Endoscopy Units Should Establish a Management Algorithm for Acute Iatrogenic Endoscopic Perforations
Douglas K. Rex, MD, MASGE, reviewing Lew D, et al. Endosc Int Open 2022 Aug 1.
In this single-center study, 8 gastroenterology fellows and 20 practicing gastroenterologists answered a 10-question pretest regarding acute iatrogenic endoscopic perforation (AIEP) diagnosis and management. This was followed by education surrounding a management algorithm for AIEP and then posttests immediately after and 6 months later.
Pretest and posttest scores were 67.5% and 96% for the fellows and 78% and 95%, respectively, for the practicing gastroenterologists. Overall test accuracy at 6 months was 83.6%, which was worse than immediate postsession accuracy but better than pretest accuracy. The questions most commonly answered incorrectly by the fellows were regarding the most common site of perforation in routine colonoscopy (the sigmoid) and the most common cause of perforation during routine colonoscopy (mechanical trauma).
The question most commonly answered incorrectly by practicing gastroenterologists was regarding the maximum size of perforation (10 mm) for which through-the-scope clips are recommended by the European Society of Gastrointestinal Endoscopy. This question remained the most common question answered incorrectly by the practicing gastroenterologists at retesting 6 months later.
In two clinical scenarios testing the application of knowledge at 6 months, the overall accuracies of fellows and practicing physicians were 67.5% for the first scenario and 60.3% for the second scenario. None of the fellows correctly answered a question regarding what to do immediately following identification of an AIEP (suction and ensure that CO2 is being used rather than air), and none of the practicing gastroenterologists believed they needed to consult interventional endoscopy, as was recommended in the algorithm.
COMMENTThere is no doubt that effective endoscopic closure of acute iatrogenic endoscopic perforations leads to better outcomes, lower costs, and happier patients compared to surgical management. This study makes an important point, which is that all endoscopists should have a plan for how to manage AIEP should it occur. Those plans may differ in a hospital-based unit versus an ambulatory endoscopy center or office practice, depending on what closure tools are available and whether other endoscopists with over-the-scope clip and suturing training are available. Having a unit-wide plan, with the availability of closure tools, decompression needles, and appropriate antibiotics, among other appropriate equipment and supplies, seems wise. The study is worthy of review by directors of endoscopy units without such a plan currently in place.
Note to readers: At the time we reviewed this paper, its publisher noted that it was not in final form and that subsequent changes might be made.
CITATION(S)
Lew D, Abboud Y, Picha S, et al. A quality improvement project on the development of a management algorithm for iatrogenic perforations and the long-term impact on physician knowledge. Endosc Int Open 2022 Aug 1. (Epub ahead of print) (https://doi.org/10.1055/a-1914-6358)
