Background
Materials and methods: expert panel and consensus conference organization
Risk of ICP | |
Q1 | What are the general recommendations to minimize the risk of ICP during screening and therapeutic colonoscopies? |
Q2 | What is the maximum incidence of ICP considered acceptable for centers where diagnostic or therapeutic colonoscopies are performed? |
Diagnosis of ICP | |
Q3 | What is the minimum information the endoscopist must report after diagnosing an ICP during a colonoscopy procedure? |
Q4 | What are the minimum biochemical and imaging investigations that should be requested in the case of suspected ICP? |
Conservative and endoscopic treatments of ICP | |
Q5 | What are the indications for a conservative treatment or an immediate surgical intervention after an ICP diagnosis? |
Q6 | What is the minimum duration of the hospital observation period for patients who have undergone successful endoscopic closure or conservative management of ICP? |
Q7 | What investigations (clinical, biochemical, and imaging) should be performed during the observation period in patients who have undergone successful endoscopic closure or conservative management of ICP? |
Q8 | What is the recommended type and duration of antibiotic therapy in patients who have undergone successful endoscopic closure or conservative management of ICP? |
Q9 | What is the recommended type and duration of antithrombotic prophylaxis in patients who have undergone successful endoscopic closure or conservative management of ICP? |
Q10 | How long is the fasting time in patients who have undergone successful endoscopic closure or conservative treatments for ICP? |
Surgical treatment of ICP | |
Q11 | Is explorative laparoscopy indicated in all patients with ICP? |
Q12 | What are the indications for conversion from laparoscopy to open surgery in patients with surgical ICP? |
Q13 | What are the key factors when choosing the best surgical approach for ICP? |
Q14 | What are the indications for performing a diverting or terminal stoma in patients with ICP? |
Q15 | What are the indications for drainages in patients with ICP? |
Q16 | What are the indications for the use of damage control surgery in patients with ICP? |
Follow-up of ICP | |
Q17 | Is there any recommendation to perform a surveillance endoscopy after a successful ICP treatment? If so, what is the recommended timing for it? |
Grade of recommendation | Description | Benefits vs. risks | Quality of supporting evidence | Implications |
---|---|---|---|---|
1A | Strong recommendation, high-quality evidence | Benefits clearly outweigh risks and burdens, or vice versa | RCTs without important limitations or overwhelming evidence from observational studies | Strong recommendation, applies to most patients in most circumstances without reservation |
1B | Strong recommendation, moderate-quality evidence | Benefits clearly outweigh risk and burdens, or vice versa | RCTs with important limitations (inconsistent results, methodological flaws, indirect or imprecise) or exceptionally strong evidence from observational studies | Strong recommendation, applies to most patients in most circumstances without reservation |
1C | Strong recommendation, low-quality or very low-quality evidence | Benefits clearly outweigh risk and burdens, or vice versa | Observational studies or case series | Strong recommendation based on limited evidence; recommendations may change when higher quality or more extensive evidence becomes available |
2A | Weak recommendation, high-quality evidence | Benefits closely balanced with risks and burdens | RCTs without important limitations or overwhelming evidence from observational studies | Weak recommendation; best action may differ depending on circumstances, expertise of clinician, the patient in question, or other social issues |
2B | Weak recommendation, moderate-quality evidence | Benefits closely balanced with risks and burdens | RCTs with important limitations (inconsistent results, methodological flaws, indirect or imprecise) or exceptionally strong evidence from observational studies | Weak recommendation; best action may differ depending on circumstances, expertise of clinician, the patient in question, or other social issues |
2C | Weak recommendation, low-quality or very low quality evidence | Uncertainty in the estimates of benefits, risks, and burdens; benefits, risks, and burdens may be closely balanced | Observational studies or case series | Very weak recommendation; other alternatives may be equally reasonable |
Results
Incidence of and risk factors for ICP
What are the general recommendations for minimizing the risk of ICP during screening and therapeutic colonoscopies?
Risk factors | References |
---|---|
Increasing age (> 65 years) | |
Female gender | |
Low BMI | |
Low albumin level | |
Presence of comorbidities | |
Crohn’s disease and diverticulosis | |
Admission in ICU | |
Endoscopist’s experience | |
Non-gastroenterologist endoscopists | |
Low volume centers | |
Previous abdominal surgery | |
Colonic obstruction | |
Bevacizumab therapy | |
Therapeutic vs. diagnostic procedure | |
Colonoscopy vs. sigmoidoscopy | |
General anesthesia |
What is the maximum incidence of ICP considered acceptable for centers where diagnostic or therapeutic colonoscopies are performed?
Diagnosis of ICP
What is the minimum information the endoscopist must report after diagnosing an ICP during a colonoscopy procedure?
Type of injury | |
• Direct mechanical trauma | |
• Barotrauma | |
• Thermal/electrical injury | |
Endoscopic therapeutic procedures at risk for ICP | |
• Colorectal stenting | |
• Polypectomy | |
• Colonic dilation | |
• Argon plasma coagulation (APC) | |
• Endoscopic mucosal resection (EMR) | |
• Endoscopic submucosal dissection (ESD) |
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Colonoscopy indication (i.e., diagnostic or therapeutic)
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Associated colonic pathology (e.g., strictures, polyps, tumors)
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Administration of sedation, analgesia, or anesthesia for the colonoscopy
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Patient’s general status and presence of comorbidities
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Gas type used for insufflation
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Quality of the colonic preparation
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Time of the ICP occurrence
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Most likely reason for ICP (e.g., thermal injury, mechanical injury)
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Injury localization and size
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Whether an endoscopic resolution was intended, attempted, or completed
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How the endoscopic repair was performed
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Presence of abdominal distention increasing the probability of abdominal compartment syndrome
Which are the minimum biochemical and imaging investigations that should be requested in the case of a suspected ICP?
Conservative and endoscopic treatments for ICP
Which are the indications for conservative treatment or an immediate surgical intervention after an ICP diagnosis?
What is the minimum duration of the hospital observation period for patients who have undergone successful endoscopic closure or conservative management of ICP?
Which investigations (clinical, biochemical, and imaging) should be performed during the observation period in patients who have undergone successful endoscopic closure or conservative management of ICP?
What is the recommended type and duration of antibiotic therapy in patients who have undergone successful endoscopic closure or conservative management of ICP?
Which is the recommended type and duration of antithrombotic prophylaxis in patients who have undergone successful endoscopic closure or conservative management of ICP?
How long is it recommended that patients fast following successful endoscopic closure or conservative treatments for ICP?
Surgical treatment of ICP
Is explorative laparoscopy indicated in all patients with ICP?
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In the case of failure of endoscopic treatment or an inability to perform endoscopic clip application after visualization of the ICP intra-procedurally
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In the case of development of peritonitis after a defined period of observation following perforation
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Recent laparotomy or previous abdominal surgery (more than 4 laparotomies) with extensive adhesions and a high risk of iatrogenic injury (relative contraindication)
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The presence of massive bowel dilatation (relative contraindication)
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Aorto-iliac aneurysmal disease (relative contraindication)
Which are the indications for conversion from laparoscopy to open surgery in patients with surgical ICP?
What are the key factors upon which to choose the best surgical approach for ICP?
What are the indications for performing a diverting or terminal stoma in patients with ICP?
What are the indications for drainage in patients with ICP?
What are the indications for the use of damage control surgery in patients with ICP?
Risk factors | Description | References |
---|---|---|
Age | > 67 | [140] |
Delayed diagnosis | > 24 h | |
Hemodynamic instability | Need for vasopressors before or during surgery | |
“Blunt” ICP | Perforation caused by excessive dilatation or during diagnostic procedures | [142] |
Medication use | Chronic steroid therapy | |
Severe sepsis | Peritonitis with organ failure | |
High surgical risk | ASA III and IV | [142] |