Surgery News - January 2008 - (Page 14) GENERAL SURGERY SURGERY NEWS • J A N U A RY 2 0 0 8 Experts Assess Options for Colonoscopic Perforation A new review suggests that clinically stable patients without peritonitis can be treated conservatively. BY BRUCE JANCIN Else vier Global Medical Ne ws C O L O R A D O S P R I N G S — Prompt surgical management remains the most appropriate strategy for most patients with iatrogenic colonoscopic perforation, although a conservative observation-based approach is “not unreasonable” in a highly select subgroup, Dr. Corey W. Iqbal said at the annual meeting of the Western Surgical Association. When properly selected, patients who are clinically stable and devoid of peritonitis do “extremely well, with shorter hospital stays and significantly less morbidity,” according to Dr. Iqbal of the Mayo Clinic, Rochester, Minn. The caveat is that any deterioration in their condition warrants an operation, he added. Dr. Iqbal reviewed the Mayo Clinic experience with colonoscopic perforations during 1980-2006. The perforation rate was 0.07% in 258,248 colonoscopies and did not differ by physician specialty. This rate of 7 perforations per 10,000 procedures remained fairly stable over the years, although the increase in annual colonoscopies (from 1,573 in 1987 to nearly 20,000 in 2005) means that physicians encounter the complication far more frequently today. A total of 165 of the 180 perforations were managed surgically, with 33% operative morbidity and 7% mortality. The mean hospital length of stay in operatively managed patients was 14 days. In contrast, the mean stay in the 15 nonoperatively managed patients was just 6 days. They had a 7% major morbidity rate and 13% mortality. Of note, both of a history of abdominal surgery, and more than 40% of those patients had undergone an examination-only colonoscopy. The mean age of affected patients was 71 years, the nonoperatively managed patients who compared with 67 years for all those undied were not deemed reasonable candi- dergoing the procedure. The perforation was located in the sigdates for nonoperative management, but moid colon in 53% of cases and in the cethey refused reoperation. Among the operatively managed pa- cum in 24%. “Sigmoid perforations were tients, 46 underwent primary repair, with almost always due to mechanical torque the remainder roughly evenly divided be- injury resulting from the scope crossing tween resection with anastomosis and the sigmoid colon,” according to Dr. Iqbal. “We found that patients with a two-stage fecal diversion promechanical mechanism of incedures. jury were twice as likely to undergo a fecal diversion proceRisk Factors dure, compared to those with “One of the common miscona polypectomy or thermal ceptions about colonoscopic injury.” perforations is that because the Blunt or torque injury was bowel is prepped, there should the mechanism in 55% of inbe minimal contamination. testinal perforations, polypecHowever, we found that 20% tomy in 27%, and thermal of patients had feculent periOur perforation injury in 18%. tonitis at the time of explodetection rate is ration. The risk factors for this high because of Management Algorithm were [inadequacy] of the bowthe staff’s low Dr. Iqbal and his colleagues el prep and a presentation threshold to call recommended the following more than 24 hours after for surgical help. management algorithm: A percolonoscopy,” Dr. Iqbal exDR. FARLEY foration identified intraproceplained. Of the colonoscopic perforations in this durally warrants immediate operation beseries, 30% were diagnosed intraprocedu- cause it is likely to be too large to safely rally or within 1 hour postoperatively. Of be observed. Surgery is also advisable for all patients with colonoscopic perforation, patients who present in unstable condition 78% presented within 24 hours. Those or with peritonitis after a colonoscopy. Details of the patient history and the enwho did so had a 50% prevalence of minimal fecal contamination and an 11% rate doscopy can be helpful in identifying which patients may be managed nonopof feculent contamination. In contrast, patients presenting after 24 eratively. “A patient who’s had a previous abhours had a 17% rate of minimal fecal contamination and a 45% prevalence of fecu- dominal operation and undergoes an exlent contamination. Of patients who pre- amination-only colonoscopy is at high risk sented after 24 hours, 63% got an ostomy, for a large perforation of the sigmoid a rate nearly twice that of patients who colon that will not be amenable to observation. This is an area where a CT scan presented earlier. Of patients with a perforation, 61% had may also be useful,” he said. Discussant Dr. Mario Villalbo said that the experience at William Beaumont Hospital, Royal Oak, Mich., has been quite similar to that of the Mayo Clinic. At William Beaumont, where he is a general surgeon, 100,142 colonoscopies have been performed in the past 7.5 years, with a 0.06% perforation rate. One in five perforations was managed nonoperatively. Dr. Villalbo hailed the Mayo Clinic’s 78% perforation detection rate within 24 hours after colonoscopy as “a remarkable achievement,” far in excess of the rate at William Beaumont. Dr. David R. Farley, an ACS Fellow who is a professor of surgery at the Mayo Clinic and a senior coauthor of its study, cited two factors in the Mayo Clinic’s high early detection rate. One is that many patients come to the clinic from great distances and stay overnight at a local hotel after their colonoscopy, so it is easy for them to seek help if abdominal distention or other symptoms develop. The other key factor is the institutional culture. “The nurses and GI doctors have a very low threshold to call for surgical help,” he said. “The Mayo Clinic is a very collegial institution and we do like to work together.” Dr. Farley agreed with Dr. Villalbo’s prediction of an increase in laparoscopic repair with intracorporeal suturing as an alternative to laparotomy in colonoscopic perforation management. “I think it’s also likely the endoscopists will address this problem with endoluminal clips,” he added. Dr. Farley stressed the value in having ready at hand an institutional management algorithm for colonoscopic perforations. “It’s a very rare complication and people can go for years without encountering it, but some of our most experienced endoscopists [have] suffered perforations,” he observed. ■ Major Rectal Cancer Trial to Evaluate Laparoscopic Surgery BY BRUCE JANCIN Else vier Global Medical Ne ws C O L O R A D O S P R I N G S — The American College of Surgeons Oncology Group is gearing up to launch a major randomized clinical trial aimed at determining whether laparoscopic surgery is an appropriate approach in rectal cancer, Dr. James W. Fleshman announced at the annual meeting of the Western Surgical Association. The trial, known as ACOSOG Z6051, will require credentialing of participating surgeons, an innovation that proved helpful in the landmark Clinical Outcomes of Surgical Therapy (COST) trial comparing results of laparoscopic and open colectomy in 872 colon cancer patients, said Dr. Fleshman, professor of surgery and chief of colon and rectal surgery at Washington University, St. Louis. Although COST has convincingly established that longterm outcomes are equivalent with laparoscopic and open colectomy for colon cancer, it would be inappropriate to assume that the same is true for rectal cancer surgery, which differs from colon cancer surgery in important ways. Neoadjuvant chemoradiation is now routine in patients with stage II and III rectal cancer. Sphincter preservation is the standard of care in nearly 95% of all rectal cancer patients—and anastomotic complication rates are far higher in rectal cancer patients after a sphincter-sparing resection than after a colon resection, continued Dr. Fleshman, an ACS Fellow and a director of the American CLASICC supports continued use of laparoscopic surgery in that setting; however, the number of rectal cancer paBoard of Surgery. Numerous retrospective single-center case series have tients included was actually rather small, Dr. Fleshman demonstrated that laparoscopic surgery in rectal cancer noted. In contrast, Z6051 will feature a planned 450 patients is technically feasible, but there isn’t adequate randomized prospective trial evidence that outcomes are as good with stage II or III rectal cancer, a body mass index no greater than 34 kg/m2, and age less than 80 years. All will as with open surgery. “Local recurrence rates have been the bane of our ex- have received neoadjuvant chemoradiation. If recruitistence in patients with rectal canment proceeds quickly, enrollment cer. They’ve been extremely high in might be expanded to 650 patients. ‘WE DON’T WANT TO MAKE A the past, and we don’t want to The primary end points in Z6051 make a mistake by accepting a new will be oncologic outcomes, inMISTAKE BY ACCEPTING A technique without fully submitting cluding rates of margin negativity NEW TECHNIQUE WITHOUT it to clinical trial,” he said. and complete total mesorectal exIndeed, the sole existing rancision, with removal of an intact FULLY SUBMITTING IT domized trial data come from the envelope and all lymphatic materiTO CLINICAL TRIAL.’ United Kingdom Medical Research al and fat. Council Conventional versus LaThe secondary end points will be paroscopic-Assisted Surgery in Co2-year overall and disease-free surlorectal Cancer (CLASICC) trial. That study, in which 794 vival and local recurrence rates. Formal quality of life aspatients were randomized 2:1 in favor of laparoscopic sessments addressing sexual and bowel function will also surgery, showed no significant differences in 3-year over- be incorporated. all survival, disease-free survival, or local recurrence Dr. Fleshman and the other trial organizers are seekrates in the overall study population ( J. Clin. Oncol. 2007; ing to recruit roughly 60 surgeons, who will each be re25:3061-8). quired to subm
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