Elsevier

Surgery

Volume 148, Issue 4, October 2010, Pages 876-882
Surgery

Central Surgical Association
Esophagogastroduodenoscopy-associated gastrointestinal perforations: A single-center experience

Presented in part at the Central Surgical Association Annual Meeting, March 13, 2010, Chicago, Illinois.
https://doi.org/10.1016/j.surg.2010.07.010Get rights and content

Background

Esophagogastroduodenoscopy (EGD) is commonly used in the diagnosis and treatment of gastrointestinal (GI) disorders. Our aim was to define the risk of perforation associated with EGD and identify patients who required operative intervention.

Methods

We retrospectively reviewed 72 patients from our institution plus 5 transferred patients who sustained EGD-associated perforations from January 1996 through July 2008. Percutaneous endoscopic gastrostomy, endoscopic ultrasonography, endoscopic retrograde cholangiopancreatography, transthoracic echocardiography, and concurrent colonoscopy procedures were excluded.

Results

Perforations in 72 of 217,507 EGD procedures were identified (incidence, 0.033%); 124,844 EGDs included an interventional procedure and 92,663 were examination only. The incidence of perforation was similar whether an interventional procedure was performed or not (0.040% vs 0.029%; P = .181). The esophagus was injured most commonly (51%), followed by the duodenum (32%), jejunum (6%), stomach (3%), and common bile duct (3%). Overall mortality after perforation was 17% with a morbidity rate of 40%. Thirty-eight patients (49%) were initially treated nonoperatively, 7 of whom (18%) failed nonoperative management. The only factors we could determine that were associated with failure were free fluid or contrast extravasation on computed tomography (75% vs 23% [P < .005] and 33% vs 0% [P = .047], respectively). The morbidity of failures was equivalent to those who underwent initial operative management (63% vs 61%; P = .917), with mortality seeming to be greater (43% vs 21%; P = .09).

Conclusion

EGD is safe in the majority of patients; however, iatrogenic perforation is associated with considerable morbidity and mortality. Nonoperative management of GI perforation can be successful if there is no evidence of contrast extravasation or free fluid on radiographic studies. If nonoperative management fails, the outcomes may be worse than those treated initially with operative repair.

Section snippets

Methods

Institutional review board approval was obtained. The procedure database at our institution was searched to identify all patients undergoing EGD from January 1996 through July 2008 exclusive of percutaneous endoscopic gastrostomy, endoscopic ultrasonography, endoscopic retrograde cholangiopancreatography, transthoracic echocardiography, and concurrent colonoscopy procedures. This subset was further narrowed down by 2 methods: (1) all patients diagnosed with “perforation” within 7 days of the

Results

We performed 217,507 EGD procedures between January 1996 and July 2008. The number of EGDs performed increased steadily from 12,183 in 1996 to >19,000 in 2008 (Figure). We included 72 patients from our institution and 5 patients transferred to our institution (46 women, 31 men), with a median age of 70 years (range, 20–95) who had an EGD-associated GI perforation. The overall incidence of perforation for EGDs performed at our institution was 0.03%. Of these procedures, 124,844 EGDs (57%)

Discussion

EGD has proven to be a safe therapeutic and diagnostic procedure in most patients. Despite its relative safety, iatrogenic perforations of the GI tract may have severe consequences.1, 2, 3, 5, 6, 7, 8, 11, 12 To the authors' knowledge, this study is the largest single-institution experience with GI perforations secondary to EGD. With rising use of EGD, particularly for more aggressive therapeutic uses including natural orifice transluminal endoscopic surgery (NOTES), there exists a need to

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