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LETTER TO THE EDITOR
Year : 2012  |  Volume : 8  |  Issue : 2  |  Page : 65-66
 

Laparoscopic perforostomy for treating a delayed colonoscopic perforation: Novel approach


Department of Surgery, Padmashree Dr. D. Y. Patil Medical College, Nerul, Navi Mumbai, Maharashtra, India

Date of Web Publication2-May-2012

Correspondence Address:
Ketan Vagholkar
Annapurna Niwas, 229 Ghantali Road, Thane-400 602
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-9941.95543

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How to cite this article:
Vagholkar K. Laparoscopic perforostomy for treating a delayed colonoscopic perforation: Novel approach. J Min Access Surg 2012;8:65-6

How to cite this URL:
Vagholkar K. Laparoscopic perforostomy for treating a delayed colonoscopic perforation: Novel approach. J Min Access Surg [serial online] 2012 [cited 2020 Sep 26];8:65-6. Available from: http://www.journalofmas.com/text.asp?2012/8/2/65/95543


Dear Sir,

I read with keen interest the article entitled "Laparoscopic perforostomy for treating a delayed colonoscopic perforation: Novel approach". [1] The concept may sound novel but lacks sound surgical foundations to be advocated as a technique.

The description of the case report is misleading to the reader and needs clarification.

Colonoscopic intervention was performed eight weeks from the time of presentation. This suggests that the pathology of the polyp may have a bearing on the perforation. [Figure 1] shows a polyp stump which is quite large suggestive of rapid growth in the interim period of normal bowel function. Hence, the histology of the polyp is vital from the point of view of malignancy which unfortunately is not mentioned.
Figure 1: Colonoscopic view of the polyp stalk after polypectomy

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The duration of abdominal symptoms prior to presentation as an emergency is not mentioned.uch a chronic presentation in a 60-year-old patient surely suggests a longer duration causing serious fecal peritonitis. This is revealed by the extent of abdominal signs being described as present all over the abdomen and guarding in the right iliac fossa along with a figure showing a pelvic abscess. The severity of septic complications is evidenced by high counts and a raised c reactive protein. Such a patient is bound to be extremely sick and requires a good intra peritoneal exploration and cleansing. Laparoscopy in such a delayed presentation would not suffice to identify and clear the pus pockets which are usually in abundance in fecal peritonitis.

A perforation amidst a pelvic abscess will have friable unhealthy walls which will be very difficult to identify clearly prior to exteriorizing the defect. Holding such a perforation with an instrument increases the chances of causing more damage to the surrounding bowel wall. It will be extremely difficult for a surgeon to take sutures to fix the bowel loop through such an area. Another issue is of the site of perforation. The description of the perforation as having been sealed and reperforated is confusing to the reader. Only if the perforation faces the peritoneal cavity by virtue of an anti mesenteric position, it can be visualized. But if If it happens to be at the mesenteric border or in the retroperitoneal location, open surgery would be logically the best option.

Iatrogenic perforations of the colon need to identified as early as possible in order to prevent lethal septic complications. A good imaging by a CT scan will reveal the extent of abscess formation in the peritoneal cavity. This will help in charting the further course of surgical treatment. If immediately diagnosed at the time of the endoscopic procedure and if it happens to be small that is less than 5 mm, then endoscopic clipping could be one option. [2] However, when the presentations are delayed, the patient will obviously be in early septic shock. Such patients require aggressive resuscitation and good open laparotomy to deal with the perforation as well as the septic process within the peritoneal cavity. [3] Laparoscopy would not be the ideal option in such a setting. Laparoscopy is acceptable only as a diagnostic modality in an early case presentation assuming limited contamination and smaller perforations. [3] With extensive abdominal signs or if there is slightest doubt, open surgical exploration is the safest and best option both therapeutically for the patient and legally for the surgeon. [4]

 
 ¤ References Top

1.Durai R, Ng PC. Laparoscopic perforostomy for treating a delayed colonoscopic perforation: Novel approach. J Min Access Surg 2011;7:239-41.  Back to cited text no. 1
[PUBMED]  Medknow Journal  
2.Orsoni P, Berdah S, Verrier C, Caamano A, Sastre B, Boutboul R, et al. Colonoscpic perforation due to colonoscopy: A retrospective study of 48 cases. Endoscopy 1997;29:160-4.  Back to cited text no. 2
    
3.Garcia Martinez MT, Ruano Poblador A, Galan Raposo L, Gay Fernandez AM, Casal Munez JE. Perforation alter colonoscopy: Our 16 year experience. Rev Esp Enterm Dig 2007;99:588-92.  Back to cited text no. 3
    
4.Luning TH, Keemers-Gels M, Baredreqt WB, Tan AC, Rosman C. Colonoscopic Perforations: A review of 30,366 patients. Surg Endosc 2007;21:884-7.  Back to cited text no. 4
    


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Durai, R. and Ng, P.C.H.
Journal of Minimal Access Surgery. 2012; 8(4): 166
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