Original article
Alimentary tract
Risk Factors for Early Colonoscopic Perforation Include Non-Gastroenterologist Endoscopists: A Multivariable Analysis

https://doi.org/10.1016/j.cgh.2013.06.030Get rights and content

Background & Aims

Bowel perforation is a rare but serious complication of colonoscopy. Its prevalence is increasing with the rapidly growing volume of procedures performed. Although colonoscopies have been performed for decades, the risk factors for perforation are not completely understood. We investigated risk factors for perforation during colonoscopy by assessing variables that included sedation type and endoscopist specialty and level of training.

Methods

We performed a retrospective multivariate analysis of risk factors for early perforation (occurring at any point during the colonoscopy but recognized during or immediately after the procedure) in adult patients by using the Clinical Outcomes Research Initiative National Endoscopic Database. Risk factors were determined from published articles. Additional variables assessed included endoscopist specialty and years of experience, trainee involvement, and sedation with propofol.

Results

We identified 192 perforation events during 1,144,900 colonoscopies from 85 centers entered into the database from January 2000–March 2011. On multivariate analysis, increasing age, American Society of Anesthesia class, female sex, hospital setting, any therapy, and polyps >10 mm were significantly associated with increased risk of early perforation. Colonoscopies performed by surgeons and endoscopists of unknown specialty had higher rates of perforation than those performed by gastroenterologists (odds ratio, 2.00; 95% confidence interval, 1.30–3.08). Propofol sedation did not significantly affect risk for perforation.

Conclusions

In addition to previously established risk factors, non-gastroenterologist specialty was found to affect risk for perforations detected during or immediately after colonoscopy. This finding could result from differences in volume and style of endoscopy training. Further investigation into these observed associations is warranted.

Section snippets

Database

This study analyzed prospectively collected data from the Clinical Outcomes Research Initiative (CORI) National Endoscopic Database, a large North American database consisting of diverse practice types. Participating physicians are provided with an electronic health record that is completed at the time of endoscopy and generates procedure reports used for recordkeeping as part of the official medical record. Users are required to document at least 95% of procedures in CORI. Once signed off,

Results

Between January 2000 and March 2011, 192 perforation events were recorded in 1,144,900 adult colonoscopies entered into the CORI database, corresponding to an early perforation rate of 0.017% or 1 in 5882 procedures. Characteristics of the study patients along with the incidence of early colonoscopy-related perforation and univariate analysis appear in Table 1.

On univariate analysis, significantly higher rates of early perforation were observed with increasing patient age and ASA class, as well

Discussion

Previous studies of perforation risk factors in colonoscopy have suggested that gastroenterologists may cause fewer perforations than surgeon endoscopists, but these differences were never shown to be significant.2, 21 The current study revealed significantly increased early perforation risk in colonoscopies performed by surgeon endoscopists when controlling for other variables. This suggests there is a difference in quality between procedures performed by gastroenterologists and

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    Conflicts of interest This author discloses the following: Dr Lieberman is the executive director of CORI, a nonprofit organization that receives funding from federal and industry sources. This potential conflict of interest has been reviewed and managed by the OHSU and Portland VA Conflict of Interest in Research Committees. The remaining authors disclose no conflicts.

    Funding This project was supported with funding from NIDDK U01DK57132, R33-DK61778-01, and R21-CA131626. In addition, the practice network (Clinical Outcomes Research Initiative) has received support from the following entities to support the infrastructure of the practice-based network: AstraZeneca, Novartis, Bard International, Pentax USA, ProVation, Endosoft, GIVEN Imaging, and Ethicon. The commercial entities had no involvement in this research.

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