inpatient attending on service. 62-year-old female comes for an average or a screening colonoscopy. It's performed in the ASC setting. A fellow is involved. The scope just could not be advanced beyond the hepatic flexure, and as they pull the scope out, they think there is a huge rent in the rectosigmoid area. So they immediately call me. I'm the service attending. We inform the ED. We inform the colorectal surgeon. An urgent CT is performed as the patient comes and hits the emergency room. You can see a large amount of free air in the abdomen, and the concern is for a rectosigmoid perv. The patient's taken to the operating room within the next hour, and there was over 50% circumferential perforation of the rectosigmoid, and they said it was a very redundant colon, and the patient was discharged two days later. The endoscopist came and saw the patient every day, wrote a note, and the goal is that lawsuits don't happen because a perforation happened. They happen because patient feels abandoned. I never saw the gastroenterologist again. So make sure even if it's a screening colonoscopy, you did it in the ASC. You go follow up on the patient. Make sure they know you're quarterbacking them. You're talking to the surgeons, and they're getting the right treatment. So this is a great diagram I'd leave you with by Dr. Raju. Our management for complications goes from just post-polypectomy syndrome to conservative management to endoscopic closure to surgical, whether it's laparoscopic, open, primary repair, whether they need an ostomy, and all those things depend on the size of the perforation, the timing, presence of sepsis, identification of the perforation, and how well you were able to close it. I will leave you this for any perforation. The goal is the four R's. I know you got your D in the morning. You're getting your R's, and the goal is reduce, identify your high-risk patients, and anticipate it. Get a good informed consent. If you're doing an invasive intervention, recognize it early. Happens to all of us, but have your armamentarium ready to fix it. Identify it early and be vigilant. Make sure you document well, follow up on the patients, and clear and open communications with the patient, with the family, with the team, and the surgeons is very essential. Review it as a part of a QI project, and learn from the event. Next time it happens, you tell yourself and your team, don't worry, we got this. Thank you.

endoscopy

colonic perforations

patient safety

post-endoscopic management

multidisciplinary collaboration