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LETTER TO EDITOR
Year : 2016  |  Volume : 10  |  Issue : 4  |  Page : 481-483

Tension pneumothorax as a complication of colonic perforation during colonoscopy: An anesthesiologist's nightmare


Department of Anesthesiology, Institute of Liver and Biliary Sciences, D-1 Vasant Kunj, New Delhi, India

Correspondence Address:
Dr. Anshuman Singh
Department of Anesthesiology, Institute of Liver and Biliary Sciences, D-1 Vasant Kunj, New Delhi - 110 070
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1658-354X.177331

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Date of Web Publication21-Sep-2016
 


How to cite this article:
Prakash K, Singh A, Sharma S, Pandey VK. Tension pneumothorax as a complication of colonic perforation during colonoscopy: An anesthesiologist's nightmare. Saudi J Anaesth 2016;10:481-3

How to cite this URL:
Prakash K, Singh A, Sharma S, Pandey VK. Tension pneumothorax as a complication of colonic perforation during colonoscopy: An anesthesiologist's nightmare. Saudi J Anaesth [serial online] 2016 [cited 2021 Apr 19];10:481-3. Available from: https://www.saudija.org/text.asp?2016/10/4/481/177331

Sir,

Colonoscopy is a routinely performed diagnostic and therapeutic procedure in the day care suite. Although rare, a colonic perforation (CP) is the most serious complication of colonoscopy. Continued insufflation of air or carbon dioxide into a perforated colon during endoscopic repair of these perforations can result in extraluminal leakage of gas resulting in pneumothorax, pneumomediastinum, subcutaneous (S/C) emphysema, and pneumoperitoneum. In this report, we describe the development of a life-threatening tension pneumothorax and S/C emphysema following iatrogenic perforation during a diagnostic colonoscopy.

A 66-year-old American Society of Anesthesiologists (ASA) class I woman with no comorbidities underwent a diagnostic colonoscopy in day care suite in propofol sedation. Monitoring of all vital parameters was done throughout the procedure in accordance with ASA standards. Supplemental oxygen was provided with a Hudson face mask at 5 L/min. The endoscopic procedure was aided with insufflation of air. Within 10 min of the procedure, a rectosigmoid perforation was recognized by the gastroenterologist. The abdomen was distended and tympanic in nature with the patient complaining of abdominal pain. Her vital parameters were stable with no respiratory distress at that time. Broad spectrum antibiotics (meropenem and metronidazole) were immediately administered intravenously; surgical opinion was sought, and a senior gastroenterologist attempted an endoscopic closure of the perforation, under air insufflation, but failed. Sedation was reduced to minimal levels required for the procedure.

During therapeutic endoscopy, she developed progressive abdominal distension, respiratory distress, and tachycardia. Fifteen minutes into the procedure, the patient developed sudden bradycardia (heart rate 40/min), hypoxia (SpO270%), and decreased level of consciousness. The colonoscope was immediately withdrawn, and the patient was turned supine. The patient was cyanosed, and her breathing was labored. Assisted bag-mask ventilation was initiated with 100% oxygen utilizing a Mapleson C breathing circuit, but her saturation remained at 70%. She was noted to have excessive S/C crepitation (suggestive of S/C emphysema) over the chest and neck. Her neck veins were extensively distended bilaterally. The patient was immediately intubated with a 7.5 mm cuffed endotracheal tube following 150 µgm fentanyl and 75 mg of succinylcholine. Following intubation (confirmed with EtCO2 monitoring), the compliance of the reservoir bag was very poor, and the patient required very high pressures to ventilate. On auscultation, breath sounds were absent on the right side, feeble peripheral pulses with systolic blood pressure of 70 mm of Hg. A large bore IV access was secured. Intravenous fluids were administered, and vasopressor (noradrenaline) was initiated. Due to the emergent nature of the situation, a rapid assessment to confirm the suspicion of pneumothorax was done using ultrasonography, which revealed the absence of any evidence of pleural sliding. A 16 gauge IV cannula was immediately inserted percutaneously in the second intercostal space in the midclavicular line. The release of a gush of air immediately from the cannula confirmed pneumothorax. The cannula was connected to an underwater drainage seal system. Immediately following decompression of the pneumothorax, the patient's vitals improved; her saturation increased to 98 %, and the compliance of the bag as assessed by manual ventilation returned to normal.

The patient was immediately shifted to the operation theater where an intercostal tube (ICD) was inserted [Figure 1]. She subsequently underwent an urgent laparotomy (within 1 h of the perforation), and a resection anastomosis was done. She was kept on mechanical ventilation postoperatively (for 36 h) and extubated after complete reexpansion of the lung was confirmed on chest X-ray. The ICD was removed on the 4th day after insertion and was discharged 1 day later uneventfully. There was no evidence of pneumomediastinum on radiological evaluation.
Figure 1: C-Xray with inter costal tube drainage in situ on the Rt. side

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The incidence of perforation following a diagnostic colonoscopy ranges from 0.016% to 0.2%, but can be as high as 5% when therapeutic interventions are performed.[1],[2] Risk factors for a perforation include therapeutic procedures, old age, previous intra-abdominal surgery, female gender, and the presence of comorbidities such as diabetes, chronic obstructive pulmonary disease, liver diseases, ulcerative colitis, and Crohn's disease. The most common site for colonic perforation is the rectosigmoid colon.[3],[4],[5],[6]

CP clinically presents most commonly by the visualization of an extraintestinal structure during the endoscopic examination. Patients can also present with symptoms and signs of peritonitis (mainly abdominal pain and tenderness) within hours after the procedure. Association of tension pneumothorax in a patient with CP is rare with only 16 such cases reported since 2000.

Mechanisms that have been proposed to explain the development of pneumothorax following CP are:

  • Following a retroperitoneal perforation, air insufflated during colonoscopy travels along fascial planes and ultimately leaks into mediastinal and pleural cavities.
  • Following an intraperitoneal perforation, leakage of air leads to the development of a pneumoperitoneum. This air passes along remnant embryonic connections as well as diaphragmatic fenestrations into the pleural and mediastinal cavities.


In our patient, the risk factor present was age. The recognition of a stricture in the rectosigmoid region at the time of colonoscopy could be retrospectively considered another risk factor for the complication.

As more and more colonoscopies are performed as routine day care procedures, it is important for anesthesia providers to be aware of the risk factors early signs and symptoms of perforation. Early recognition and intervention are essential to improve patient outcomes and prevent catastrophes.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Damore LJ 2nd, Rantis PC, Vernava AM 3rd, Longo WE. Colonoscopic perforations. Etiology, diagnosis, and management. Dis Colon Rectum 1996;39:1308-14.  Back to cited text no. 1
    
2.
Repici A, Pellicano R, Strangio G, Danese S, Fagoonee S, Malesci A. Endoscopic mucosal resection for early colorectal neoplasia: Pathologic basis, procedures, and outcomes. Dis Colon Rectum 2009; 52:1502-15.  Back to cited text no. 2
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3.
Lohsiriwat V, Sujarittanakarn S, Akaraviputh T, Lertakyamanee N, Lohsiriwat D, Kachinthorn U. Colonoscopic perforation: A report from World Gastroenterology Organization endoscopy training center in Thailand. World J Gastroenterol 2008;14:6722-5.  Back to cited text no. 3
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4.
Iqbal CW, Cullinane DC, Schiller HJ, Sawyer MD, Zietlow SP, Farley DR. Surgical management and outcomes of 165 colonoscopic perforations from a single institution. Arch Surg 2008;143:701-6.  Back to cited text no. 4
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5.
Teoh AY, Poon CM, Lee JF, Leong HT, Ng SS, Sung JJ, et al. Outcomes and predictors of mortality and stoma formation in surgical management of colonoscopic perforations: A multicenter review. Arch Surg 2009;144:9-13.  Back to cited text no. 5
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6.
Lüning TH, Keemers-Gels ME, Barendregt WB, Tan AC, Rosman C. Colonoscopic perforations: A review of 30,366 patients. Surg Endosc 2007;21:994-7.  Back to cited text no. 6
    


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