Colon perforation is a rare complication of diagnostic and therapeutic colonoscopy. The standard for treating colonoscopic perforation remains explorative laparotomy with primary perforation closure or bowel resection, with or without diverting stoma [1], despite some reports of the use of conservative management with antibiotics alone or with endoclipping [2, 3]. In the last decade, laparoscopy has been accepted as a valid surgical approach in colonic surgery, with low morbidity and shorter postoperative stay, even for complicated or cancerous disease [4–10]. Some case reports and small series of laparoscopic repair of colonoscopic perforations have been published, but strong scientific evidence demonstrating interest in this approach is still lacking.

In their growing clinical experience with laparoscopic colonic surgery, the authors gradually modified their approach to treating colonoscopic perforation, from systematic explorative laparotomy in the 1980s to laparoscopic management if possible, without systematic protection with diverting stoma, more recently. The aim of this report was to compare the outcome of patients who underwent open and laparoscopic surgical repair of colonoscopic perforations in order to evaluate the safety of the laparoscopic approach. We hypothesized that laparoscopic treatment of iatrogenic colonoscopic perforation may result in equal therapeutic efficacy, less perioperative morbidity, decreased length of stay, and overall better short-term outcome compared to open methods.

Patients and methods

The authors retrospectively reviewed the medical charts of 43 patients (22 males, 21 females, mean age = 66 years old) who suffered from colonoscopic perforation between 1989 and 2008 in two large tertiary centers. The patients’ demographic data, perforation location, surgical characteristics, length of hospital stay, and outcome were recorded. The perioperative complications related to the secondary surgery necessary for stoma reintegration were not taken into account in this analysis.

Diagnosis of colon perforation was suspected on clinical grounds and confirmed by abdominal plain radiograph and/or computed tomography. The type of surgical approach and the surgical procedure itself (direct closure versus bowel resection, diverting stoma versus no stoma) was decided by the surgeon according to his/her experience with laparoscopy, the time between the colonoscopy and the diagnosis of perforation, and degree of peritoneal contamination. There was a clear tendency to favor the laparoscopic approach in the most recent years. In addition to the bowel repair, all patients underwent extensive peritoneal cleaning and rinsing, peritoneal drainage, and intravenous broad-spectrum antibiotics.

Among the 43 patients, one underwent conservative management, 23 immediate exploratory laparotomy, and 19 exploratory laparoscopy. Three of the 19 explorative laparoscopies were converted to laparotomies because of surgical difficulties closing the perforation because of the length of the colon (1 case) or colon tissue fragility (2 cases). These three cases were excluded from subsequent analysis in order to evaluate the safety of the “laparoscopy only” approach. In the 16 remaining patients, full laparoscopic management was performed. We compared the outcome of the 16 patients who underwent complete laparoscopy management (laparoscopy group, n = 16) to the patients who underwent direct laparotomy (laparotomy group, n = 23). These groups were similar with respect to age and sex ratio (Table 1).

Table 1 Patients’ characteristics
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Data are presented as means ± standard error of the mean (SEM). Means were compared using Student’s t test or the Mann–Whitney test, and proportions were compared with Fischer’s exact test. A value of P < 0.05 was considered significant. Data were analyzed using the Instat 3.0b and Prism 5 software for Macintosh (GraphPad Software, San Diego, CA).

Results

The characteristics of the surgical procedures are presented in the Table 2. The time delay between the colonoscopy and the surgery was up to 24 h in 35% of the patients in the laparotomy group compared to 6% in the laparoscopy group (P = 0.056). The majority of perforations occurred in the sigmoid colon in both groups. Numerically, there were more stercoral peritoneal contaminations and diverting stoma in the laparotomy group than in the laparoscopy group, despite the fact that the difference was not significant due to the small size of the series.

Table 2 Surgical findings and surgical procedures
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The postoperative course of both groups is presented in the Table 3. The mean hospital stay was shorter for the laparoscopy group (P = 0.02). There was no mortality (NS) and fewer postoperative complications in the laparoscopy group (P = 0.01). In the laparoscopy group, one patient presented a prolonged postoperative ileus that was treated conservatively, and one developed Clostridium difficile pseudomembranous colitis that was treated with medication. There was no reoperation in this group. In the laparotomy group, two patients died from multiorgan failure 8 and 11 days after the surgical procedure, and postoperative infection (parietal abscess, n = 3; urinary tract infection, n = 1; pulmonary infection, n = 2) was the main cause of postoperative complications. One laparotomy patient needed early relaparotomy for residual peritoneal abscesses.

Table 3 Postoperative results
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Discussion

The analysis of this series demonstrated that colonoscopic perforation diagnosed early (<24 h) may be managed safely laparoscopically, combining perforation suture, peritoneal rinsing, and drainage. In the absence of stercoral peritoneal contamination, diverting stoma may not be necessary. This policy may lead to reduced surgical and psychological stress for the patient, a very low rate of morbidity and mortality, and shorter hospital stay compared to the usual open approach. This finding is particularly important in the setting of this severe iatrogenic complication whose legal implications are evident.

In this retrospective and nonrandomized study, a true comparison of postoperative complication rates between open and laparoscopic approaches cannot be performed because the two cohorts of patients are not identical. The delay in diagnosing the perforation was longer for the open group, leading to more frequent peritoneal stercoral contamination and to an increased rate of postoperative septic complications. Moreover, the laparoscopic approach for this situation was progressively favored with time and experience, and primary explorative laparoscopy has become the standard procedure in our departments for this rare indication. However, the complications showed low morbidity and mortality rates and a short postoperative stay in the laparoscopic group in this series.

Our series of 19 patients who underwent laparoscopy for colonoscopic perforations represents the largest reported study to date. Most of the published reports described one or two successful cases [11–21]. The publications on series of more than five patients [22–26] are presented in Table 4. These series confirmed the same excellent results of laparoscopic management of colonoscopic perforations that we experienced in our study. Should a randomized evaluation comparing the open approach with laparoscopy be performed in colonoscopic perforation? First, the low frequency of this complication of colonoscopy renders a prospective randomized study very difficult, even in a multicenter fashion. Furthermore, this prospective study would be ethically and medically unacceptable in our departments because we are convinced of the advantages of the laparoscopic approach. Such a study could be performed in centers where explorative laparotomy and stoma are still the standard method of managing colonoscopic perforation. The laparoscopic management of colonoscopic perforation could also be compared to the recently described endoscopic repair using clips that may be efficient in small perforations, as described in some case reports.

Table 4 Published series of more than five patients managed by laparoscopy
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The main message of our study is to advise surgeons with good laparoscopic experience to first perform an explorative laparoscopy in patients with early diagnosed colonoscopic perforation. Peritoneal contamination is usually very mild thanks to the colonoscopic bowel preparation that the patient performed. In the majority of cases, the perforation may be found in the sigmoid loop and can be safely closed by stitches or GIA staplers without a diverting stoma. However, the main objective of surgical treatment of colonoscopic perforation is, and should always remain, patient safety, and conversion to laparotomy and stoma after explorative laparoscopy should never been considered a failure or a mistake. The peritoneal cavity should also be thoroughly rinsed and drained, and the patient should receive broad-spectrum antibiotics. This minimally invasive approach to managing colonoscopy perforation, avoiding laparotomy and diverting stoma, has a low complication rate, decreases the hospital stay, and may render this severe iatrogenic complication of colonoscopy more acceptable to the patient. This may reduce the related legal issues related to this iatrogenic complication of colonoscopy. Therefore, from the literature review and from this study, we consider that a laparoscopic exploration and repair should be attempted in all patients with colonoscopic perforation as soon as this diagnosis is suspected.