Woman Requires Colectomy After Botched Treatment of Polyp

This case involves an elderly woman who underwent a polypectomy. There was a target sign seen with deep cautery effect, and a decision was made to place several hemostatic clips. The patient was discharged the same day with no imaging modality performed. The next day, the patient awoke with increasing abdominal pain, elevated heart rate, and fever. She was admitted to the hospital with fecal peritonitis due to bowel perforation. She was given an open total abdominal colectomy as drainage of an intra-abdominal abscess.

Question(s) For Expert Witness

1. How often do you perform endoscopic polypectomy procedures?

2. What is the clinical significance of finding a target sign on colonoscopy and what would be the appropriate management?

3. What are the complications of an endoscopic polypectomy and subsequent staple placement and how are they recognized after the procedure?

4. When is follow up imaging ordered after a colonoscopy and when should a patient be admitted for observation after a colonoscopy?

Expert Witness Response E-075323

I am an advanced endoscopist, and have been involved in complex and difficult procedures throughout my 26 years in practice. I perform over 500 polypectomy procedures per year, and I have trained over 50 advanced endoscopists in my career. I am considered an international expert on many aspects of endoscopy, including submucosal resection of lesions in the lower and upper gasrtointestinal tract.

The "Target Sign" is a descriptive term that suggests a possible breach of the colon's outer muscle layer with a heightened risk of perforation. To avoid the risk of resulting infections, such as sepsis and peritonitis, it is standard care to closely examine the polypectomy site post procedure. The examiner should look for 1) residual polyp tissue that may remain, 2) risk of bleeding at the polypectomy site and 3) risk of injury to the outer muscle layer. If a potential risk is recognized, it is customary to place clips to close the defect, if possible. Occasionally, the defect is so large that clips may not be sufficient to prevent a perforation.

Whether or not to admit the patient for observation and or obtain post-polypectomy imaging depends on the clinical concern of a perforation as well as the post-procedure recovery evaluation. Post-procedure, nursing staff must monitor several parameters-- including vital signs and pain level--to ensure the patient is safe and ready for discharge. If the Endoscopist is confident the defect has been successfully closed, it is proper to discharge the patient after an appropriate observation period. A review of the records is necessary to determine if sufficient evidence mandated overnight observation and or CT Imaging along with surgical consultation. Not all perforations require surgery. Some are managed by withholding food, antibiotics, and close monitoring.