Improved Outcomes in Colon and Rectal Surgery part 15 pps

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Vascular Intervention: a Clinical Approach. Thieme medical Publisher, New York, 1998. 282. Kerr DJ, McArdle CS, Ledermann J et al. Intrahepatic arterial versus intravenous fluorouracil and folinic acid for colorectal cancer liver metastases: a multicenter randomized trial. Lancet 2003; 361: 368–73.   Transanal endoscopy Terry C Hicks CHALLENGING CASE A 60-year-old woman with a strongly positive family history of colorectal cancer undergoes a colonoscopy. She has a 1.5 cm pedunculated polyp snared from the transverse colon. Five days after the colonoscopy the patient experienced two bloody bowel movements. She presents to the emergency room with a heart rate of 120 and a blood pressure of 100/70. CASE MANAGEMENT You have two large bore intravenous lines started and begin rapid infusion of 2 L of lactated Ringers. Blood is drawn for a CBC, basic metabolic profile, coagulation studies, and type and cross for 4 units of packed RBC. A nasogastric tube is placed and billous heme negative fluid is aspirated. A proctoscopy reveals blood and clots in rectum, but no source of bleeding. A tagged RBC scan is obtained which is immediately positive in the cecum. An angiogram of the ileocolic artery reveals active bleeding in the cecum. Using a micro catheter, the interventional radiologist is able to embolize a segmental vessel and the bleeding ceases. The patient is transferred to the ICU for observation. INTRODUCTION Endoscopy is commonly used to evaluate the gastrointestinal (GI) tract. Endoscopy of the lower GI tract may include colonoscopy, flexible sigmoidoscopy, rigid proctoscopy, and anoscopy. While each of these procedures may have associated risks, discussion of colonoscopy will address the other procedures. This chapter will address the technical and nontechnical issues associated with this procedure. Colonoscopy is a procedure commonly used to diagnose and treat colonic conditions. It is a natural extension of the colon and rectal physical exam, and it has significant advantages over other examinations of the lower GI tract. This procedure allows direct inspection of the mucosal surface with the potential to identify and/or treat polyps, neoplasia, vascular lesions, and inflammatory bowel disease. The success of a colonoscopy is dependent on operator experience, patient selection, as well as the timing and extent of the bowel preparation. Although colonoscopy is an invasive procedure, complications are fortunately infrequent. However, major complications associated with colonoscopy can result in significant morbidity or even death. Serious complications can arise with either a diagnostic or therapeutic colonoscopy and include: perforation, hemorrhage, postpolypectomy coagulation syndrome, problems related to mechanical bowel preparation, infections, and anesthetic mala- dies (intravenous medications).(1) NONTECHNICAL COMPLICATIONS Colonic complications may occur that are essentially unrelated to the actual technical performance of the procedure. These complications include patient selection, method of preparation of the colon, and administration of medication for sedation before and during the procedure, as well as the clinical decisions that are made concerning those patients who are on anticoagulation. Minimizing preventable colonoscopic complications begins with the patient selection process. The endoscopist needs to identify those patients who have enhanced risks for endoscopist injury. This can usually be accomplished by obtaining an appropriate medical history and physical examination, along with any necessary laboratory studies. Before performing an endoscopic examination of the colon, the physician must consider the patient’s general condition. The risk of potential injury must be balanced against the anticipated therapeutic gain, and this includes being cognizant of the patient’s ability to tolerate injury. For example, a patient with signs or symptoms suggestive of a colorectal carcinoma who requires a colon evaluation, but who has recently had a myocardial infarction, may be better evaluated with CT colography or barium enema. Consultation with a patient’s obstetrician is appropriate to insure that the test is merited and falls within acceptable safety guidelines for patients in their last two trimesters of pregnancy. Other relative contraindications to a colonoscopy include large abdominal aortic aneurysms or substantial splenomegaly. COLORECTAL PREPARATION Every effort should be utilized to cleanse the colon of feces and particulate matter before the examination as an adequate bowel preparation is one of the most important factors in avoiding injury and maximizing the quality of the exam. The ultimate success of the colonoscopy depends on operator experience as well as the timing and extent of bowel preparation. Inadequate colon preparation is reported in approx. 25% of cases and leads to lower cecal intubation rates and decreased polyp detection.(2–4) Other potential problems associated with a suboptimal bowel preparation include: increased rate of complications, longer procedural times, or the need to for repeat examination.(4, 5) Among the many factors that lead to inadequate bowel preparations, poor compliance due to incomplete consumption of the preparation is the most frequent etiology.(6) Reports of poor compliance are usually attributed to the patient’s intolerance of the high volume of ingested cleansing solutions.(7) Some preparations are associated with specific adverse effects in some subpopulations, including those who have renal insufficiency, preexisting electrolyte abnormalities, or congestive heart failure. The clinician must be cognizant of the advantages and disadvantages for different bowel preparations in order to obtain not only the best clinical exam but also to protect the patient from complications. The variety of colonoscopy preparations in clinical use involve combinations of diet restriction and laxatives. As an adjunct, most bowel preparations include a period of time during which the patient is restricted to a clear liquid or low residue diet, to reduce the amount of stool in the colon. However, dietary restriction by itself  transanal endoscopy is insufficient to adequately cleanse the colon. Current cleansing preparations include lavage solutions (usually polyethylene glycol— electrolyte lavage solution) and hypertonic electrolyte solutions. Oral Lavage Oral lavage methods have been developed to reduce the time required for mechanical cleansing (usually only 2–4 hours are required). Oral lavage consists of the ingestion of a large volume of osmotically balanced, nonabsorbable solutions that act as a purgative, clearing the colon of stool through mechanical forces. Polyethylene glycol (PEG) containing preparations have become the most preferred method of colonic preparation.(8) A meta-analysis of eight trials reported that PEG preparations were associated with either an adequate or excel- lent preparation in 70% of patients.(9) Unfortunately, up to 20% of patients are unable to complete the PEG preparation because of the poor palatability of the solution or its required large volumes. Recently, there have been new strategies to increase the efficacy in patient tolerability of PEG containing solutions. Recent studies have evaluated whether or not there is increased tolerability when using flavor versus nonflavor preparations.(10) There are also recent reports of investigations into the use of lower volume PEG solutions (i.e., 2 L rather than the standard 4 L), with or without the utilization of adjunct purgatives.(11) Other variations include the addition of adjunct purgatives (senna, magnesium citrate, or bisacodyl) in an effort to increase the efficacy of PEG solutions.(12, 13) To assist patients with the volume of fluid that must be ingested some endoscopists have tried adding metoclopramide, in the hopes that it would reduce nausea and increasing bowel motility. A study by Brady et al. (14) (a small placebo trial) utilizing metclopramide as an adjunct reported no significant benefits in the terms of bowel preparation or decrease in abdominal discomfort. Contraindication to oral lavage solutions include significant gas- tric retention, suspected or established mechanical bowel obstruction, severe colitis, or the presence of ileus. Hypertonic Electrolyte Solutions Salt-based agents for bowel preparation are known as saline laxatives and include those containing magnesium cations or phosphate anions. Salt-based agents work by exerting a hyperosmotic effect in the intestines. The poorly absorbed magnesium or phosphate ions within the small intestine result in retention of water that directly stimulates stretched receptors and increases peristalsis. Sodium phosphate (NaP) is one of the more commonly used saline laxatives and is available in liquid or tablet form. This hyperosmotic product draws fluid into the intestinal tract result- ing in a purgative action. Proponents of the utilization of NaP refer to studies that show that in healthy individuals the prep is safe, better tolerated, and equally or more effective than PEG. (15, 16) It is imperative to note that the downside of using oral sodium phosphate solutions is the potential for significant fluid shifts which can precipitate intravascular volume depletion. A few cases of nephrocalcinosis with subsequent renal insufficiency have also been reported.(17) The effect seems to be age and dose related. Additional risk factors for this unusual occurrence include underlying renal disease, dehydration, hypercalcemia, or hypertension with the use of angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs). These issues makes it imperative that (NaP) not be used in patients with congestive heart failure, decompensated cirrho- sis, renal failure, or those presenting with baseline electrolyte abnormalities.(18) There is also the current concern for the development of hyperphosphatemia. Patients who have renal insufficiencies (familial filtration rate of <50% of normal) can develop life threatening hyperphosphatemia. Most patients with normal renal function find the sodium phosphate NaP preparation safe. Rejchrt and his colleagues reported on the utilization of NaP preparations and its effects on the colonic lining. They found the preparation induced mucosal lesions, erosions, and aphthous lesions in up to 3% of patients.(19) They concluded that this preparation should not be utilized for patients under- going diagnostic evaluation for potential inflammatory bowel disease because it may lead to misinterpretation secondary to the mucosa lesions induced by the preparation.(20) As discussed previously, multiple studies have indicated the necessity for good bowel cleansing before endoscopic evaluation, as it adds not only to the quality of the examination, but also reduces potential complications. At present, the choice of bowel preparation is dependent on the clinical context, and the presence or absence of associated risk factors. The endoscopist should be cognitive of these issues before prescribing a colonoscopy preparation. Intravenous Sedation Conscious sedation reduces patient symptoms during endoscopy, but accounts for significant risks including vasovagal reac- tions and cardiopulmonary events. Conscious sedation can in fact cause respiratory depression, hypotension, tachycardia, or brachycardia.(33, 34) Patients who develop severe hypotension or hypoxia associated with sedation are also at risk for myocardial infarction. To reduce these risks and prevent excessive sedation, it is important that the physician and/or nurse providing the medication carefully titrate it throughout the procedure.(35) In the United States, it is standard to monitor blood pressure, pulse, and oxygen saturation on a timely basis throughout the procedure. It is also common to administer supplemental oxygen via nasal can- nula. It is interesting to note that a prospective study of private patients (men and women), less than one-third were willing to undergo colonoscopy without sedation.(36) At present, the most commonly utilized agents for colonoscopic sedation are meperidine, fentanyl, and midazolam. Meperidine and fentanyl are used for analgesia. Fentanyl has a shorter time of onset and recovery, while meperdine appears to potentiate the sedative effect of benzodiazepines. Midazolam provides an anter- ograde amnesia and possesses a short half life, which is a distinct advantage for the safety of the patient. Midazolam also poten- tiates the narcotic effect and permits the reduction of narcotic doses and their associated complications. The utilization of these agents affects the psycho motor function of the patient for hours, and thus postprocedure monitoring is necessary before their dis- charge from endoscopy unit. Some centers are now evaluating the use of propofol (Diprivan). Propofol lacks analgesic effect but is a rapid onset and effective sedative. It also has a shorter recovery time. Propofol’s most serious potential side effect is sudden respiratory depression, which may require intubation in order to control the airway. Therefore, utilization of this drug usually requires improved outcomes in colon and rectal surgery  administration by an anesthesiologist, a nurse anesthetist, or a dedicated physician. Most endoscopy centers, with an adequate number of procedure rooms and recovery space have not found this drug cost-effective. Hemodynamic depression is managed with increased intravenous fluids, while respiratory depression is treated with supplemental oxygen and sedation reversal. Naloxone (Narcan); 0.4 mg intravenously (or 0.2 mg intravenously and 0.2 mg intramuscu- larily) will reverse the narcotic effect. Flumazenil (Romazicon); 0.2 to 1.0 milligrams intravenously, will reverse sedation from Midazolam. Excessive colonic distention may produce a vasovagal reaction which responds to increased intravenous fluids and decompression of colon gas. Significant bradycardia, secondary to the sedation may require administration of atropine (0.5 mg IV every 3–5 minutes to a dose of 3 mg). Infectious Disease Complications Colonoscopy can produce infectious complication by transmission of disease from patient to patient, from patient to examiner, or from bacteremia related to the procedure. Current national recommendations for mechanical cleansing of endoscopic equipment, if followed properly, should prevent the transmission of such dis- eases as HIV and hepatitis. Transmission of disease from patient to examiner can also be prevented by appropriate eye, facial, and hand protection and endoscopic suites should be equipped with goggles, disposable aprons and gloves, or facial splash guards. The incidence of bacteremia associated with colonoscopy has been reported from 1 to 20%. Despite the potential risks of bacteremia, there are presently only five reported cases of endocarditis associated with colonoscopy, despite the millions of colonoscopies performed annually.(37, 38) The American Heart Association (AHA) had previously recommended antibiotic treatment for patients that were described as high-risk (patients with pros- thetic heart valves, congenital cardiac malformations, surgically constructed systemic pulmonary shunts, and previous history of endocarditis). More recently, the AHA SBE prophylaxis panel after extensive study, now recommends that the risk of antibiotic complications greatly outweighs the potential for bacteremia leading to endocarditis. They conclude that no antibiotics should be administered for SBE prophylaxis during colonoscopy.(39) TECHNICAL COMPLICATIONS Hemorrhage Hemorrhage after colonoscopy is most commonly associated with polypectomy, but can occur with diagnostic procedures. Hemorrhage is most frequently associated with intraluminal bleeding, but can also arise from extraluminal sources, such as a mesen- tery laceration, secondary to mechanical forces produced during instrumentation. Splenic injury or rupture results in intraperitoneal hemorrhage (see miscellaneous complications section for more details). Hemorrhage following colonoscopic polypectomy has a prevalence that ranges between 1–2.5%, and is the most common complication of polypectomy.(21) The hemorrhage may be an immediate or delayed event and has been reported up to 14 days postpolypectomy.(22) Those hemorrhages occurring during the endoscopic procedure represent 1.5% of polypectomies, and those in the delayed setting, after the completion of the procedure represent 2% of polypectomies.(23) Immediate hemorrhage upon transection of the pedicle of a pedunculated polyp occurs because of inadequate coagulation of the feeding vessels. Pedunculated polyps, >1 cm in diameter with fixed stalks have the highest risk for immediate hemorrhage, as they have substantial vessels.(24) The utilization of the cold biopsy technique can result in capillary bleeding, which is usually of no clinical significance. The corollary to this observation is that significant bleeding can occur with cold or hot biopsy techniques if the patient is being treated with anticoagulants or antiplatelet medications. Though most postpolypectomy hemorrhage is self- contained, the endoscopist must respect the clinical potential of the bleeding to produce enough hypotension as to cause stroke, myocardial infarction, or frank shock. With persistent and significant ongoing bleeding, the endoscopist my have difficulty in locating the residual stalk. This Figure 12.1 Management of postpolypectomy hemorrhage.  transanal endoscopy makes it imperative that the source be quickly controlled at the onset of bleeding before the field being obscured by blood and clot. Initially, the endoscopist can utilize the polypectomy snare to regrasp the stalk and hold it taut for approximately 15 minutes without the utilization of any electrocautery. This maneuver if unsuccessful can be performed again and this usually suffices to control the bleeding. Other options are: the placement of clips or detachable snares. If these are not available, the residual stalk can be injected with 1–10,000 solution of epinephrine plus saline, or the base of the residual stalk can be recoagulated without enough energy to transect the stalk. Many endoscopists now suggest that if one identifies a potentially significant polyp that might produce postpolypectomy bleeding (i.e., large in size or patient’s condition mandates they continue anticoagulation), that the utilization of clips or a detachable snare in advance of the resection may be beneficial. It should be noted that if one elects to use electrocautery after initial snaring, that they should be careful to prevent full thickness injury at the site. Delayed hemorrhage occurs when the retained scar from a polyp site separates prematurely from the coagulation bed, leading to hematochezia. This type of bleeding usually occurs within 2–15 days of the after the procedure, typically within the first 7–10 days. Postpolypectomy bleeding can be significant enough to require in-hospital fluid resuscitation and potential therapeutic intervention. These patients usually have arterial bleeding, and pass bright red bloody bowel movements spaced at close intervals (i.e., 30–60 minutes).(25) The active bleeder (after appropriate resuscitation) may benefit from a prompt colonoscopy without bowel prep to identify the site of bleeding. If the bleeding site is located it can be treated with judicious multipolar cautery, injection of epinephrine solution, detachable snare, or placement of hemoclips. Often times, it is clinically difficult to determine if the hemorrhage has ceased because the hematochezia may continue for several hours afterwards. If the hemorrhage appears persistent, despite local efforts or if the patient needs urgent intervention, the location of the active bleeding may be identified with a tagged RBC scan.(26) If the scan is positive, arteriography can confirm the bleeding location and offers potential treatment modalities for either selective arterial vasopressin infusion, or embolization. The choice depends upon the patient’s clinical history and presentation as well as the skill and experience of the radiogra- pher. Figure 12.1 describes the authors’ and editors’ management algorithm for postpolypectomy bleeding. Prophylactic techniques during polypectomy may decrease the incidence of postpolypectomy bleeding.(27) During the technique of taking a large polyp, some endoscopists use a saline inter- mucosal lift or an epinephrine solution injection into the stalk of the polyp in efforts to control hemostasis. Detachable snares and clips have also been used with a similar goal in mind. Although successful, even in skilled hands, clips may slip or transmit current if cautery makes contact with the metal. Detachable snares may slip from their initial position, or if pulled too tight can cut through the base of the polyp, leading to the problem that one is trying to prevent. The absence of national guidelines concerning the prophylactic approaches to postpolypectomy bleeding, makes each endoscopist responsible for evaluating the clinical situation and being cognitive of his level of expertise. Another factor in postpolypectomy hemorrhage relates to the management of patients on antiplatelet agents or anticoagulants.(28, 29) The American Society for Gastrointestinal Endoscopy has recommended that aspirin need not to be stopped before polypectomy as there is insufficient evidence supporting an increased risk with its utilization.(30) However, many endoscopists will hold a patient’s aspirin for 7 days if their indication for taking aspirin is weak. If the patient can tolerate it, the author and editors withhold clopidogrel (Plavi ® , Sanofi-Aventic, Bridgewater, NJ) for a minimum of 7 days before the colonoscopy and hold warfarin for a minimum of 3 days before the procedure and check a prothrombin time (PT) before the colonoscopy.(31) Therapeutic procedures are usually safe with an INR of <2.(32) If the patient’s INR is above this level, the procedure may be delayed until the INR is lower or if the anticipated need for a therapeutic procedure is low (e.g., a screening indication) a diagnostic procedure may be performed with the understanding that if significant lesions are identified, therapeutic maneuvers (i.e., biopsy or polypectomy) will be deferred. Patients who cannot tolerate reversal of anticoagulation (a determination usually made by the patient’s cardiologist or neu- rologist) can often be managed with a bridging with enoxaparin sodium (Lovenox ® , Sanofi-Aventic, Bridgewater, NJ) or consid- ered for alternate procedures such as CT colography. Recommendations for restarting anticoagulation or antiplatelet agents postpolypectomy are difficult clinical decisions that must be based on the patient’s risk-benefit ratio, (i.e., the risk of stroke, or coagulation of cardiac stents versus the risk of postpolypectomy hemorrhage). Unfortunately, there is little prospective data to sup- port recommendations. The author and editors restart these medications at their normal daily dose the day following a diagnostic procedure. Recommendations after a polypectomy depend on the size and number of polyps removed and the level of anticoagulation at the start of the procedure. Warfarin is usually started at the normal daily dose, 1–5 days after the procedure, while clopidogrel is restarted 1 week after the procedure.(32) Anticoagulant recommendations are summarized in Table 12.1. Perforation The most serious complication of colonoscopy is overt perforation.(40) Perforation can result from mechanical forces during colonoscopic insertion or from barotrauma during colonic insufflation, or during the process of polyp removal. Perforation Table 12.1 Anticoagulant recommendations. Drug Before Procedure After Diagnostic Procedure After Therapeutic Procedure Aspirin Continued or stopped 7 days prior Continued or started day of procedure Restarted 5–7 days after Clopidogel Held for > 7 days prior Restarted day after procedure Restarted 7 days after Warfarin Held for > 3 days prior and check PT Restarted day after procedure Restarted 1–5 days after Note: PT Prothrombin time.  improved outcomes in colon and rectal surgery occurs in 0.6% to 0.8% of diagnostic procedures and 0.5% to 3% (See Table 12.2).(41, 42) Perforation is diagnosed during the procedure by observation of extraluminal fat or other intraab- dominal contents (e.g., small bowel, liver) via the colonoscope. These patients usually report immediate pain and demonstrate signs of peritoneal irritation. Patients that develop symptomatol- ogy postprocedure vary from, asymptomatic free intraabdomi- nal air, a tense abdomen, or florid peritonitis and sepsis. Patients presenting with localized symptoms can be observed and treated with intravenous fluids, antibiotics, and bowel rest.(43) Patients who present with or develop signs of generalized peritoneal irritation during observation, should receive a laparotomy. Repair or resection of the perforation is performed with or without a diverting ostomy. An algorithm for the management of colonoscopic perforations is presented in Figure 12.2. It is important to remember that a perforation can come from an unsuccessful encounter with the colon wall with the tip, the deflection bend, and/or the shaft of the colonoscope. The inexperienced examiner can drive the tip of the scope through a large diverticulum; or may, while advancing the scope form a significant loop, allowing the shaft of the scope to make a laceration in the bowel wall, away from the tip of the scope, which may go on unrecognized. Significant clinical experience, along with judgment and good technique, serve as the best preventative tools against a perforation.(50, 51) MISCELLANEOUS COMPLICATIONS Though the major complications associated with colonoscopy are hemorrhage and perforation, there exists a large body litera- ture that has reported rarely encountered complications. These include incarceration of the colonoscope within an inguinal hernia, (52) cecal volvulus with subsequent perforation, (53) ischemic colitis, (54) aortic thrombosis in a patient with Bechcet’s syndrome, (55) and splenic injury (56). There have been approximately 59 clinical reports which detail 67 cases of splenic injury, following diagnostic or therapeutic colonoscopy.(56, 57) The authors note the most likely etiology of splenic injury is related to the performance of the procedure rather than any therapeutic maneuver. It is theorized that the mechanism of injury is thought to be excessive traction on the splenocolic ligament or adhesions. This theory has been confirmed by laparotomy in several of the reported cases. It is interesting to note that in most of the injuries, the endoscopists felt the procedure had been performed without difficulty. The presentation for these injuries span between 6–24 hours, and vary from vague abdominal pain of the left upper quadrant, with mild orthostatic hypotension, and a decreased hematocrit to severe hypotension and shock. It is suggested that an abdominal CT scan is the most helpful diagnostic test as it may show a splenic laceration, with free intraperitoneal blood or a splenic hematoma. Most of the cases, required surgery, and the patient’s overall condition dictated whether an emergency intervention was necessary. Observation and conservative management was rarely successful. Awareness of the potential for splenic injury during colonoscopy is important as it may help avoid any delay in diagnosis. Unfortunately, these cases are so rare that no iden- tifiable risk factors have been documented that potentially could help prevent this complication. Patients with reducible hernias, merit additional attention by the endoscopist who must consider the benefits of a diagnostic or therapeutic procedure versus the potential for injury or the delay Table 12.2 Colonoscopy perforation rates. Author, Year (Reference) Colonoscopies, n Perforations, n (%) Setting Lo and Beaton, 1994 (44) 26,708 12 (0.045) University, teaching Farley et al., 1997 (43) 57,028 43 (0.075) Mayo clinic, teaching Anderson et al., 2000 (44) 10,486 10 (0.19) Mayo clinic, teaching Araghizadeh et al., 2001 (45) 34,620 31 (0.09) Ochsner Clinic, teaching Korman, et al., 2003 (46) 116,000 37 (0.03) ASC, private practice Cobb et al., 2004 (47) 43,609 14 (0.032) Teaching Lqbal et al., 2005 (48) 78,702 66 (0.084) Mayo clinic, teaching Levin et al., 2006 (49) 16,318 15 (0.09) Kaiser Permanente Figure 12.2 Management of colonoscopic perforation.  transanal endoscopy until the hernia is repaired. For patients with reducible inguinal hernias, the procedure can be performed with general pressure on the hernia sac during the colonoscopy or with the utilization of a truss. Should the colonoscope become incarcerated in an inguinal hernia, a “pulley” technique has been described where a relatively large easily graspable colonoscope loop is created within the hernia sac and then is withdrawn over the pulley “hand” one limb at a time.(52) Development of a cecal volvulus, may occur with a hypermobile cecum.(53) Postpolypectomy Syndrome The postpolypectomy syndrome is believed to result from a transmural burn to the colonic wall and usually presents with a syndrome similar to that of diverticulitis.(58) This represents the second most common polypectomy complication with rates ranging from 0.5% to 1%.(59) Usually this complication occurs in the thin right-sided bowel after removal of a sessile polyp or performance of a hot biopsy. It is felt that the factors leading to this syndrome include the utilization of high cumulative quality and longer duration of electrocautery. It is also possible for the electric current to enter the mucosa opposite the polyp if the tip of the polyp is allowed to touch the opposing wall during the application of the cautery. Moving the polyp back-and-forth during cautery may dissipate the current. This syndrome is usually seen in sessile polyps that are >2 cm in diameter.(60) The patients may present within hours of the procedure but some may not show some significant symptomology until 5–6 days postprocedure. Patients usually present with pain which may or may not include fever, an elevated white count, and localized tenderness. Initial studies include plain x-rays or a CT scan, which confirm by definition an absence of free air. Patients are started on broad spectrum antibiotics and bowel rest, then most importantly patients are examined over appropriate intervals to make sure there is no progression from the localized tenderness to frank peritonitis.(61) Fortunately, most of the patients that are properly managed progress to recovery without surgical intervention, and they can be discharged when their pain has resolved, and their white blood cell count has normalized. Prevention of postpolypectomy syndrome aided by adherence to the previously described guidelines for a safe polypectomy. PROCTOSCOPIC PERFORATIONS Proctoscopic perforations are rare, serious complications of intestinal endoscopy.(62) Nelson et al. reported only three perforations in 16,325 proscopic exams.(63) The injury most commonly occurs when the bowel wall has been weakened by disease such as colitis, a rectal tumor, or constricting lesion. The line of force during insertion guides the scope to the anterior rectal wall where the usual site of injury is located between the peritoneal reflection and the rectosigmoid junction.(64) The perforation is usually recognized as the scope enters the peritoneal cavity or the endoscopist encounters the perirectal fat or local bleeding. (52) Significant rectal trauma with a rectal perforation requires operative treatment. Most authors believe that delayed treatment increases the mortality from 8% to 20%.(65) The major morbidity and mortality are associated with the fact that the proximal colon typically is not mechanically cleansed. The treatment involves resection of associated pathology, repair of the perforation site, rectal washout, pelvic drainage, and a diverting colos- tomy (see chapter 35).(66) SUMMARY Training, experience, and conservative technique help to minimize complications associated with endoscopic procedures of the colorectum. 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Maglinte DD, Balthazar EJ, Kelvin FM, Megibow AJ. The role of radiology in the diagnosis of small-bowel obstruction after Warfarin Held for > 3 days prior and check PT Restarted day after procedure Restarted 1–5 days after Note: PT Prothrombin time.  improved outcomes in colon and rectal surgery occurs in