Overview
Definition:
Colonic Endoscopic Mucosal Resection (EMR) is a minimally invasive endoscopic technique used to remove superficial neoplastic lesions or flat lesions from the colonic mucosa
Surgical rescue refers to the management of complications arising from EMR that necessitate surgical intervention, ranging from prompt laparotomy to delayed reconstructive procedures.
Epidemiology:
EMR is increasingly performed for early-stage colorectal cancers and large polyps
Complications requiring surgical rescue are relatively uncommon, with perforation rates cited between 0.1-1.5% and significant bleeding rates around 1-5%, depending on lesion size, location, and patient factors
Delayed complications, such as stricture or perforation, can occur days to weeks post-procedure.
Clinical Significance:
Understanding the potential complications of EMR and the indications for surgical rescue is crucial for colorectal surgeons and gastroenterologists
Timely recognition and appropriate management of these complications can significantly impact patient morbidity and mortality, directly affecting surgical outcomes and patient safety
This knowledge is vital for DNB and NEET SS examinations.
Indications For Surgical Rescue
Perforation:
Identified free air on imaging, hemodynamic instability, peritonitis, or failure of endoscopic/conservative management of a recognized perforation.
Hemorrhage:
Massive, uncontrolled post-EMR bleeding unresponsive to endoscopic hemostasis, leading to hemodynamic instability and hypovolemic shock.
Delayed Complications:
Late perforation, contained perforation leading to abscess, significant stricture formation causing obstruction, or anastomotic leak if EMR was performed in the setting of prior surgery.
Diagnostic Uncertainty:
In rare cases, if significant suspicion of deeply invasive cancer remains after EMR and cannot be definitively excluded or managed endoscopically, surgical resection may be indicated.
Preoperative Assessment And Preparation
History And Physical Exam:
Thorough assessment for signs of peritonitis, hemodynamic instability, and evidence of significant bleeding
Assess comorbidities impacting surgical risk.
Imaging:
Computed tomography (CT) scan of the abdomen and pelvis is essential to confirm perforation, assess the extent of contamination, identify abscesses, and evaluate for bowel obstruction or other intra-abdominal pathology.
Laboratory Investigations:
Complete blood count (CBC) for hemoglobin and platelet count, coagulation profile, electrolytes, renal function tests, and liver function tests
Type and screen/crossmatch for potential blood transfusion.
Endoscopic Review:
If feasible and safe, review the EMR procedure report and images to understand the extent of the resection, any hemostatic measures applied, and the initial assessment of the resection site.
Surgical Management Strategies
Perforation Management:
Laparoscopic or open exploration
Primary repair with omentoplasty for small, contained perforations without contamination
Resection of the perforated segment with primary anastomosis (if feasible) or stoma creation for larger, more contaminated perforations or unstable patients.
Hemorrhage Management:
Urgent surgical exploration
Identification of the bleeding site
Ligation of bleeding vessels, local excision of the EMR site, or segmental bowel resection with anastomosis or stoma, depending on the extent and location of bleeding.
Management Of Abscess:
Percutaneous drainage if feasible and patient is stable
Surgical drainage and debridement
May require resection of the affected segment if bowel viability is compromised or if drainage alone is insufficient.
Stricture Management:
Endoscopic balloon dilation for short, non-obstructing strictures
Surgical resection and reconstruction for long, symptomatic, or obstructive strictures, particularly if associated with inflammation or ischemia.
Postoperative Care And Follow Up
Intensive Monitoring:
Close monitoring of vital signs, urine output, abdominal examination, and pain control
Intravenous fluid resuscitation and broad-spectrum antibiotics are usually indicated for perforated bowel.
Nasogastric Decompression:
Often required in cases of perforation or obstruction to decompress the bowel.
Nutritional Support:
Initiation of enteral or parenteral nutrition as dictated by the extent of bowel resection and expected recovery time.
Long Term Surveillance:
Regular colonoscopic surveillance is crucial to monitor for recurrence at the EMR site and to assess for new neoplastic lesions
The frequency and duration of surveillance depend on the initial lesion characteristics and the extent of surgery performed.
Key Points
Exam Focus:
Recognize complications like perforation and bleeding
Understand indications for surgery vs
endoscopic management
Differentiate acute vs
delayed complications
Know surgical options for different scenarios.
Clinical Pearls:
Always consider the possibility of perforation or delayed bleeding in a patient with post-colonoscopy abdominal pain or signs of instability
CT scan is paramount for diagnosing perforation
Aim for minimal resection while ensuring oncologic safety.
Common Mistakes:
Delaying surgical intervention in the presence of peritonitis or hemodynamic instability
Inadequate fluid resuscitation and broad-spectrum antibiotic coverage in perforated cases
Underestimating the risk of delayed bleeding.