**4. Colonic perforation associated with polypectomy**

Perforation of the colon is the most dreaded complication of colonoscopy and polypectomy and this risk, albeit small, should be cited in the process of obtaining informed consent form the patient for the procedure.

Abdominal pain, abdominal distention, +/- abdominal tenderness, hiccoughs, loss of bowel sounds indicative of ileus, and late developing peritoneal signs are the hallmarks of perfora‐ tion following colonoscopy. As physical examination, chest x-ray and abdominal flat and upright x-ray alone or in combination may not be diagnostic of colonic perforation patients suspected of having this complication should undergo CT scanning of the abdomen and pel‐ vis [52]. The rate of perforation after colonoscopy ranges from 0.1-0.3% [19] and may be in‐ creased (along with the risk of hemorrhage) in those physicians who have a low procedure volume [53]. It has been suggested that physicians who have a high perforation rate should be evaluated for inappropriate colonoscopy practice technique [54].

avoiding "looping" of the colonoscope, avoiding excess traction applied to the bowel mes‐ entery, adequately removing insufflated gas, using carbon dioxide instead of insufflated air

The Major Complications of Colonoscopy: Sedation-Related, Hemorrhage Associated with Polypectomy and...

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Postpolypectomy electrocagulation syndrome refers to a transmural burn and localized per‐ itonitis occurring up to a few days after the removal of a polyp without clinical or radio‐ graphic evidence of perforation of the viscus. Patients may present with localized abdominal pain, fever, and leukocytosis. Inpatient [69] and outpatient [70] therapy have both proven to

Transient bacteremia after colonoscopy with polypectomy is rare and signs and symptoms of infection are even rarer [71,72]. Current guidelines exist generally advocating against an‐ tibiotic prophylaxis for those undergoing colonoscopy with or without polypectomy [73]. As these represent only guidelines it is best for the endoscopist to consult with the patient and the referring physician before deciding to forego the use of antibiotic prophylaxis in certain clinical situations (prosthetic heart valve, history of endocarditis, newly placed pros‐ thetic joint, etc.). Both diverticulitis [74] and appendicitis [75] the latter possibly due to bar‐ otrauma have been reported complicating colonoscopy done with and without polypectomy. These clinical possibilities must be kept in mind in patients with post-proce‐

Rare complications of colonoscopy with and without polypectomy have been reported and include infections related to instrument cleanliness [76] incarceration of the colonoscope in an inguinal hernia [77], splenic injury during colonoscopy [78], and intracolonic gas explo‐ sion during colonoscopic polypectomy [79,80]. CT colonography, the alternative to colono‐ scopy in many patients, however, is not without its own complications and adverse events

It is incumbent upon physicians performing colonoscopy to stay current in their field, keep abreast of the medical literature and the ongoing technological advances associated with endoscopic equipment and technique, and to be meticulous in their approach to detail in caring for their patients, particularly when gastrointestinal endoscopic diagnostic and ther‐

[67] and by using a water insufflation technique instead of the insufflation of gas [68].

**5.2. Postpolypectomy electrocoagulation syndrome**

be successful in treatment of this complication.

**5.3. Infection**

dure abdominal pain.

**5.4. Rare complications**

[81].

**6. Conclusion**

apeutic procedures are involved.

Perforation risk for polypectomy may be minimized by proper technique. One should avoid ensnaring colonic folds, particularly when the anatomy is obscured by large penduculated or sessile lesions. By not properly lifting an ensnare polyp into the lumen of the colon before applying current, there may be spread of thermal injury to the deeper layers of the bowel wall increasing the risk of delayed perforation. Likewise, a pedunculated polyp should not be resected close to the bowel wall. Care should be taken to leave some residual stalk. The polypectomy snare should be tightly closed before applying coagulation in order to avoid the tip of the snare behind the polyp from touching the bowel wall.

Endoscopic mucosal resection for the piecemeal removal of benign appearing sessile colonic adenomas has become routine. Endoscopic submucosal dissection is a resection technique applied to early gastrointestinal cancers. Complications rates are higher with endoscopic submucosal dissection than with endoscopic mucosal resection with perforations occurring in up to 10 percent of patients. Often these perforations can be managed by endoscopic clip‐ ping and conservative therapy, however surgery is still required in some cases and pro‐ longed hospital stays are common. [55-57].

All patients found to have evidence of colonic perforation following colonoscopy should be seen in surgical consultation because perforation often requires surgical repair which in some cases may be accomplished using a laparoscopic technique with avoidance of divert‐ ing colostomy formation [58,59]. It has been reported that nonsurgical management may be appropriate for some individuals [60,61] but these patients should still undergo surgical consultation and close monitoring for signs of deterioration. Successful endoscopic repair of an iatrogenic colonic perforation occurring during *diagnostic* colonoscopy has been reported [62] and the efficacy of a new Over-the Scope-Clip (OTSC-Ovesco Endoscopy AG, Tübingen, Germany) device (a bear trap-like, large clip with a wingspan of 12 mms. that grasps much more tissue than the small endoscopic clips used previously and can create a full-thickness closure of perforations up to 3 cms. in diameter) in treating acute perforation of the gastroin‐ testinal tract has been reported [63].
