Colonic Perforation Management (WSES 2020)

Algorithm Steps

1. ▶

   Start

   Colonic Perforation Recognized

   During or after colonoscopy/intervention

   1. ●

      Action

      Classify Timing of Recognition

      Timing affects management

      • INTRA-PROCEDURAL: Seen during colonoscopy
      • IMMEDIATE: <4 hours post-procedure
      • DELAYED: 4-24 hours post-procedure
      • LATE: >24 hours post-procedure
      • Earlier recognition = better outcomes
      1. ●

         Action

         Assess Size and Location

         Determines management approach

         • SIZE: <1cm vs 1-2cm vs >2cm
         • LOCATION: Right colon, transverse, left, rectosigmoid
         • TYPE: Intramural, transmural, retroperitoneal
         • MECHANISM: Mechanical vs barotrauma vs thermal
         • Bowel prep quality (contamination risk)
         1. ◆

            Decision

            Signs of Peritonitis?

            Determines urgency

            • Diffuse abdominal tenderness
            • Rebound, guarding
            • Hemodynamic instability
            • Sepsis signs
            1. ⚠

               Warning

               EMERGENCY SURGERY

               Immediate laparotomy indicated

               • Generalized peritonitis
               • Sepsis/hemodynamic instability
               • Delayed diagnosis >24h
               • Failed endoscopic closure
               • Large perforation >2cm
               • Poor bowel prep
               1. ●

                  Action

                  Surgical Options

                  Based on findings and patient status

                  • PRIMARY REPAIR: Clean field, minimal contamination
                  • RESECTION + ANASTOMOSIS: If viable bowel, minimal contamination
                  • RESECTION + STOMA (Hartmann's): Contamination, unstable patient
                  • DAMAGE CONTROL: Severely septic, second look planned
                  • Laparoscopic approach if stable and expertise
                  1. ●

                     Action

                     Intraoperative Decision Factors

                     Guide surgical approach

                     • FAVOR PRIMARY REPAIR/ANASTOMOSIS:
                     • - Minimal contamination
                     • - Stable patient
                     • - Good tissue quality
                     • FAVOR STOMA:
                     • - Feculent peritonitis
                     • - Hemodynamic instability
                     • - Significant comorbidities
                     • - Delayed presentation
                     1. ●

                        Action

                        Post-Operative Care

                        Recovery and monitoring

                        • ICU if septic
                        • Continue IV antibiotics (5-7 days if complicated)
                        • NGT if ileus
                        • Advance diet when bowel function returns
                        • Monitor for anastomotic leak if performed
                        • Stoma teaching if applicable
                        1. ✓

                           Outcome

                           Outcomes

                           Prognosis and follow-up

                           • Mortality: 5-25% (higher with delay)
                           • Endoscopic closure success: 70-90%
                           • Stoma reversal rate: 70-80%
                           • Follow-up colonoscopy for polypectomy completion
            2. ◆

               Decision

               Recognized During Colonoscopy?

               Endoscopic closure opportunity

               1. ●

                  Action

                  Attempt Endoscopic Closure

                  If expertise available and criteria met

                  • Good bowel prep
                  • Small defect <1-2cm
                  • Visible edges
                  • OPTIONS:
                  • - Endoclips (through-the-scope)
                  • - Over-the-scope clip (OTSC)
                  • - Endoscopic suturing
                  • Mark site for surgery if fails
                  1. ◆

                     Decision

                     Successful Closure?

                     Assess completeness

                     1. ●

                        Action

                        Conservative Management

                        Close monitoring required

                        • NPO, IV fluids
                        • IV antibiotics (broad-spectrum)
                        • Serial abdominal exams
                        • CT if clinical deterioration
                        • Low threshold to operate
                        • Duration: 24-72 hours