Iatrogenic colon perforation: endoscopic management or surgery

Abstract

Iatrogenic colonic perforation is a rare but serious complication of colonoscopy, particularly during therapeutic procedures. Prompt recognition and individualized management are essential to prevent adverse outcomes. This review summarizes current treatment strategies based on major international guidelines. Endoscopic closure is recommended for selected cases involving minor defects, early detection, and adequate bowel preparation. Techniques such as clipping, endoloop application, and suturing have demonstrated favorable success rates. Surgical intervention is crucial for larger, delayed, or complicated perforations, particularly those associated with significant contamination or clinical deterioration. Recognizing risk factors such as age, diverticulosis, and inadequate bowel preparation can help prevent this complication.

INTRODUCTION

Colonoscopy is widely used for the diagnosis and treatment of colonic diseases.1 While generally safe, it carries a risk of iatrogenic colon perforation, a serious complication occurring in 0.02% to 0.8% and 0.15% to 3% of diagnostic and therapeutic procedures, respectively.2-7 Perforation is often detected during or shortly after the procedure, although delayed cases can occur several days later, potentially requiring colostomy and increasing the risk of postoperative complications and mortality.8,9 Traditionally, surgery has been the mainstay of treatment, although advances in endoscopic closure techniques now offer safe and effective alternatives for select patients.10-13 Recent guidelines from the European Society of Gastrointestinal Endoscopy (ESGE), American Gastroenterological Association (AGA), and World Society of Emergency Surgery (WSES) provide structured recommendations to guide clinical decision-making in these complex cases.14-16 This review summarizes current evidence and expert guidance on managing iatrogenic colonic perforation, with a focus on determining the optimal approach between endoscopic and surgical interventions.

MECHANISMS AND RISK FACTORS

Table 1 summarizes key risk factors for iatrogenic colon perforation based on guidelines from the ESGE, AGA, and WSES. Colonic perforation during colonoscopy typically results from mechanical trauma, barotrauma due to over-insufflation, or thermal injury during therapeutic procedures, with mechanical injury being the most common mechanism, especially in the sigmoid colon, which is involved in 51% to 65% of cases.4,10,17,18 The sigmoid colon’s angulated anatomy and the torque required for scope navigation make it particularly susceptible to perforation, with forceful insertion or manipulation of the endoscope further increasing the risk of mechanical trauma.15,19 The ESGE and AGA guidelines identify endoscopic submucosal dissection (ESD) and large endoscopic mucosal resection (EMR) as significant procedure-related risks. These techniques involve deeper tissue planes and carry a potential for thermal injury, which can lead to delayed perforation presenting hours or even days after the procedure.20-22 Patient-related factors, such as poor bowel preparation, diverticulosis, and colonic strictures, increase the risk of perforation by impairing mucosal visualization, necessitating blind maneuvering, and compromising wall integrity and flexibility.14 The WSES guideline highlights malignancy and severe colonic inflammation as high-risk conditions, in which tissue fragility significantly increases the likelihood of perforation, even with minimal mechanical stress.16 Recognizing these risk factors is crucial for prevention and prompt response in the event of perforation.

Table 1.

Risk factors for iatrogenic colonic perforation based on clinical guidelines

Category	Risk factors	References
Procedure-related	Endoscopic submucosal dissection	ESGE 2020, AGA 2021
	Endoscopic mucosal resection for a large polyp	ESGE 2020, AGA 2021
Anatomical site	Sigmoid colon (most common site due to scope torque)	AGA 2021
Technical	Forceful insertion or manipulation of the scope	AGA 2021
Patient-related	Poor bowel preparation	ESGE 2020
	Presence of diverticulosis or stricture	ESGE 2020
	Malignancy or severe inflammation	WSES 2017

ESGE, European Society of Gastrointestinal Endoscopy; AGA, American Gastroenterological Association; WSES, World Society of Emergency Surgery.

CLINICAL PRESENTATION AND DIAGNOSIS

The presentation of iatrogenic perforation varies depending on its timing and severity. Immediate perforations may be detected during colonoscopy through direct mucosal defect visualization, sudden patient discomfort, or abrupt loss of luminal distension.22 In contrast, delayed perforation refers to an intestinal defect that becomes clinically apparent after the procedure has been completed. It typically follows EMR or ESD but can occasionally occur even after a diagnostic colonoscopy, during which no perforation was initially recognized.23 Delayed cases may present with nonspecific symptoms such as abdominal pain, fever, nausea, leukocytosis, and signs of peritoneal irritation or systemic inflammatory response, most commonly within 14 hours, although approximately one-third may present after 24 hours.10,23,24 Since plain abdominal radiographs may fail to detect subdiaphragmatic free air, the ESGE and AGA guidelines recommend early computed tomography (CT) imaging in suspected cases because a CT scan is more sensitive for diagnosing perforation, identifying its location and extent, and detecting pneumoperitoneum, pericolic fluid, and intra-abdominal contamination.14,15,25

ENDOSCOPIC MANAGEMENT

In selected cases, endoscopic closure offers a safe and effective alternative to surgery.10,11,24,26 Table 2 summarizes the key differences among the AGA, ESGE, and WSES guidelines regarding indications for endoscopic management of iatrogenic colon perforation and associated surgical criteria. The ESGE and AGA guidelines recommend attempting endoscopic closure for perforations <30 mm when identified within 4 hours, provided the patient is hemodynamically stable with adequate bowel preparation.14,15 Time is critical, as mucosal inflammation can progress rapidly, making closure technically difficult or unfeasible.27 The mainstay of endoscopic closure is clipping. Table 3 outlines the indications, reported technical success rates, and clinical considerations for various endoscopic closure techniques.10,11,15,26,28-32 Through-the-scope clips, illustrated in Figure 1, are suitable for small defects (<10 mm), while over-the-scope clips (OTSCs) offer better efficacy for larger (10–30 mm) or difficult-to-access defects.11,28-31 However, the use of OTSCs can present technical challenges in clinical practice, as the endoscope must be completely withdrawn to mount the OTSCs on its tip, and reinsertion with the large device can be difficult, particularly when navigating the sigmoid colon or sharply angulated segments.10 Endoloop-assisted clipping (also known as the purse-string closure technique, Fig. 2) is suitable for intermediate-sized perforations.10,26,32 Endoscopic suturing is an emerging technique showing promise, especially for rectal and full-thickness defects, although its availability remains limited.10,15 Additional recommendations include using carbon dioxide insufflation during all therapeutic procedures due to its rapid absorption and reduced risk of barotrauma. The AGA also recommends gentle suction of luminal fluid or stool around the defect before closure to minimize contamination.15 If endoscopic closure is successful, patients can be managed conservatively with bowel rest, intravenous antibiotics, and close inpatient monitoring.9,12,22,24 Early signs of clinical deterioration, such as increasing abdominal pain, fever, or leukocytosis, require immediate reassessment and potential surgical intervention.16,21,27,31 Under optimal conditions, including early identification, minimal contamination, and adequate bowel preparation, endoscopic closure can facilitate early recovery, and in select cases, enable outpatient management.

Table 2.

Therapeutic strategies for iatrogenic colonic perforation based on clinical guidelines

Aspect	AGA 2021	ESGE 2020	WSES 2017
Focus of guidelines	Endoscopy+surgery	Endoscopic management	Emergency surgery and trauma
Criteria for endoscopic management	<30 mm, <4 h, stable	<30 mm, <4 h, stable vitals, clean bowel	Only in highly selected stable cases
Timing threshold for endoscopy	Within 4 h	Within 4 h	Not explicitly stated but favors early surgery
Surgical indications	Unstable condition, delayed diagnosis, underlying disease	>30 mm, unstable condition, delayed diagnosis, poor preparation	Moderate to severe peritonitis, any instability, radiologic contamination

AGA, American Gastroenterological Association; ESGE, European Society of Gastrointestinal Endoscopy; WSES, World Society of Emergency Surgery.

Table 3.

Comparative success rates of endoscopic closure modalities in iatrogenic colonic perforation

Closure tool	Indication	Technical success rates	References	Comments
TTSC	Small perforations (<10 mm)	81.3% (13/16)	Kim et al.11	Widely available, easy to use
		90.6% (29/32)	Cho et al.31
		83.8% (meta-analysis, 212/253)	Verlaan et al.28
OTSC	Large perforations (10–30 mm), difficult locations	100% (colon, 8; rectum, 4)	Haito-Chavez et al.29	Requires experience, scope reinsertion
		92.3% (12/13)	Voermans et al.30
Endoloop+TTSC	Intermediate perforations (10–20 mm), OTSC not available	100% (6/6)	Ryu et al.26	Effective alternative if OTSC is unavailable
		A successful case report	Russo et al.32
Endoscopic suturing	Full-thickness defects, rectal or distal colonic sites	No pooled success rate was reported	Lee et al.15	Limited availability, technically demanding
			Jung et al.10

TTSC, through-the-scope clip; OTSC, over-the-scope clip; AGA, American Gastroenterological Association.

Fig. 1.

Endoscopic closure of a colonic perforation using through-the-scope clips (TTSCs). (A) Linear perforation in the sigmoid colon is observed during diagnostic colonoscopy. (B) Complete closure is achieved by applying multiple TTSCs across the defect.

Fig. 2.

Purse-string closure technique with endoloop and through-the-scope clips (TTSCs) for colonic perforation using a dual-channel endoscope. Sequential images show the placement of TTSCs along the perforation margin and approximation using an endoloop for full-thickness closure.

SURGICAL MANAGEMENT

Surgery is indicated when endoscopic closure is not feasible or fails, or when the patient presents late or in an unstable condition.27,33 The ESGE and AGA guidelines recommend surgical intervention for large perforations (>30 mm), delayed diagnosis (>4 hours), inadequate bowel preparation, significant peritoneal contamination, or systemic signs of sepsis.14,15 Unlike diagnostic endoscopy, therapeutic endoscopy carries a risk of delayed perforation due to thermal injury from electrosurgical devices.21 The 2017 WSES guidelines recommend a more aggressive surgical approach, emphasizing early operative intervention in the presence of moderate to severe peritonitis or radiologic evidence of diffuse contamination.16 Systematic reviews show that delayed or failed conservative management is linked to increased postoperative morbidity, prolonged hospital stays, and a higher likelihood of multistage operations such as Hartmann’s procedure.34 Clinical experience indicates that early surgery (within 6 hours of perforation) may enable laparoscopic primary repair without colostomy, due to limited inflammation. In contrast, delayed diagnosis (>24 hours) often necessitates resection with or without colostomy, due to progressive peritoneal contamination.27,33 Laparoscopic surgery is increasingly adopted for primary surgical closure (Fig. 3) or resection with anastomosis as a safe primary treatment for colonoscopy-related perforations.35,36 Ultimately, surgical decisions should be individualized, taking into account the timing of diagnosis, patient status, and radiologic and intraoperative findings.

Fig. 3.

Laparoscopic management of iatrogenic colonic perforation. (A) Intraoperative identification of the perforation site (green arrow) on the antimesenteric border of the colon. (B) Successful laparoscopic primary repair of the defect with interrupted sutures.

CONCLUSIONS

Iatrogenic colon perforation, though rare, presents a significant clinical challenge that demands prompt recognition and tailored management. Figure 4 presents a practical algorithm for treatment decision-making, considering key factors such as perforation size, recognition timing, bowel preparation, and patient condition. Endoscopic closure is an effective and increasingly utilized technique, particularly in cases with early identification, favorable anatomy, and stable patient status. Guidelines from the ESGE, AGA, and WSES provide evidence-based frameworks to guide treatment decisions. Delayed recognition or the failure of conservative strategies may necessitate more invasive surgical intervention and are associated with poorer outcomes. A high index of suspicion, appropriate imaging, and interdisciplinary collaboration are essential for optimal care. As endoscopic technologies and techniques continue to evolve, the role of non-surgical management is expected to expand, although patient selection and timing will remain the cornerstone of effective treatment.

Fig. 4.

Clinical decision-making algorithm for the management of iatrogenic colonic perforation. TTSC, through-the-scope clip; OTSC, over-the-scope clip.