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322 Ahmad Assalia · Anat Ilivitzki
Always transfer these “sick” patients to the surgical service regardless
of the immediate need for surgical intervention. In the interests of ev-
eryone, especially the patient, the best environment is the surgical floor
where patients can be monitored and treated appropriately.
Recognition and early management of complications is the key for a suc-
cessful outcome. So, if you do not think about it, you will not diagnose it.
Regardless of the etiology, always treat shock immediately and prepare the
patient with obvious peritonitis for urgent laparotomy.
Always READ carefully any admission and progress notes and the endo-
scopic report; TALK to patient, the patient’s doctor, and directly contact the
gastrointestinal (GI) specialist who performed the “uneventful” procedure
(many clues for the nature of the complication are there); VIEW, personally,
all images taken at the endoscopy and after it.
Complications of Upper Gastrointestinal Endoscopy
Flexible esophagogastroduodenoscopy (EGD) is a relatively safe procedure
with few complications. Almost half of the serious complications that occur are
cardiopulmonary, related to aspiration, hypoxemia, vasovagal reflexes, and endocarditis. The surgical complications include:
Esophageal perforation. The cervical esophagus is the area most at risk. Risk
factors include anterior cervical osteophytes, Zenker’s diverticulum, esophageal
stricture or web, and a cervical rib. Most cervical esophageal perforations occur
during rigid endoscopy or with blind passage of a flexible endoscope. Retching
with an overinflated stomach and the endoscope occluding the gastroesophageal
junction can result in Mallory-Weiss tears or transmural perforation. Cervical pain,
crepitus, and cellulitis are all signs of high esophageal perforation. Halitosis develops rapidly due to overgrowth of anaerobic bacteria. Distal perforations cause chest
pain. A cervical soft tissue X-ray and chest radiograph may be helpful in the initial
stages for the detection of cervical air, pneumomediastinum, and pneumothorax
or pleural effusion. The diagnosis is confirmed with water-soluble esophagography
or computed tomographic (CT) scan. Do not waste time: obtain an urgent CT scan
with oral contrast medium; it will detect minimal perforations and provide additional valuable information regarding the location and extent of the inflammatory
pro ces s. The management of esophageal perforation is outlined in > Chap. 15.
Post-EGD upper GI bleeding (variceal and nonvariceal) is approached and
treated according to the principles presented in > Chap. 17.
Other complications. Following sclerotherapy, and less frequently after band
ligation for esophageal varices, up to half of the patients will experience one or more
of the following: chest pain, pleural effusion, pulmonary infiltrates, and bacteremia
30 Surgical Complications of Endoscopy 323
(without perforation). Bacteremia is especially common after esophageal dilatation,
so antibiotic prophylaxis should be considered in an effort to prevent bacterial endocarditis in susceptible individuals. Esophageal placement of stents for malignant
strictures may cause erosions, bleeding, migration, tumor ingrowth with recurrent
obstruction, food impaction, or (if they are inserted across the gastroesophageal junction) reflux with aspiration. Remember—these patients have a short life expectancy;
do no more than the minimum required for palliation. This may include repeated
endoscopies for ablation of the tumor ingrowth or placement of a second stent.
Complications of Percutaneous Endoscopic Gastrostomy
“DIB (death in bed)—a common early sequel of ‘tracheostomy and gastrostomy.’”
Percutaneous endoscopic gastrostomy (PEG) tubes are commonly used as a
feeding route in elderly and debilitated patients. In some cultures and places, it seems
that patients are not allowed to die without having a PEG tube inserted. This is an
invasive procedure, and complications after PEG insertion are not uncommon.
Leakage
Leakage is by far the most important complication. It tends to present in
the first days following the procedure. The clinical scenario ranges from asymptomatic leakage around the gastrostomy tube to overwhelming peritonitis and
sepsis. The reason is inadequate fixation of the stomach against the inner abdominal wall or the separation of the two due to various factors, especially ischemia and necrosis of the gastric wall due to excessive tightness of the fixing
device—whatever method is used.
Clinical features depend on whether the leaking gastric juice or feeding solution leaks only to the outside around the tube or whether the leak is into the peritoneal cavity. If the latter is the case, the clinical picture may range from mild pain
and abdominal distention due to ileus to full-blown peritonitis and “sepsis.”
Diagnosis The finding of free intraperitoneal air is not diagnostic be-
cause pneumoperitoneum may be present for weeks after uncomplicated PEG
insertion. Intraperitoneal leak should be excluded by a contrast study, with contrast instilled through the PEG tube.
Management If a contrast study excludes intraperitoneal leakage, then
the PEG tube has to be “rested,” allowing the tissue around it to seal. Attach the
PEG tube to gravity drainage, administer intravenous fluids and antibiotics, and
follow the patient closely. Wait a week and then repeat the contrast study before
attempting PEG feeding. This, with the addition of a nasogastric tube, should also
be the approach when the PEG tube is pulled out inadvertently less than 2 weeks
324 Ahmad Assalia · Anat Ilivitzki
after insertion, and there are no signs of peritonitis or sepsis and no evidence of
intraperitoneal leak on contrast study. In cases with obvious leakage into the
peritoneal cavity, your management should be guided by the clinical scenario.
While minor and asymptomatic leaks can be treated conservatively, operative
treatment is mandatory with free intraperitoneal leaks and signs of infection.
Operation Early on, in the absence of significant tissue edema, place a
purse-string suture around the PEG tube and (carefully and all around) refix the
stomach to the abdominal wall. But, if the surrounding tissues and the hole in
the stomach look “bad,” then take out the tube and carefully suture or staple off
the hole. Based on the condition of the patient and the degree of peritonitis, consider whether you wish to insert a gastrostomy (or jejunostomy) tube in another,
healthier location. Needless to say, thorough “peritoneal toilet” is mandatory
(> Chap. 12). This procedure could be accomplished laparoscopically if you have
enough skills or by a minilaparotomy in the upper midline.
Late Leaks Less frequently, leaks may occur long after PEG insertion,
particularly in patients with poor healing capabilities and occasionally also after
inadvertent or planned removal of the tube. Most often, such late leaks behave
like a controlled gastric fistula and will eventually seal spontaneously with conservative measures. However, an uncontrolled leak into the peritoneal cavity may
occur and should be managed according to the principles outlined.
Perforation of a Viscus
Rarely, the colon or even small bowel can be “impaled” by the PEG tube during
its placement. This could present early with a free leak and peritonitis or later with an
abscess or colonic fistula (external or communicating with the stomach). The management (conservative vs. operative) depends on the acuteness of presentation, the
anatomy of the complication, and the patient’s general condition. Free leaks must be
controlled, abscesses have to be drained, while controlled fistulas are managed conservatively. Cologastric-PEG fistulas usually subside when the tube is pulled out.
Complications of ERCP
The ERCP procedure carries a relatively high incidence of complications.
Were we not constrained by the editors, who forbade mention of percentages in
this book, we would have told you that in decreasing order of frequency, the
complications include pancreatitis (2–5%), bleeding (2%), cholangitis (1–2%),
and perforation (0.5–1.2%). The mortality rate of the last-mentioned complication may be as high as 15%. Therefore, ERCP—especially therapeutic ERCP—
should be viewed as a potentially risky endoscopic procedure.
30 Surgical Complications of Endoscopy 325
Pancreatitis
While hyperamylasemia may be seen in up to two-thirds of patients, clinical
pancreatitis occurs rarely. The incidence is the same for both diagnostic and therapeutic procedures. The severity in the majority of cases is usually mild to moderate
and self-limiting. Unfortunately, however, severe post-ERCP pancreatitis and even
fatalities can occur. Interestingly, pancreatitis is more common in younger patients
and has its highest incidence in patients having ERCP for suspected “sphincter of
Oddi dysfunction” [one of those mystifying diagnoses seen only by those who write
the articles—The Editors].
Diagnosis Any significant upper abdominal pain coupled with hyper-
amylasemia after ERCP should raise the suspicion of pancreatitis. Sometimes,
the diagnosis is difficult to make since perforation (discussed separately) may
give a similar clinical presentation. If cannulation of the duct was easy and no
“precut” or therapeutic interventions were attempted, the likelihood of duodenal
perforation is low. Even so, whenever you suspect a perforation, order a
Gastrografin upper GI study, or preferably a CT scan, to exclude the perforation
and to confirm the pancreatitis.
Management For management, intravenous fluids and nothing by mouth
(nil per os, NPO) until the symptoms abate are usually all that is required. In a
minority of patients, a more severe and protracted course may follow. The management strategy in such cases is discussed in > Chap. 19. Obviously, impacted
common bile duct stones may precipitate pancreatitis and protract its course; if
so, repeated ERCP or operative common bile duct exploration may be indicated
(se e > Chap. 20.3).
Hemorrhage
Clinically significant hemorrhage may occur after endoscopic sphincterotomy (ES).
Diagnosis Bleeding may present as upper GI bleeding or mimic lower GI
bleeding; the patient may develop hemodynamic compromise before hematemesis
or melena appears. Admit the patient to the intensive care unit (ICU) or the surgical
floor for close monitoring and apply all the principles of management of GI bleeding
(> Chap. 17).
Management Repeat endoscopy is indicated for accurate diagnosis, to con-
firm if the bleeding is in the form of oozing or brisk arterial “pumping,” and to
326 Ahmad Assalia · Anat Ilivitzki
achieve hemostasis. If endoscopic hemostasis fails, the patient’s condition is still
stable, and an experienced interventional radiologist is available, then celiac an-
giography with selective embolization of the gastroduodenal artery bleeding branch
may avoid operative intervention. However, if this in turn fails or is unavailable and
the bleeding continues or the patient is unstable, then operative intervention must
be undertaken. After full Kocherization of the duodenum, a longitudinal duodeno-
tomy in the second part will allow access to the papilla of Vater. The bleeding is
controlled by suture-ligatures, being careful not to stenose the opening of the papilla or the sphincterotomy site (it may be advisable to convert the sphincterotomy
to sphincteroplasty). In a “stable” patient in whom ERCP and ES has failed, one can
proceed with a definitive surgical correction of the problem for which the ES had
been attempted. Otherwise, the minimum should be done that allows drainage of
the obstructed biliary system (e.g., cholecystostomy or a T tube).
Perforation
Perforation is by far the most serious complication of ERCP and endoscopy
in general, with up to one-fifth of the patients dying. The vast majority of perforations are into the retroperitoneum in the periampullary area. They are caused by
a “precut” or ES. Less frequently, guidewire perforations of the common bile duct
and the pancreatic duct may occur. Only a tenth of perforations are intraperitoneal
and are caused by the endoscope itself (usually in the anterior wall of the second
part of the duodenum). Risk factors for this include limited experience of the endoscopist, too generous precut or ES, therapeutic procedure, intramural injection
of contrast material, repeated ERCP, and patients with a Billroth II gastrectomy.
Diagnosis Diagnosis is often apparent during the procedure or at the con-
clusion of it when the endoscopist suspects that something went awry. Abdominal
and back pain during or immediately after ERCP together with the presence of
retroperitoneal air on plain X-ray of the abdomen will confirm the diagnosis.
Alternatively, injection of contrast medium by the endoscopist with demonstration of a leak is possible. The best single modality for the diagnosis is an abdomi-
nal CT scan detecting retro- or intraperitoneal air and contrast leakage. This
prevents a mistaken diagnosis of pancreatitis, which could delay the appropriate
management.
Management In highly specialized centers, a repeat ERCP with insertion
of a stent, to “seal” the perforation, may be attempted for management, but most
endoscopists are reluctant to have another go at these patients after endoscopy
has caused the problem in the first place. Although there is lack of consensus
30 Surgical Complications of Endoscopy 327
regarding the best management strategy, it seems that if the following conditions
are met, the majority of these patients can be successfully treated nonoperatively:
Absence of free leakage of contrast
Absence of clinical peritonitis or systemic inflammation (hemodynamic
compromise, high fever, and leukocytosis)
Absence of large pneumoperitoneum
All other patients with a free leak, intraperitoneal air (denoting intraperi-
toneal perforation), peritonitis, or sepsis should be treated surgically.
If conditions for nonoperative management are met, a nasogastric tube
should be inserted and broad-spectrum antibiotics with adequate Gram-negative
coverage administered. Patients should be followed closely, and improvement
should be expected within 12–24 hrs. Normally, these patients recover within
7–10 days, and repeated procedures, if still indicated, can be done at that time.
Lack of improvement with the appearance of peritoneal irritation or signs of ongoing sepsis mandate immediate operative intervention. After fully “Kocherizing”
the duodenum, the site of perforation is usually revealed at its posterior aspect.
Depending on the degree of induration and inflammation of the tissues, either
primary closure or an omental patch repair (see > Chap. 18) are performed and
a drain left in situ. The next step depends on the patient’s condition, underlying
pathology, failure or success of the “index” ERCP, and the adequacy of the duodenal closure. The principles are as follows: if the patient’s condition is stable and
the repair looks adequate (this occurs with early perforations), there is no need
for a pyloric exclusion procedure. An obstructed biliary system should be decompressed, preferably by a T tube (after cholecystectomy and common bile duct
exploration and clearance). If you are already there, please do not leave the pa-
tient at the mercy of the endoscopist again! If you are worried about the duodenal
repair, or its lumen, do add a pyloric exclusion procedure. This is accomplished
by making a gastrotomy just proximal to the pylorus and closing the pylorus from
the inside with an absorbable suture, then forming a gastrojejunostomy (see
>
Chap. 39.2). Finally, feed a narrow-bore nasogastric tube deep into the efferent
loop of the gastrojejunostomy to feed your patient distal to the stoma and the
duodenal repair.
Severe complications and deaths after ERCP are heartbreaking. But, what is
tragic is that in many such cases it is clear in retrospect that the original procedure was
not really indicated. (For example, MRCP could have excluded the suspected chole-
docholithiasis.)
328 Ahmad Assalia · Anat Ilivitzki
Complications of Colonoscopy
Colonoscopy is a relatively safe procedure, with the main complications perforation and hemorrhage. The complication rate is very low for diagnostic procedures and rises when the procedure is therapeutic, especially after polypectomy.
Bleeding
Bleeding might occur immediately after the procedure or may be “secondary” or delayed from an ulcer developing at the site of the polypectomy or biopsy.
The risk is higher with resection of polyps larger than 15 mm, recurrent or difficult procedures, or a bleeding tendency. Rarely, bleeding may occur due to mucosal injury caused by traumatic insertion and manipulation of the scope. Very
rarely, vigorous manipulations in the region of the splenic flexure of the colon
result in a splenic injury and intra-abdominal hemorrhage.
Management Management includes resuscitation and correction of any
coagulopathy followed by an endoscopic attempt to treat the bleeding. If, after
replacing fluids and correcting coagulation deficits, the patient has clearly
stopped bleeding, one may elect not to repeat the colonoscopy to minimize the
risk of a perforation at the biopsy site. In selected stable patients whose pathology
does not require resection, an angiographic selective distal embolization may be
attempted provided a highly skilled interventional radiologist is available. Just
remember the (low) possibility of bowel ischemia following such an intervention.
Persistence of bleeding after unsuccessful colonoscopic or radiological management mandates an immediate abdominal exploration. Always have the endosco-
pist ready in the operating room to perform an intraoperative colonoscopy (or
even better, master the technique yourself). Remember that finding the bleeding
spot could be a difficult task: an intraoperative colonoscopy will minimize blood
loss and prevent unnecessary bowel resections. In most instances, after localizing the bleeding source, all you have to do is to place a colotomy and achieve
hemostasis by oversewing the site of bleeding; then, close the colotomy. If bleeding originates from a source that requires resection (e.g., a large polyp or carcinoma), then an appropriate colectomy should be performed.
Perforation
The mechanism of perforation determines the size of the hole, which occasionally can
then be managed selectively by the smart surgeon, not the “blind” gastroenterologist.
30 Surgical Complications of Endoscopy 329
Difficult, traumatic, and therapeutic colonoscopies are associated with an
increased risk of perforation of the colon. Barotrauma from excessive insufflation of air, excessive use of cautery, or overzealous dilatation of strictures are
common causative factors. In addition, prior surgery, diverticulitis, or preexisting intra-abdominal adhesions and a poorly prepared bowel may increase the
difficulty of the procedure and the possibility of perforation.
When a colonic perforation occurs, the spectrum of consequences is wide
and unpredictable. The mechanism of perforation matters; perforations that follow therapeutic colonoscopy (at a biopsy or polypectomy site) are usually small
and more amenable to nonoperative treatment. On the other hand, perforations
following diagnostic colonoscopy often result in sizeable rents in the colonic wall
and thus require prompt surgical treatment.
Diagnosis The key to diagnosis is to suspect it. Think about the possibility
of perforation in any patient who develops abdominal discomfort or pain at any
time after colonoscopy. Presentation is varied: abdominal complaints and signs may
develop immediately after the colonoscopy when there is a large colonic tear. On the
other hand, patients may present a few days later with gradually increasing local and
systemic manifestations of infection. Such delayed presentation is typical of perforations that are initially contained within the retroperitoneum or the mesenteric leaves
and gradually leak or rupture into the free peritoneal cavity. Polypectomy with cautery necrosis of the bowel wall may also result in delayed perforation.
The abdominal-peritoneal signs and systemic repercussions of colonic
perforation are well known to you. But, remember that loops of bowel—
pumped up with air during colonoscopy—may still be tender many hours after
the procedure.
Start with a plain upright chest X-ray and left lateral decubitus films of the
abdomen and look for free air. The findings of free intra-abdominal air together
with a clinical picture of local or systemic peritonitis are diagnostic of perforation. Pneumoperitoneum may be seen after colonoscopy with minimal or no
clinical evidence suggesting perforation (“benign” postcolonoscopic pneumoperitoneum). Conversely, free air may be missing when the perforation is initially contained or retroperitoneal. Basing decision making on the absence or
presence of free air reflects naïveté common to nonsurgeons (e.g., gastroenterologists) attempting to treat abdominal surgical emergencies.
Obviously, clinical signs of perforation and free air on abdominal X-ray are
diagnostic of perforation. In the absence of free air, insist on obtaining a CT scan
(or a Gastrografin enema if CT is not available). Not only is CT able to show free
air not visualized by plain X-rays, but also it may show other details suggestive
of injury, such as colonic wall hematoma or air in the colonic wall, the mesentery,
or the retroperitoneum. When combined with rectal contrast, CT usually
330 Ahmad Assalia · Anat Ilivitzki
Fig. 30.1. “Nurse, is that the omentum?”
demonstrates the site and size of the leak and whether it is contained or not. Free
fluid may reflect spillage of bowel contents or developing peritonitis.
Remember: the chief cause of death following colonoscopic perforation is
delay in diagnosis and consequent delay in treatment. This holdup usually results from the failure of the responsible clinician (it is usually the colonoscopist
to whom the patient presents with the complication) to consider such a diagnosis. Remember the “surgical ostrich” who cannot diagnose his or her own complications? Well, gastroenterologists are no different (> Fig. 30.1). We have to
help them get their head out of the sand.
Non-operative Management Not all patients with colonoscopic bowel in-
jury need a laparotomy. Patients who are minimally symptomatic, without fever
or tachycardia, and in whom the abdominal exam is benign (i.e., no features of
peritonitis) can be managed nonoperatively with nothing by mouth and broadspectrum antibiotics (as you would manage acute diverticulitis; > Chap. 26).
Patients who respond to conservative treatment typically have no or minimal
pneumoperitoneum and no or minimal leak of contrast on CT.
As stated, perforation at the site of a polypectomy is more amenable to a
trial of nonoperative management. Such an approach is often successful because
these patients have had bowel preparation prior to colonoscopy; therefore, the
potential for abdominal contamination is reduced. All such patients should be
closely monitored for local and systemic progression of the process or failure to
improve. Deterioration should prompt an urgent surgical intervention. If the
perforation is at the site of pathology for which a colectomy will be recommended
anyway, what is the point of sweating through conservative management? Go
ahead and do the definitive surgery right away.
30 Surgical Complications of Endoscopy 331
Surgical Management Patients who look sick, complain of localized or
spreading pain, and have systemic sepsis and localized or generalized peritonitis
should receive antibiotics and undergo an emergency laparotomy. In most patients undergoing early exploration, the findings are those of peritoneal contam-
ination rather than established infection; all that is required is “peritoneal toilet”
(> Chap. 12) and primary suture of the perforation as you would do with any
traumatic colonic injury (> Chap. 39.2). The absence of feces in the colon helps
to minimize the severity of contamination and infection. A diverting or exteriorizing colostomy may be indicated in selected patients, such as those with neglected established peritonitis or severe debilitating comorbidities such as
malnutrition or steroid dependence. The role of laparoscopy in the diagnosis and
treatment of colonic perforations is not defined yet. However, an experienced
laparoscopist, with the help of intraoperative colonoscopy, may accurately diagnose and treat colonic perforations.
Conclusions
The management of endoscopic injury to any hollow GI viscus, from the
esophagus down to the rectum, can be summed up as follows:
Always suspect disaster.
Image for diagnosis.
Those who are missed and neglected tend to die.
Some can be managed conservatively.
Some need an immediate operation.
Some who are managed conservatively may eventually need an operation.
To achieve optimal results, be selective, alert, and always ready to change
your mind. You are not a politician; you can be proud to be a flip-flopper!
A fool with a tool is still a fool.
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