Pain in the recovery area?
This 3cm polyp was removed from the sigmoid colon. After returning to the recovery area the patient is complaining of severe low abdominal pain.
WHAT WOULD YOU DO NOW?
■ Keep in 'recovery area' for observation
Not 'wrong' a such but you can do more!
■ Bring back into endoscopy room to apply more clips
Now is your chanse to do this before that peritonitis takes hold!
■ Organise a CT
In my experience, it often muddies the water and adds little useful information in this scenario
■ Admit, organise a CT and start AB's
Not 'wrong' but placing clips is more important than any of this
Large sessile colonic polyps are a particular challenge for endoscopists. That surface crypt pattern may not be an accurate reflection of what is hiding inside! When there is cancer hidden at the centre of the polyp, this will induce a fibrotic response (the pathologists call this a 'desmoplastic response') which can tether the polyp to the muscle propria layer. Large polyps being yanked about by peristalsis can also develop fibrosis beneath even if they are benign (example below of an entirely benign VA+TSA harbouring LGD only with dense fibrosis in its centre). Of course, non-lifting is usually obvious when the lesion is small or flat but can be impossible to see below a large sessile polyp.
The first sign that something is amiss is when in spite of 20-30 seconds of yellow pedal power (i.e. a blended cut/coag/pause diathermy cycle), the polyp is still in place! When this happened, I used to curse under my breath, re-set the diathermy and with a strong hand and a further 30 seconds of diathermy, I would usually 'win' the battle and the polyp would fall off. Unfortunately, this would often turn out to be a 'Pyrrhic victory'. There would either be quite alarming bleeding or a perforation.
Nowadays, I believe that these large, sessile polyps are best removed by ESD. In a slow, controlled manner you can then dissect below the lesion. If you encounter fibrous tissue you can attempt to dissect around it, abandon or (if you've got the balls) attempt to continue the dissection in the same plane through the fibrous tissue. Of course, you can also deal with those chunky vessels, one-by-one in a more controlled manner.
Back to the scenario in question. If I think that there could be any risk that I've perforated, I would bring the patient back into the procedure room to place LOTS OF CLIPS. In truth, I did immediately recognise the peri-colonic fat in the middle image on the right and closed the perforation without delay. That white base to the upturned polyp in the last image, is a sizeable chunk of muscle propria layer.
Anyway, provided that there is no peritoneal contamination, the perforation has been thoroughly closed with a virtual 'suture line' of clips and the patient is young and 'sensible', I would observe them for another few hours in recovery and discharge provided that they remain free of abdominal pain. Beware of the patient who remains in pain but claims to be comfortable because he is desperate to get back home...
Of course, the patient must understand my verbal and written information that there may have been a small perforation which I have closed with clips but that he/she must return to hospital if further pain develops. Of course, my standard post-resection information leaflet always advice patients to return to hospital if bleeding or pain develops up to 2 weeks after the resection.
No antibiotics, no scans, no admission!?! Controversial of course and I must stress that this is my own management strategy. I believe that my way of dealing with micro-perforations is safer than admission (exposing the patient to all the in-hospital hazards of multi-resistant bugs, Covid-19 etc), reduces the risk of 'over-treatment' (CT scans after EMR's or ESDs' always look alarming to the radiologists with gas in the wall of the bowel and the peritoneal cavity which means that surgeons will be reaching for their knives) and cheaper (of course).
By the way, I am no great fan of the over-the-scope (OVESCO) clips for three reasons; a) time is of the essence in perforations and with the OVESCO clip you loose time but having to withdraw the scope to attach the device and b) it is very cumbersome and it can be difficult to reach the lesion and c) you only get one chance to get the clip in the correct position. With 'normal clips, it doesn't matter if a clip goes on a little wonkily, you just place another one!