Resection vs. primary closure in iatrogenic colon perf...why?

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Dares Dareson

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Why does it seem you always have to do a bowel resection when there is a perf during routine colonoscopy? Can't you just oversew the hole and be done with it? I know there are even endoscopic suturing devices in development.

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Do you mean patients who you actually have to take to the OR? Because there are many patients who can be managed conservatively after iatrogenic colon injury.
 
Colonic perf during Cscope is generally from barotrauma due to overdistension of the colon with air, rather than the colonoscope poking through the wall (although the later can certainly occur). With barotrauma, you don’t just get a hole, you get the colon kind of splitting in longitudinal tears. For short segment you can oversew but frequently if the patient ends up in the OR, the damage is such that the entire area needs to be resected. Smaller tears which might otherwise be oversewn are frequently treated conservatively with bowel rest and antibiotics and don’t end up in the OR.
 
Why does it seem you always have to do a bowel resection when there is a perf during routine colonoscopy? Can't you just oversew the hole and be done with it? I know there are even endoscopic suturing devices in development.

Depends on the etiology of the perforation. The most common cause of perforation is a radial injury from a loop in the sigmoid...the endoscopist is staring at the middle of the lumen, but pushing hard and causing more and more tension in the loop until it perforates...this causes a significant longitudinal tear that's not amenable to repair.

Perforation from barotrauma is very rare, and usually only occurs in the background of a large bowel obstruction. When it does happen, it's typically the cecum and the blowout injury requires resection.

Occasionally, a very small hole can be observed, often after polypectomy or something similar. Most holes are big enough where observation doesn't work.

If there's a small perforation, e.g. driving the tip of the scope through a diverticulum, then it is reasonable to consider simple laparoscopic suture repair.
 
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