Summary of the current guidelines for managing iatrogenic colorectal perforations and the evolving role of endoluminal vacuum therapy

Colonoscopy represents a safe procedure that is widely used in medical practice either to diagnose or treat various gastrointestinal diseases.During the last few years,the incidence rate of perforations in colonoscopic procedures has increased,especially in therapeutic colonoscopies.The recent advancements in endoscopic techniques and gastrointestinal tumoral resection procedures such as endoscopic mucosal resection,endoscopic full-thickness resection,and endoscopic submucosal dissection(ESD)could be a risk factor for this increased risk.The incidence rate of mortality of serious colonoscopic perforations is 7.1%.The management plan for these perforations starts with conservative treatment in mild cases,endoscopic closure,and surgical management in severe cases.Recently,endoluminal vacuum therapy was found to be effective in the management of colorectal perforations and this has been reported in multiple case reports.This editorial provides an overview of the current guidelines for the management of iatrogenic colorectal perforations.These insights are from the perspectives of endoscopists and gastroenterologists.We also present a management algorithm based on the guidelines of the European Society of Gastrointestinal Endoscopy,the American Gastroenterological Association,and the World Society of Emergency Surgery.We also discussed in brief the use of endoluminal vacuum therapy in colorectal perforations.

Is there a place for endoscopic management in postcholecystectomy iatrogenic bile duct injuries?

In this editorial we comment on the article by Emara et al published in the recent issue of the World Journal of Gastrointestinal Surgery.Previously,surgery was the primary treatment for bile duct injuries(BDI).The treatment of BDI has advanced due to technological breakthroughs and minimally invasive procedures.Endoscopic and percutaneous treatments have largely supplanted surgery as the primary treatment for most instances in recent years.Patient management,including the specific technique,is typically impacted by local knowledge and the kind and severity of the injury.Endoscopic therapy is a highly successful treatment for postoperative benign bile duct stenosis and offers superior long-term outcomes compared to surgical correction.Based on the damage features of BDI,therapeutic options include endoscopic duodenal papillary sphincterotomy,endoscopic nasobiliary drainage,and endoscopic biliary stent implantation.

Boari Kuss Technique for Iatrogenic Ureter Injury on Single Kidney at C.H.U le Luxembourg about a Case and Review of the Literature

Introduction: Ureteral lesions, most often iatrogenic, generally follow pelvic surgery. They are serious and can be life-threatening. Uretero-vesical reimplantation using the BOARI technique, modified by KUSS, was popularized in humans in 1954, and appears to be the most appropriate treatment for lesions of the lower ureter with significant loss of substance. Observation: We report in this work a case of iatrogenic ligation of the pelvic ureter on a single functional kidney (of fortuitous discovery) during gynecological surgery, having led to an Alteration of the General State (important Urinoma and collapse of the renal function) and treated by the surgical technique of BOARI KUSS at the urology department of the CHU Le Luxembourg. Follow-up and postoperative follow-up were excellent. Conclusion: Surgical repair of the ureter is very often indicated in cases of stenosis or iatrogenic lesions of the ureter. The BOARI KUSS technique is a good choice in cases of significant loss of substance due to injury to the lower ureter. Gynecological surgery is the main source of these lesions, and the prognosis of the treatment depends on how early the diagnosis is made, the anatomical condition of the ureter and the expertise of the surgical team.

Iatrogenic Tumor Implantation

Iatrogenic tumor implantation is a condition that results from various medical procedures used during diagnosis or treatment of a malignancy.It involves desquamation and dissemination of tumor cells that develop into a local recurrence or distant metastasis from the tumor under treatment.The main clinical feature of the condition is nodules at the operation's porous channel or incision,which is easily diagnosed in accordance with the case history.Final diagnosis can be made based on pathological examination.Tumor implantation may occur in various puncturing porous channels,including a laparoscopic port,abdominal wall incision,and perineal incision,etc.Besides a malignant tumor, implantation potential exists with diseases,such as a borderline tumor and endometriosis etc.Once a tumor implantation is diagnosed,or suspected,surgical resection is usually conducted. During the diagnosis and treatment of diseases,avoiding and reducing iatrogenic implantation and dissemination has been regarded as an important principle for surgical treatment of tumors.In a clinical practice setting,if possible,excisional biopsy should be employed,if a biopsy is needed.Repeated puncturing should be avoided during a paracentesis.In a laparoscopic procedure,the tissue is first put into a sample bag and then is taken out from the point of incision.After a laparoscopic procedure,the peritoneum,abdominal muscular fasciae,and skin should be carefully closed,and/or the punctured porous channel be excised.In addition,the sample/tissue should be rinsed with distilled water before surgical closure of the abdominal cavity, allowing the exfoliated tumor cells to swell and rupture in the hypo-osmolar solution.Then surgical closure can be conducted following a change of gloves and equipment.The extent of hysteromyomectomy should as far as possible be away from the uterine cavity.The purpose of this study is to make clinicians aware of the possibility of tumor implantation and to give special attention to avoid,or reduce iatrogenic implantation during a surgical procedure.

Iatrogenic bile duct injuries:Etiology,diagnosis and management

Iatrogenic bile duct injuries (IBDI) remain an important problem in gastrointestinal surgery. They are most frequently caused by laparoscopic cholecystectomy which is one of the commonest surgical procedures in the world. The early and proper diagnosis of IBDI is very important for surgeons and gastroenterologists, because unrecognized IBDI lead to serious complications such as biliary cirrhosis, hepatic failure and death. Laboratory and radiological investigations play an important role in the diagnosis of biliary injuries. There are many classifications of IBDI. The most popular and simple classification of IBDI is the Bismuth scale. Endoscopic techniques are recommended for initial treatment of IBDI. When endoscopic treatment is not effective, surgical management is considered. Different surgical reconstructions are performed in patients with IBDI. According to the literature, Roux- en-Y hepaticojejunostomy is the most frequent surgical reconstruction and recommended by most authors. In the opinion of some authors, a more physiological and equally effective type of reconstruction is end- to-end ductal anastomosis. Long term results are the most important in the assessment of the effectiveness of IBDI treatment. There are a few classifications for the long term results in patients treated for IBDI; the Terblanche scale, based on clinical biliary symptoms, is regarded as the most useful classification. Proper diagnosis and treatment of IBDI may avoid many serious complications and improve quality of life.

Adult iatrogenic ureteral injury and strictureeincidence and treatment strategies

Iatrogenic ureteral injuries and strictures are relatively common complication of pelvic surgery and radiation treatment.Left untreated they are associated with severe shortand long-term complications such as urinoma,septic state,renal failure,and loss of a renal unit.Treatment depends on timing of diagnosis,as well as extent of injury,and ranges from simple endoscopic management to complex surgical reconstruction under usage of pedicled grafts.While recent advances in ureteral tissue engineering are promising the topic is still underreported.Historically a domain of open surgery,laparoscopic and robotic-assisted approaches have proven their feasibility in small case series,and are increasingly being utilized as means of reconstructive surgery.This review aims to give an outline of incidence and treatment of ureteral injuries and strictures in light of the latest advances.

Iatrogenic esophago-tracheal fistula:Challenges in diagnosis and management

Esophageo-tracheal fistula is a rare condition,and in most cases such fistulas are caused by malignant disease or emergency endotracheal intubation.A case where a wrapped tablet produced a fistula between the esophagus and trachea is described.The patient is a male born in 1938 who swallowed a tablet without unwrapping it.The patient was treated with selfexpanding metal stents(SEMS),but closure of the fistula was not achieved.Different examinations and treatment options are discussed.Surgical treatment for this condition has demonstrated considerable mortality and morbidity.In some cases closure of the fistula can be achieved by use of SEMS.Although we advise treatment of such cases with SEMS,in some cases treatment with stents will prove troublesome and the risk/benefit analysis will have to be reevaluated.

Management of iatrogenic colorectal perforation: From surgery to endoscopy

Iatrogenic colon perforation is one the most pernicious complications for patients undergoing endoscopic screening or therapy.It is a serious but rare complication of colonoscopy.However,with the expansion of the indications for endoscopic therapies for gastrointestinal diseases,the frequency of colorectal perforation has increased.The management of iatrogenic colorectal perforation is still a challenge for many endoscopists.The methods for treating this complication vary,including conservative treatment,surgical treatment,laparoscopy and endoscopy.In this review,we highlight the etiology,recognition and treatment of colorectal iatrogenic perforation.Specifically,we shed light on the endoscopic management of this rare complication.

Iatrogenic bile duct injuries from biliary tract surgery

BACKGROUND:Cholecystectomy is the most commonly performed procedure in general surgery.However,bile duct injury is a rare but still one of the most common complications.These injuries sometimes present variably after primary surgery.Timely detection and appropriate management decrease the morbidity and mortality of the operation. METHODS:Five cases of iatrogenic bile duct injury(IBDI) were managed at the Department of Surgery,First Affiliated Hospital,Xi’an Jiaotong University.All the cases who underwent both open and laparoscopic cholecystectomy had persistent injury to the biliary tract and were treated accordingly. RESULTS:Recovery of the patients was uneventful.All patients were followed-up at the surgical outpatient department for six months to three years.So far the patients have shown good recovery. CONCLUSIONS:In cases of IBDI it is necessary to perform the operation under the supervision of an experienced surgeon who is specialized in the repair of bile duct injuries,and it is also necessary to detect and treat the injury as soon as possible to obtain a satisfactory outcome.

Liver transplantation in the treatment of severe iatrogenic liver injuries

The place of liver transplantation in the treatment of severe iatrogenic liver injuries has not yet been widely discussed in the literature. Bile duct injuries during cholecystectomy represent the leading cause of liver transplantation in this setting, while other indications after abdominal surgery are less common. Urgent liver transplantation for the treatment of severe iatrogenic liver injury may-represent a surgical challenge requiring technically difficult and time consuming procedures. A debate is ongoing on the need for centralization of complex surgery in tertiary referral centers. The early referral of patients with severe iatrogenic liver injuries to a tertiary center with experienced hepato-pancreatobiliary and transplant surgery has emerged as the best treatment of care. Despite widespread interest in the use of liver transplantation as a treatment option for severe iatrogenic injuries, reported experiences indicate few liver transplants are performed. This review analyzes the literature on liver transplantation after hepatic injury and discusses our own experience along with surgical advances and future prospects in this uncommon transplant setting.

Iatrogenic colorectal perforation induced by anorectal manometry:Report of two cases after restorative proctectomy for distal rectal cancer

There are no reports regarding perforation of the colorectum induced by anorectal manometry. We report two cases of colorectal perforation that occurred during manometry in the patients undergoing restorative proctectomy for distal rectal cancer. In the first patient, computed tomography showed an extraperitoneal perforation in the pelvic cavity and a rupture of the rectal wall. A localized perforation into the retroperitoneum was managed conservatively. In the second patient, a 3 cm linear colon rupture was detected above the anastomotic site. A primary closure of the perforated colon and proximal ileostomy were conducted, but the patient died 2 wk later. We hypothesize that the perforation induced by anorectal manometry may be associated with the relative weakening of the proximal bowel wall due to anastomosis, decreased compliance, and abnormal rectal sensation. We suggest that measurement of the maximum tolerable volume should not be routinely performed alter restorative proctectomy for distal rectal cancer.

Acute iatrogenic Budd-Chiari syndrome following hepatectomy for hepatolithiasis:A report of two cases

Budd-Chiari syndrome(BCS)is defined as hepatic venous outflow obstruction at any level from the small hepatic veins to the junction of the inferior vena cava(IVC)and the right atrium,regardless of the cause of obstruction.We present two cases of acute iatrogenic BCS and our clinical management of these cases.The first case was a 43-year-old woman who developed acute BCS following the implantation of an IVC stent for the correction of stenosis in the IVC after hepatectomy for hepatolithiasis.The second case was a61-year-old woman with complete obstruction of the outflow of hepatic veins during bilateral hepatectomy for hepatolithiasis.Acute iatrogenic BCS should be con-sidered a rare complication following hepatectomy for hepatolithiasis.Awareness of potential hepatic outflow obstructions and timely management are critical to avoid poor outcomes when performing hepatectomy for hepatolithiasis.

Iatrogenic extrahepatic bile duct injury in 182 patients: causes and management

Objective: To describe the causes and treatment ofiatrogenic bile duct injury caused by cholecystecto-my.Methods: 182 patients with iatrogenic extrahepaticbile duct injury from 4 university hospitals of Chinawere reviewed. Details of primary cholecystectomy,biliary reconstruction as well as postoperative ma-nagement were recorded. All patients were followedup for at least 6 months (6 months to 9 years, medi-an 3.5 years). The adequacy of repair was assessedby regular evaluation of the patients clinical statusand liver function variables. Hepatobiliary B-ultra-sonography was used routinely in the follow up of pa-tients, and magnetic resonance cholangiopancreatog-raphy was applied in the patients suggestive of abnor-mality.Results: In 152 patients, bile duct injury happenedduring open cholecystectomy, and in 30 patients dur-ing laparoscopic cholecystectomy. All the injuries de-veloped during anterograde cholecystectomy (at theCalot’s triangle). All the patients with these injuriesunderwent choledochocholedochostomy or Roux-en-Ycholedochojejunostomy with good results (161 pa-tients), recurrent stricture (11), and death (10).Conclusions: During cholecystectomy, the Calot’s tri-angle should be identified anatomically, but retro-grade cholecystectomy is the optimal choice. Bileduct injury should be discovered as soon as possibleand be managed timely. Different operative methodsare optional according to the degree of injury and thepostoperative period.

International multi-center study of iatrogenic retinal tears in pars plana vitrectomy

AIM: To study and compare the effect of different surgical settings on the development of iatrogenic retinal tears(IRT) in conventional(20-gauge) and microincisional vitrectomy.METHODS: An international retrospective comparative study of 394 patients who had simple vitrectomy at three tertiary centers. Surgeries were performed by four retina surgeons using different viewing systems. Two groups of eyes were compared: microincisional vitrectomy(327 eyes) and conventional(67 eyes) vitrectomy. An iatrogenic tear was defined as the occurrence of one or more peripheral retinal tears during surgery or at any visit in the first 6 wk postoperatively.RESULTS: Mean age was 67±12 y and 55% were female. Iatrogenic tears occurred in 11/394(2.8%) of eyes. The rate of tears was similar among different surgeons and viewing systems(P=0.93 and P=0.76, respectively). Surgical indication, preexisting pseudophakia/aphakia, induction of posterior vitreous detachment(PVD) during surgery, and the use triamcinolone acetonide didn’t significantly affect the rate of tears(P>0.1 for all factors). A higher rate of tears was found in the conventional group compared to the microincisional group(respectively, 7.5%, 1.8%, P=0.02).CONCLUSION: The rate of IRT in vitrectomy is not significantly affected by surgical indication, preexisting PVD or pseudophakia, or use of triamcinolone or different viewing systems but is significantly higher in conventional vitrectomy. Microincisional platforms improve the safety of vitrectomy regardless of the viewing system used.

Treatment of a rotator cuff tear combined with iatrogenic glenoid fracture and shoulder instability:A rare case report

BACKGROUND The brisement manipulation is an effective treatment for refractory shoulder stiffness.Rotator cuff tears can sometimes exist in combination with adhesive capsulitis.Arthroscopic capsular release combined with rotator cuff repair has achieved good outcomes in published reports.CASE SUMMARY We report the case of a patient with right shoulder pain for more than 1 year that was suspected to have adhesive capsulitis and a rotator cuff tear that was treated with brisement manipulation and arthroscopic management.An iatrogenic glenoid fracture with shoulder instability occurred during the manipulation.Arthroscopic treatment for fracture fixation,capsular release,and rotator cuff repair was performed,and the functional results are reported.CONCLUSION Arthroscopic fixation for iatrogenic glenoid fracture and repairing coexisting rotator cuff tear can provide the stability needed for early rehabilitation.

Focal intramural hematoma as a potential pitfall for iatrogenic aortic dissection during subclavian artery stenting: A case report

BACKGROUND Iatrogenic aortic dissection(IAD)is a rare but fatal complication of interventional treatment for the proximal supra-aortic large vessels.Several cases of IAD after endovascular treatment of subclavian artery have been reported.Nevertheless,the pathogenesis of IAD is still unclear.Here we report a patient with IAD following a balloon expandable stent implanted into the left subclavian artery(LSA).CASE SUMMARY An 84-year-old man with a history of hypertension was admitted to the Neurology Department of our hospital complaining of dizziness and gait disturbance for more than 1 mo.Computed tomography angiography of the head and neck showed severe stenosis at the proximal LSA and the origin of the left vertebral artery.Magnetic resonance diffusion-weighted imaging of the brain revealed subacute infarctions in cerebellum,occipital lobe and medulla oblongata.He suffered a Stanford type B aortic dissection after the proximal LSA angioplasty with a balloon expandable stent.Thoracic endovascular aortic repair was performed immediately with the chimney technique and he was discharged 20 d later.After exploring the pathogenesis with multimodal imaging analysis,an easily neglected focal intramural hematoma(IMH)in the aorta near the junction of the LSA was found to be the main cause of the IAD.The risk of IAD should be sufficiently evaluated according to the characteristics of aortic arch lesions before the proximal LSA angioplasty.CONCLUSION Focal aortic IMH is a potential risk factor for IAD during a seemingly simple stenting of the proximal LSA.

Percutaneous transcatheter super-selective renal arterial embolization with N-butyl cyanoacrylate for iatrogenic renal hemorrhage

Background:To evaluate the safety and efficacy of percutaneous transcatheter super-selective renal arterial embolization(SRAE)with N-butyl cyanoacrylate(NBCA)for iatrogenic renal hemorrhage.Methods:Between January 2014 and December 2019,45 patients(including 18 patients with coagulopathy),who underwent percutaneous transcatheter SRAE with NBCA for iatrogenic renal hemorrhage at our institution,were retrospectively reviewed.The technical success rate,clinical success rate,and embolization-related complications were analyzed.The values of estimated glomerular filtration rate(eGFR),serum creatinine(sCr),and serum urea(sUr)were analyzed at the time of pre-SRAE,post-SRAE,and last follow-up to evaluate the effects of NBCA-based SRAE on renal function.Results:Diagnostic renal arteriography revealed contrast extravasation in 18 patients and pseudoaneurysms in 27 patients.NBCA mixed with iodized oil in a 1:2–1:4 ratio was the sole embolic agent.No procedure-related mortality or major complications occurred.The technical and clinical success rates were both 100%.The values of eGFR,sCr and sUr were not found to be significantly different between pre-SRAE,post-SRAE and last follow-up(eGFR:91.52±21.17 vs.90.98±22.11 vs.92.14±23.51 mL/min/1.73 m^(2),p=0.729;sCr:74.73±11.08 vs.75.27±12.43 vs.73.95±10.14μmol/L,p=0.543;sUr:5.69±0.84 vs.5.71±0.96 vs.5.70±0.79,p=0.515,respectively).Conclusions:Percutaneous transcatheter SRAE with NBCA is a safe and effective treatment modality for iatrogenic renal hemorrhage with no deterioration of renal function.

Post-cholecystectomy iatrogenic bile duct injuries:Emerging role for endoscopic management

Post-cholecystectomy iatrogenic bile duct injuries(IBDIs),are not uncommon and although the frequency of IBDIs vary across the literature,the rates following the procedure of laparoscopic cholecystectomy are much higher than open cholecystectomy.These injuries caries a great burden on the patients,physicians and the health care systems and sometime are life-threatening.IBDIs are associated with different manifestations that are not limited to abdominal pain,bile leaks from the surgical drains,peritonitis with fever and sometimes jaundice.Such injuries if not witnessed during the surgery,can be diagnosed by combining clinical manifestations,biochemical tests and imaging techniques.Among such techniques abdominal US is usually the first choice while Magnetic Resonance Cholangio-Pancreatography seems the most appropriate.Surgical approach was the ideal approach for such cases,however the introduction of Endoscopic Retrograde Cholangio-Pancreatography(ERCP)was a paradigm shift in the management of such injuries due to accepted success rates,lower cost and lower rates of associated morbidity and mortality.However,the literature lacks consensus for the optimal timing of ERCP intervention in the management of IBDIs.ERCP management of IBDIs can be tailored according to the nature of the underlying injury.For the subgroup of patients with complete bile duct ligation and lost ductal continuity,transfer to surgery is indicated without delay.Those patients will not benefit from endoscopy and hence should not do unnecessary ERCP.For low–flow leaks e.g.gallbladder bed leaks,conservative management for 1-2 wk prior to ERCP is advised,in contrary to high-flow leaks e.g.cystic duct leaks and stricture lesions in whom early ERCP is encouraged.Sphincterotomy plus stenting is the ideal management line for cases of IBDIs.Interventional radiologic techniques are promising options especially for cases of failed endoscopic repair and also for cases with altered anatomy.Future studies will solve many unsolved issues in the management of IBDIs.

Identifi cation and Management of Iatrogenic Aortocoronary Dissection

Iatrogenic aortocoronary dissection(IACD)is a rare but potentially life-threatening complication during coronary catheterizations.Although the incidence was relatively low,the dissection often leads to procedure failure with increased risk of myocardial infarction and death.IACD is mainly caused by disruption of intima at the ostia of left or right coronary artery during interventional procedures,and appears as luminal filling defects or persistence of contrast(“extraluminal cap”)or intimal tear outside the coronary lumen.Dissection could disseminate antegradely and lead to subtotal or total occlusion of the coronary lumen.Similarly,it could extend retrogradely into the sinus of Valsalva and cusp,or even the ascending aorta,aortic arch,or descending aorta,leading to hemodynamic collapse.Early identifi cation and prompt management is crucial to the prognosis of patients with IACD.Immediate bail-out stenting should be performed as rapidly as possible in most cases of severe dissection,even when signifi cant propagation has already occurred.Surgery should only be considered when stenting failed to seal the dissection and the patients had hemodynamic compromise.

Iatrogenic flexor tendon rupture caused by misdiagnosing sarcoidosis-related flexor tendon contracture as tenosynovitis: A case report

BACKGROUND Sarcoidosis is a multisystem disease characterized by granuloma formation in various organs.Sarcoidosis-related flexor tendon contractures are uncommon in clinical settings.This contracture is similar to stenosing tenosynovitis and po-tentially leads to misdiagnosis and mistreatment.Herein,we report a rare case of sarcoidosis-related finger flexor tendon contracture that was misdiagnosed as tenosynovitis.A 44-year-old woman presented to our department with flexion contracture of the right ring and middle fingers.The patient was misdiagnosed with tenosynovitis and underwent acupotomy release of the A1 pulley of the middle finger in an-other hospital that resulted in iatrogenic rupture of both the superficial and profundus flexors.Radiological presentation showed multiple sarcoid involve-ments in the pulmonary locations and ipsilateral forearm.A diagnosis of sar-coidosis was made based on the presence of non-caseating granulomas with tubercles consisting of Langhans giant cells with lymphocyte infiltration on biopsy,and the patient underwent surgical repair for the contracture.After 2 mo,the patient experienced another spontaneous rupture of the repaired middle finger tendon and underwent surgical re-repair.Satisfactory results were achieved at the 10 mo follow-up after reoperation.CONCLUSION Sarcoidosis-related finger contractures are rare;thus,caution should be exercised when dealing with such patients to avoid incorrect treatment.